1
|
Chen SY, Ourshalimian S, Hijaz D, Odegard MN, Kim E, Andras L, Kelley-Quon LI. Opioid consumption before discharge predicts outpatient opioid use in adolescents undergoing surgery. Surgery 2024:S0039-6060(24)00207-1. [PMID: 38763792 DOI: 10.1016/j.surg.2024.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/10/2024] [Accepted: 03/25/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND The majority of adolescents undergoing surgery report unused prescription opioids after surgery, increasing the risk of diversion, misuse, and addiction. Adult studies have demonstrated that opioid use 24 hours before discharge corresponds with opioid use at home. We hypothesized that inpatient opioid consumption is associated with outpatient opioid use in adolescents. METHODS Adolescents aged 13-20 years undergoing elective surgery associated with an opioid prescription were prospectively recruited. Parent-adolescent dyads were surveyed preoperatively to assess sociodemographics, health literacy, and baseline substance use, and opioid use was measured at 30- and 90-days postoperatively. Medical records were reviewed to calculate cumulative opioid use during hospitalization. Inpatient and postoperative opioid use was converted to oral morphine equivalents. Adjusting for age, sex, race, health literacy, alcohol use, pain score, and surgery, multivariable linear regression identified factors associated with outpatient oral morphine equivalent use 90 days postoperatively. RESULTS Overall, 103 adolescents were enrolled. Median oral morphine equivalents used from 24 and 48 hours before discharge and throughout the hospitalization were 30.8 (interquartile range:11.7-45.0), 67.5 (interquartile range:37.5-94.3), and 97.5 (interquartile range:18.0-152.7), respectively. Regression analysis demonstrated that adolescent-reported pain at discharge (P = .028) and cumulative oral morphine equivalents used 24 hours (P < .001) and 48 hours (P = .003) before discharge were significantly associated with postoperative oral morphine equivalents use at home. Oral morphine equivalents consumption 24 hours before discharge estimated cumulative oral morphine equivalents use 90 days postoperatively at a 1-to-5 ratio in 94.1% of patients. CONCLUSION For adolescents undergoing surgery, patient-reported pain at discharge and oral morphine equivalents administered 24 hours before discharge are associated with cumulative outpatient opioid use. Tailoring outpatient prescriptions to total oral morphine equivalent consumption 24 hours before discharge could reduce excess opioid prescribing.
Collapse
Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA. https://twitter.com/steph_y_chen
| | | | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Marjorie N Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA. https://twitter.com/MarjorieOdegard
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lindsay Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery & Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| |
Collapse
|
2
|
Dumbarton TC. Regional anesthesia in complex pediatric patients: advances in opioid-sparing analgesia. Can J Anaesth 2023:10.1007/s12630-023-02616-x. [PMID: 37884770 DOI: 10.1007/s12630-023-02616-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/17/2023] [Accepted: 06/19/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- Tristan C Dumbarton
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Halifax, NS, Canada.
- IWK Health Centre, Halifax, NS, Canada.
- IWK Health Centre, 5850 University Ave., Halifax, NS, B3K 6R8, Canada.
| |
Collapse
|
3
|
Pace D, Mack SJ, Sadacharam K, Lang RS, Burke B, Fishlock K, Berman L. Implementation of a quadratus lumborum regional block protocol with assessment of effectiveness for patients with appendicitis: a quality improvement project. Pediatr Surg Int 2023; 39:267. [PMID: 37676327 DOI: 10.1007/s00383-023-05522-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia. METHODS Children undergoing laparoscopic appendectomy within a multi-hospital children's healthcare system were retrospectively reviewed from 2017 to 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 h postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type. RESULTS 2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6% vs. NB 54.6%, p = 0.005; complicated: QLB 28.5% vs. NB 39.9%, p = 0.01) and postoperatively (complicated: QLB 33.7% vs. NB 52.9%, p < 0.001) for those who received a QLB. This resulted in reduced opioid consumption as measured by morphine milligram equivalents per kilogram postoperatively. CONCLUSION QLBs can be safely administered in children and provide improvements in opioid consumption postoperatively. QLBs should remain a strongly favored regional anesthetic technique because of their wide applicability for abdominal surgeries to minimize rescue opioid analgesic use. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Devon Pace
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, USA.
