Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children

Pediatric Surgical Opioid Prescribing by Procedure, 2020-2021

BACKGROUND AND OBJECTIVES

Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing.

METHODS

We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years.

RESULTS

Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%).

CONCLUSIONS

Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control.

Adenotonsillectomy for Obstructive Sleep Apnea in Children

Obstructed breathing is the most common indication for tonsillectomy in children. Although tonsillectomy is performed frequently worldwide, the surgery is associated with a number of significant complications such as bleeding and respiratory failure. Complication risk depends on a number of complex factors, including indications for surgery, demographics, patient comorbidities, and variations in perioperative techniques. While polysomnography is currently accepted as the gold standard diagnostic tool for obstructive sleep apnea, studies evaluating outcomes following surgery suggest that more research is needed on the identification of more readily available and accurate tools for the diagnosis and follow-up of children with obstructed breathing.

Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do

Purpose of review

To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls.

Recent findings

Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity.

Summary

Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.

Impact of state legislation and institutional protocols on opioid prescribing practices following pediatric tonsillectomy

Objectives

Tonsillectomy is a common pediatric surgery, and pain is an important consideration in recovery. Due to the opioid epidemic, individual states, medical societies, and institutions have all taken steps to limit postoperative opioids, yet few studies have examined the effect of these interventions on pediatric otolaryngology practices. The primary aim of this study was to characterize opioid prescribing practices following North Carolina state opioid legislation and targeted institutional changes.

Methods

This single center retrospective cohort study included 1552 pediatric tonsillectomy patient records from 2014 to 2021. The primary outcome was number of oxycodone doses per prescription. This outcome was assessed over three time periods: (1) Before 2018 North Carolina opioid legislation. (2) Following legislation, before institutional changes. (3) After institutional opioid-specific protocols.

Results

The mean (± standard deviation) number of doses per prescription in Periods 1, 2, and 3 was: 58 ± 53, range 4-493; 28 ± 36, range 3-488; and 23 ± 17, range 1-139, respectively. In the adjusted model, Periods 2 and 3 had lower doses by -41% (95% CI -49%, -32%) and -40% (95% CI -55%, -19%) compared to Period 1. After 2018 North Carolina legislation, dosage decreased by -9% (95% CI -13%, -5%) per year. Despite interventions, ongoing variability in prescription regimens remained in all periods.

Conclusion

Legislative and institution specific opioid interventions was associated with a 40% decrease in oxycodone doses per prescription following pediatric tonsillectomy. While variability in opioid practices decreased post-interventions, it was not eliminated.

Level of evidence

3.

Sustaining standardized opioid prescribing practices after pediatric tonsillectomy

INTRODUCTION

Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes.

METHODS

A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure.

RESULTS

From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28).

CONCLUSION

An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.

Using prescription opioids throughout a traumatic injury recovery: A qualitative exploratory study of adolescents in a Midwestern state

BACKGROUND

Injury is one of the most common reasons adolescents are prescribed opioids. Little is known about adolescent experiences who used prescription opioids throughout their recovery from traumatic injury.

METHODS

We used a qualitative exploratory study design nested within a longitudinal cohort study conducted at two trauma hospitals in the United States. We conducted semi-structured telephone interviews with adolescents (n = 28) aged from 12 to 20 years at the time of their hospital admission for injury. We used purposive sampling to gather a broad range of experiences from the longitudinal patient cohort. We conducted a modified thematic analysis of transcribed interviews.

RESULTS

Adolescents reported a wide range of efficacy with which prescription opioids controlled their pain during the injury recovery and numerous opioid-related side effects. A desire for relief from acute pain caused by the injury was the most common driver for using opioids in the hospital. At home, adolescents' decisions to use opioids were influenced by family history of addiction, awareness of harms associated with opioids, and desire to challenge themselves. Adolescents reported closely adhering to a prescribed regimen or using fewer opioids than prescribed while recovering at home. Finally, adolescents reported considerable variability in parental involvement in prescription opioid use, ranging from giving adolescents unrestricted access to prescription opioids to complete parental discretion and administration upon request.