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 613, Philadelphia, PA, 19107, USA.
| | - Shale J Mack
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kesavan Sadacharam
- Department of Anesthesiology and Perioperative Medicine, Nemours Children's Health, Wilmington, DE, USA
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert S Lang
- Department of Anesthesiology and Perioperative Medicine, Nemours Children's Health, Wilmington, DE, USA
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian Burke
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Keith Fishlock
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Loren Berman
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, USA
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
4
|
Decrease in Residual Neurological Symptoms After Institutional Changes in Peripheral Nerve Block Use for Pediatric Knee Surgery. J Pediatr Orthop 2022; 42:e138-e142. [PMID: 34995258 DOI: 10.1097/bpo.0000000000002014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) have recently been associated with a higher incidence of complications than previously thought. We compared: (1) incidence of PNB-related residual neurological symptoms and (2) patient selection, operative practices, and anesthesia practices for pediatric knee surgery patients before and after changes in PNB administration at our institution. METHODS We compared data from pediatric patients who underwent knee surgery with PNBs from 2014 to 2016 (cohort 1; 100 patients) or 2017 to 2019 (cohort 2; 104 patients). Cohort 2 was treated after PNB administration was limited to a dedicated anesthesia block team at our institution. We used t tests and χ2 tests, with an α level of 0.05. RESULTS The incidence of PNB-related neurological complications was lower in cohort 2 (0.96%;) than cohort 1 (6%) (P=0.045). The 1 complication in cohort 2 was numbness proximal to the knee. Cohort 1 had 5 cases of numbness proximal to the knee and 1 case of neuropathic pain upon palpation of the PNB site. The proportion of female patients was greater in cohort 2 (57%) than cohort 1 (36%) (P=0.01); age and body mass index did not differ between cohorts. In cohort 2, the mean operating time was longer, and tourniquets were used more frequently (both, P<0.01). A greater proportion of PNBs were performed by fellows in cohort 2 (67%) versus cohort 1 (55%) (P=0.01). A smaller proportion of PNBs were performed by residents in cohort 2 (6.9%) versus cohort 1 (16%) (P=0.01). The most common anatomic site for PNBs was the femoral nerve (51%) in cohort 1 and the saphenous nerve (51%) in cohort 2 (P<0.01). CONCLUSIONS The incidence of PNB-related complications after pediatric knee surgery decreased significantly after institutional changes in the regulation of PNB use. This decrease may be explained by shifts toward more experienced providers administering PNBs and preference for more distal anatomic sites, suggesting ways other institutions may lower their PNB complication rates. LEVEL OF EVIDENCE Level III-retrospective prognostic study.
Collapse
|
5
|
Luo R, Tong X, Yan W, Liu H, Yang L, Zuo Y. Effects of erector spinae plane block on postoperative pain in children undergoing surgery: A systematic review and meta-analysis of randomized controlled trials. Paediatr Anaesth 2021; 31:1046-1055. [PMID: 34270146 DOI: 10.1111/pan.14255] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/13/2021] [Accepted: 06/25/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The erector spinae plane block is a novel regional anesthetic technique that is gaining popularity in pediatrics. However, the efficacy of erector spinae plane block in children is unclear. The aim of the systematic review and meta-analysis was to investigate effects of erector spinae plane block on postoperative pain relief in children. METHODS We searched MEDLINE, Cochrane Library, EMBASE, China National Knowledge Infrastructure, and Wan fang databases for randomized controlled trials that compared erector spinae plane block with no block or other types of block in pediatric patients undergoing surgeries. The primary outcomes were pain intensity at rest within 24 h postoperatively and the number of patients requiring rescue analgesics. Data were analyzed using the fixed- or random-effects model, depending on whether the heterogeneity tested by the I2 statistic was >30%. We assessed the quality of evidence for the outcomes using the Grading of Recommendations, Assessment, Development, and Evaluation method. RESULTS Seven randomized controlled trials involving 379 patients were reviewed. Compared with no block, erector spinae plane block slightly reduced the pain scores at 0 h (standardized mean difference [SMD]: -1.07; 95% confidence interval [CI]: -1.60 to -0.54; I2 = 52%), 6 h (SMD: -0.82; 95% CI: -1.39 to -0.25; I2 = 79%) postoperatively at rest and significantly reduced the need for rescue analgesics (odds ratio 0.09; 95% CI: 0.04 to 0.21; I2 = 16%). One trial demonstrated the analgesic effect of erector spinae plane block was similar to a quadratus lumborum block, while another trial demonstrated the analgesic effect of ESPB was superior to an ilioinguinal nerve block. CONCLUSIONS This review provides low-quality evidence that erector spinae plane block exhibits superior analgesia compared to no block in children. Due to the limited data, evidence regarding the comparison with other regional blocks remains unclear. Future large-sized and well-designed randomized controlled trials are needed.