CONCLUSIONS

Adolescents had diverse experiences with prescription opioids during recovery from traumatic injury. Educational interventions that focus on the appropriate use of opioids to address pain care needs among adolescents with traumatic injuries are urgently needed.

Association Between Default Number of Opioid Doses in Electronic Health Record Systems and Opioid Prescribing to Adolescents and Young Adults Undergoing Tonsillectomy

IMPORTANCE

In prior studies, decreasing the default number of doses in opioid prescriptions written in electronic health record systems reduced opioid prescribing. However, these studies did not rigorously assess patient-reported outcomes, and few included pediatric patients.

OBJECTIVE

To evaluate the association between decreasing the default number of doses in opioid prescriptions written in electronic health record systems and opioid prescribing and patient-reported outcomes among adolescents and young adults undergoing tonsillectomy.

DESIGN, SETTING, AND PARTICIPANTS

This nonrandomized clinical trial included adolescents and young adults aged 12 to 50 years undergoing tonsillectomy from October 1, 2019, through July 31, 2021, at a tertiary medical center. The treatment group comprised patients from a pediatric otolaryngology service (mostly aged 12-21 years) and the control group comprised patients from a general otolaryngology service (mostly aged 18-25 years).

INTERVENTIONS

Data on patient-reported opioid consumption and outcomes were collected via a survey on postoperative day 14. Based on opioid consumption among pediatric otolaryngology patients before the intervention, the default number of opioid doses was decreased from 30 to 12 in a tonsillectomy order set. This change occurred only for pediatric otolaryngology patients.

MAIN OUTCOMES AND MEASURES

Proportion of patients with 12 doses in the discharge opioid prescription, number of doses in this prescription, and refills and pain-related visits within 2 weeks of surgery. In a secondary analysis of patients completing the postoperative survey, patient-reported opioid consumption, pain control, sleep disturbance, anxiety, and depression were assessed. Linear or log-linear difference-in-differences models were fitted, adjusting for patients' demographic characteristics and presence of a mental health or substance use disorder.

RESULTS

The study included 237 patients (147 female patients [62.0%]; mean [SD] age, 17.3 [3.6] years). Among 131 pediatric otolaryngology patients, 1 of 70 (1.4%) in the preintervention period and 27 of 61 (44.3%) in the postintervention period had 12 doses in the discharge opioid prescription (differential change, 45.5 percentage points; 95% CI, 32.2-58.8 percentage points). Among pediatric otolaryngology patients, the mean (SD) number of doses prescribed in the preintervention period was 22.3 (7.4) and in the postintervention period was 16.1 (6.5) (differential percentage change, -29.2%; 95% CI, -43.2% to -11.7%). The intervention was not associated with changes in refills or pain-related visits. The secondary analysis included 150 patients. The intervention was not associated with changes in patient-reported outcomes except for a 3.5-point (95% CI, 1.5-5.5 points) differential increase in a sleep disturbance score that ranged from 4 to 20, with higher scores indicating poorer sleep quality.

CONCLUSIONS AND RELEVANCE

This nonrandomized clinical trial suggests that evidence-based default dosing settings may decrease perioperative opioid prescribing among adolescents and young adults undergoing tonsillectomy, without compromising analgesia.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04066829.

Can Use of Default Dispensing Quantities in Electronic Medical Record Lower Opioid Prescribing?

OBJECTIVES

Leftover opioids can contribute to misuse and abuse. Recommended dosing quantities in the electronic medical record can guide prescribing patterns. We hypothesized that decreasing the default from 30 doses to 12 doses would decrease the overall number of opioids prescribed without increasing second opioid prescriptions or additional health utilization.

METHODS

We performed a single-center retrospective study of children with forearm and elbow fractures who presented to the emergency department for evaluation and subsequent orthopedic follow-up between January 15, and September 19, 2017. The default dispensing quantity was decreased on June 1, 2016 from 30 doses to 12 doses. Patients were categorized to preintervention and postintervention groups. We compared the number of opioids prescribed, second opioid prescriptions, emergency department visits, and pain-related telephone calls and orthopedic visits with χ2 and logistic regression analyses.

RESULTS

There were 1107 patients included. Rates of opioid prescribing were similar preintervention and postintervention (61% vs 56%, P = 0.13). After the change to the default quantity, the median number of doses decreased from 18 to 12 doses, with opioid prescriptions of 30 or more doses dropping from 35% to 11%. No significant association was found between preintervention versus postintervention, opioid prescription at discharge, and having 1 or more pain-related or unexpected follow-up visits.

CONCLUSIONS

Lowering the default dispensing quantity of opioids in the electronic medical record decreases the number of opioids prescribed without increasing second prescriptions or additional health care utilization. These findings suggest that a further reduction in the number of opioids prescribed for upper-extremity fractures may be possible.

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses

BACKGROUND AND OBJECTIVES

Treatment of retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs) includes antibiotics, with possible surgical drainage. Although corticosteroids may decrease inflammation, their role in the management of RPAs and PPAs is unclear. We evaluated the association of corticosteroid administration as part of initial medical management on drainage rates and length of stay for children admitted with RPAs and PPAs.

METHODS

We conducted a retrospective study using administrative data of children aged 2 months to 8 years discharged with RPAs and PPAs from 2016 to 2019. Exposure was defined as systemic corticosteroids administered as part of initial management. Primary outcome was surgical drainage. Bivariate comparisons were made between patients in the corticosteroid and noncorticosteroid groups by using Wilcoxon rank or χ² tests. Outcomes were modeled by using generalized linear mixed-effects models.

RESULTS

Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22-0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92-1.02).

CONCLUSIONS

Corticosteroids were associated with lower odds of surgical drainage among children with RPAs and PPAs.

Does ibuprofen, prednisolone, or amoxicillin reduce post-tonsillectomy pain in children? A prospective randomized controlled trial

OBJECTIVE

To evaluate whether the use of anti-inflammatory or antibiotic in the postoperative period modifies pain in children undergoing tonsillectomy.

METHODS

225 children who underwent cold knife tonsillectomy ± adenoidectomy were randomized into five groups, receiving #1 metamizole/acetaminophen, #2 amoxicillin, #3 ibuprofen, #4 prednisolone, or #5 amoxicillin plus prednisolone. All groups received oral analgesics (metamizole/acetaminophen) to use as needed. Pain was monitored during the 7 days following surgery using the Parents' Postoperative Pain Measurement (PPPM) and the Faces Pain Scale - Revised (FPS-R). Pain was also indirectly evaluated by the dose of analgesics administered on each day and by the time needed to return to a solid diet.

RESULTS

After losses (24%), 170 individuals were submitted for analysis. Multiple comparisons demonstrated that the evolution of pain between the different groups, as matched day-per-day, was not significantly different by either PPPM or FPS-R (p > 0.05). The instances of analgesic intake were also similar in all the groups (p > 0.05), as was the return to solid food ingestion (p = 0.41). All groups presented a similar standard of clinical improvement at intervals of 2 days (p < 0.01). Independent of postoperative pain management, patients developed significant pain up to the day 4 following surgery.

CONCLUSION

The addition of amoxicillin, ibuprofen, prednisolone, or amoxicillin and prednisolone does not modify postoperative pain in children undergoing cold-knife tonsillectomy. Special pain control should be performed on the first 4 days following tonsillectomy in children.

Opioid Prescribing to US Children and Young Adults in 2019

BACKGROUND

Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years.

METHODS

We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with ≥1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by ≥1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the ≥95th percentile.

RESULTS

Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had ≥1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of ≥50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by ≥1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions.

CONCLUSIONS

Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.

Opioid prescribing practices in academic otolaryngology: A single institutional survey

OBJECTIVES

Opioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing.

METHODS

This quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents.

RESULTS

A total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively).

CONCLUSION

There was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education.

LEVEL OF EVIDENCE

4.

Pharmacologic management of post-tonsillectomy pain in children

Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.

Postoperative tonsil/adenoidectomy bleeding management in patients with diagnosed bleeding disorders

OBJECTIVE

Tonsil/adenoidectomy (T/A) is a commonly performed procedure with an average post-tonsillectomy bleed (PTB) rate between 3 and 5%. Patients with bleeding disorders (BDs) are believed to have an increased risk of PTB. We hypothesize that our medical management of BD patients using a combination of DDAVP/antifibrinolytic agents has a similar PTB rate to control patients. This study suggests a standardized protocol for patients with BDs to avoid PTB.

METHODS

A retrospective cohort study was completed for patients with BD who underwent tonsillectomy or T/A at Promedica Toledo or Flower Hospital between 2013 and 2020. Exclusion criteria included incomplete records, diagnosis of BD after surgery, and inability to find age and sex matched control. We defined the control group as patients who underwent T/A without BD. The following variables were collected: age, sex, medical history, BD severity, medications, type of surgery, indication for surgery, estimated blood loss (EBL), pre/postoperative medications, PTB status, and post-PTB intervention.

RESULTS

A total of 164 patient charts were reviewed. There were 82 patients in both cohorts. The BDs represented were platelet function disorder (80.5%), von Willebrand disease (14.6%), and others such as Factor VII and IX deficiency (4.9%). Of the BD patients included, 13.4% had severe disease. There was no significant difference between the age, sex, EBL, and PTB rates. Of the 8 BD patients with PTB, 62% bled 9-10 days postoperatively and none had severe disease.

CONCLUSION

Our protocol to prevent PTB in patients with BDs produced similar bleed rates to control patients in this study. Further studies are required to assess postoperative length of antifibrinolytic treatment in BD patients.

LEVEL OF EVIDENCE

III.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Reduction in Pediatric Ambulatory Adenotonsillectomy Length of Stay Using Clinical Care Guidelines

OBJECTIVE

Standardization of postoperative care using clinical care guidelines (CCG) improves quality by minimizing unwarranted variation. It is unknown whether CCGs impact patient throughput in outpatient adenotonsillectomy (T&A). We hypothesize that CCG implementation is associated with decreased postoperative length of stay (LOS) in outpatient T&A.

METHODS

A multidisciplinary team was assembled to design and implement a T&A CCG. Standardized discharge criteria were established, including goal fluid intake and parental demonstration of medication administration. An order set was created that included a hard stop for discharge timeframe with choices "meets criteria," "4-hour observation," and "overnight stay." Consensus was achieved in June 2018, and the CCG was implemented in October 2018. Postoperative LOS for patients discharged the same day was tracked using control chart analysis with standard definitions for centerline shift being utilized. Trends in discharge timeframe selection were also followed.

RESULTS

Between July 2015 and August 2017, the average LOS was 4.82 hours. This decreased to 4.39 hours in September 2017 despite no known interventions and remained stable for 17 months. After CCG implementation, an initial trend toward increased LOS was followed by centerline shifts to 3.83 and 3.53 hours in March and October 2019, respectively. Selection of the "meets criteria" discharge timeframe increased over time after CCG implementation (R²  = 0.38 P = .003).

CONCLUSIONS

Implementation of a CCG with standardized discharge criteria was associated with shortened postoperative LOS in outpatient T&A. Concurrently, surgeons shifted practice to discharge patients upon meeting criteria rather than after a designated timeframe.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Clinical Decision Support Systems in Otolaryngology-Head and Neck Surgery: A State of the Art Review

OBJECTIVE

To offer practical, evidence-informed knowledge on clinical decision support systems (CDSSs) and their utility in improving care and reducing costs in otolaryngology-head and neck surgery. This primer on CDSSs introduces clinicians to both the capabilities and the limitations of this technology, reviews the literature on current state, and seeks to spur further progress in this area.

DATA SOURCES

PubMed/MEDLINE, Embase, and Web of Science.

REVIEW METHODS

Scoping review of CDSS literature applicable to otolaryngology clinical practice. Investigators identified articles that incorporated knowledge-based computerized CDSSs to aid clinicians in decision making and workflow. Data extraction included level of evidence, Osheroff classification of CDSS intervention type, otolaryngology subspecialty or domain, and impact on provider performance or patient outcomes.

CONCLUSIONS

Of 3191 studies retrieved, 11 articles met formal inclusion criteria. CDSS interventions included guideline or protocols support (n = 8), forms and templates (n = 5), data presentation aids (n = 2), and reactive alerts, reference information, or order sets (all n = 1); 4 studies had multiple interventions. CDSS studies demonstrated effectiveness across diverse domains, including antibiotic stewardship, cancer survivorship, guideline adherence, data capture, cost reduction, and workflow. Implementing CDSSs often involved collaboration with health information technologists.

IMPLICATIONS FOR PRACTICE

While the published literature on CDSSs in otolaryngology is finite, CDSS interventions are proliferating in clinical practice, with roles in preventing medical errors, streamlining workflows, and improving adherence to best practices for head and neck disorders. Clinicians may collaborate with information technologists and health systems scientists to develop, implement, and investigate the impact of CDSSs in otolaryngology.

A prospective cohort register-based study of chronic postsurgical pain and long-term use of pain medication after otorhinolaryngological surgery

Data on chronic postsurgical pain (CPSP) after otorhinolaryngological surgery are sparse. Adult in-patients treated in 2017 were included into the prospective PAIN OUT registry. Patients’ pain on the first postoperative day (D1), after six months (M6) and 12 months (M12) were evaluated. Determining factor for CPSP was an average pain intensity ≥ 3 (numeric rating scale 0–10) at M6. Risk factors associated with CPSP were evaluated by univariate and multivariate analyses. 10% of 191 included patients (60% male, median age: 52 years; maximal pain at D1: 3.5 ± 2.7), had CPSP. Average pain at M6 was 0.1 ± 0.5 for patients without CPSP and 4.2 ± 1.2 with CPSP. Average pain with CPSP still was 3.7 ± 1.1 at M12. Higher ASA status (Odds ratio [OR] = 4.052; 95% confidence interval [CI] = 1.453–11.189; p = 0.007), and higher minimal pain at D1 (OR = 1.721; CI = 1.189–2.492; p = 0.004) were independent predictors of CPSP at M6. Minimal pain at D1 (OR = 1.443; CI = 1.008–2.064; p = 0.045) and maximal pain at M6 (OR = 1.665; CI = 1.340–2.069; p < 0.001) were independent predictors for CPSP at M12. CPSP is an important issue after otorhinolaryngological surgery. Better instrument for perioperative assessment should be defined to identify patients at risk for CPSP.

Association of perioperative ibuprofen exposure with post-tonsillectomy bleeding requiring operative management

INTRODUCTION

Pediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not.

METHODS

Retrospective cohort study of patients 0-18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred.

RESULTS

A total of 4098 patients with a median age of 6 years old (IQR 4-10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3-8) in the non-ibuprofen group.

CONCLUSIONS

No difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy.

Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy

OBJECTIVES/HYPOTHESIS

To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools.

STUDY DESIGN

Prospective quality improvement initiative.

METHODS

Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED).

RESULTS

In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED.

CONCLUSIONS

Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2337-E2343, 2021.

Radiofrequency Ablation vs Electrocautery Blinded Randomized Trial: Impact on Clinically Meaningful Outcomes

OBJECTIVE

To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation.

STUDY DESIGN

Randomized double-blinded clinical trial based on prospective parallel design.

SETTING

Academic medical center and tertiary children's hospital between March 2018 and July 2019.

METHODS

Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events.

RESULTS

Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity (P = .89), daily pain scores over 15 postoperative days (P = .46), postoperative narcotic use (P = .61), or return to hospital for any reason (P = .60), including bleeding as an adverse event (P = .13).

CONCLUSIONS

As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.

Opioid Prescribing Patterns Following Pediatric Tonsillectomy in the United States, 2009-2017

OBJECTIVES

Assess national trends in opioid prescription following pediatric tonsillectomy: 1) overall percentage receiving opioids and mean quantity, 2) changes during 2009-2017, and 3) determinants of prescription patterns.

METHODS

Cross-sectional analysis using 2009-2017 Optum claims data to identify opioid-naïve children aged 1-18 with claims codes for tonsillectomy (n = 82,842). Quantities of opioids filled in outpatient pharmacies during the perioperative period were extracted and converted into milligram morphine equivalents (MMEs) for statistical comparison. Demographic, clinical, and socioeconomic predictors of opioid fill rate and quantity were determined using regression analyses.

RESULTS

In 2009, 83.3% of children received opioids, decreasing to 58.3% by 2017. Rates of all-cause readmissions and post-tonsillectomy hemorrhages were similar over time. Mean quantity received was 153.47MME (95% confidence intervals [95%CI]: 151.19, 155.76) and did not significantly change during 2009-2017. Opioids were more likely in older children and those with higher household income, but less likely in children with obstructive sleep apnea, other comorbidities, and Hispanic race. Higher quantities of opioids were more likely in older children, while lower quantities were associated with female sex, Hispanic race, and higher household income. Outpatient steroids were prescribed to 8.04% of patients, who were less likely to receive opioids.

CONCLUSION

While the percentage of children receiving post-tonsillectomy opioids decreased during 2009-2017, prescribed quantities remain high and have not decreased over time. Prescription practices were also influenced by clinical and sociodemographic factors. These results highlight the need for guidance, particularly with regard to opioid quantity, in children after tonsillectomy.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:E1722-E1729, 2021.

Pediatric Post-Tonsillectomy Opioid Prescribing Practices

OBJECTIVE

To evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding.

METHODS

Retrospective chart review of pre- and post-intervention in pediatric post-tonsillectomy patients, 0-18 years old (n = 1486). Order sets were installed with age-specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time-balanced pre- and post-intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed.

RESULTS

Discharge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg [95% CI, 0.092-0.099] vs. 0.079 [95% CI, 0.076-0.083], P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 [95% CI, 43.6-49.1] to 20.3 [95% CI, 19.1-21.5], P < .001). Patients <7 years old prescribed opioids remained rare in pre- and post-intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post-intervention group showed an increase in readmissions for post-tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post-intervention group after stratification by age.

CONCLUSION

Utilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post-tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1386-1391, 2021.

How should we approach parental refusals of opioids on behalf of children in the perioperative setting? A practical approach based on ethical theory

In the midst of the current opioid epidemic, we have encountered more parents who are concerned about the use of opioids in the perioperative setting. Some parents have completely refused the use of opioids on behalf of their children. How should we approach this treatment refusal? This article describes ethical theory related to the refusal of treatment by parents on behalf of their children, and when it is justified to override parental decisions. We propose a decision-making framework that focuses on improving communication and considering alternatives. Assessment of harm to the child from avoiding opioids, as well as potential harms from overriding parental autonomy must be undertaken prior to considering overriding parents.

Parental assessment of pain control following pediatric adenotonsillectomy: Do opioids make a difference?

INTRODUCTION

Postoperative prescribing of opioids following pediatric adenotonsillectomy can have negative consequences including unnecessary opioid exposure and potential for respiratory depression. While guidelines from The American Academy of Otolaryngology/Head & Neck Surgery recommend treatment of post adenotonsillectomy pain using acetaminophen and ibuprofen, many providers continue to prescribe opioids and may do so, in part with concern for parental dissatisfaction with post-operative analgesia. Our aim was to determine whether a post-operative prescription for opioids affects parental assessment of pain control following pediatric adenotonsillectomy.

METHODS

This post-operative survey assessed the parental assessment of pain control in 324 patients, ages 1-17 years undergoing adenotonsillectomy. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 1, 2018 through March 31, 2019. Post-operative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for post-operative analgesia based on the attending surgeons prescribing preferences. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric adenotonsillectomy as poor or inadequate based on the post-operative analgesic regimen including opioids.

RESULTS

Of the 798 surveys sent, the response rate was 42% (324/775) of those who received the survey email, and 69% (324/470) for those who opened the email. Between the opioid and non-opioid groups, there was no difference in gender (male; 48% vs. 51.3%; p = 0.58), race/ethnicity (white; 53% vs. 46%; p = 0.35) or insurance status (insured; 62% vs. 50.9%; p = 0.06). The proportion of parents who rated their child's pain as poor or inadequately controlled following adenotonsillectomy was relatively rare: 9% and 5% in the non-opioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following adenotonsillectomy were 58% and 50% in the non-opioids and opioid groups respectively.

CONCLUSION

The results of this study indicate that non-opioid analgesic regimens following pediatric adenotonsillectomy were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric adenotonsillectomy is feasible and does not result in worse parental satisfaction with the analgesic plan.