Collapse
Affiliation(s)
- Rong Luo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan, China
| | - Xin Tong
- Department of Anesthesiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second Hospital of Sichuan University, Sichuan University, Chengdu, China
| | - Weidong Yan
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardio-vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Haibei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan, China
| | - Lei Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan, China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
6
|
Analgesic Efficacy of Quadratus Lumborum Block in Infants Undergoing Pyeloplasty. SURGERIES 2021. [DOI: 10.3390/surgeries2030028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Post-operative analgesic management is challenging in infants and opioids have been the standard of care. However, they are associated with adverse effects which may negatively impact infants. In this retrospective cohort study, we sought to explore the postoperative analgesic efficacy of quadratus lumborum (QL) block in the infant population undergoing dorsal lumbotomy pyeloplasty. Chart review of 34 infants (≤12 months) who underwent dorsal lumbotomy pyeloplasty between 2016–2020 was performed. Post-operative pain was assessed using externally validated pain scales (CRIES & FLACC) and monitored hemodynamics (pulse and blood pressure). Opioid doses were standardized by using morphine milligram equivalency (MME). The Prescription Database Monitoring Program (PDMP) was utilized to determine if discharge opioid prescriptions were filled. Of 34 patients, 13 received the QL block. Mean age at the time of surgery was 6.2 months ± 3.2 months. The QL group received 0.8 MME postoperatively, whereas the non-QL group received 0.9 MME (p = 0.82). The QL group (20%) filled their discharge opioid prescription less frequently compared to non-QL group (100%) (p = 0.002). There were no observed differences between pain scale or hemodynamic variables. Further studies are warranted to explore QL block’s efficacy for post-operative infant pain management.
Collapse
|
7
|
Rodriguez-Merchan EC, De la Corte-Rodriguez H. Pain management in people with hemophilia in childhood and young adulthood. Expert Rev Hematol 2021; 14:525-535. [PMID: 34042011 DOI: 10.1080/17474086.2021.1935852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: People with hemophilia (PWH) commonly experience acute and chronic musculoskeletal pain during childhood and young adulthood, but their treatment is often inadequate.Areas covered: From 1 September 2020 to 15 April 2021, authors performed a literature search in PubMed and the Cochrane Library using 'hemophilia AND pain' as keywords. Authors found 1082 articles, 51 of which were chosen because we considered them to be intimately connected with the topic of this report. Multimodal pain treatment, including multimodal analgesia, physical and rehabilitation medicine (PRM), and psychological therapies (imagery or relaxation, hypnosis), is currently the most recommended treatment for PWH. In acute hemarthrosis, in addition to hematologic treatment and joint aspiration, paracetamol/acetaminophen should be prescribed if the pain is mild, metamizole if the pain is moderate, and soft opioids (codeine or tramadol) if the pain is severe. In cases of chronic musculoskeletal pain due to hemophilic arthropathy, paracetamol/acetaminophen, COX-2 inhibitors, PRM, intra-articular injections of some drugs (corticosteroids, hyaluronic acid, platelet-rich plasma, mesenchymal stem cells), radiosynovectomy and behavioral therapies are advised.Expert opinion: Management of musculoskeletal pain in children and young adults with hemophilia should employ multimodal pain treatment (multimodal analgesia, PRM, and psychological strategies).
Collapse
Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
| | | |
Collapse
|
8
|
Poirier C, Alencar Cavalcante Nascimento Lima L, Ingelmo P. It is time to prove that regional anesthesia can be a game changer in the recovery after surgery in children. Minerva Anestesiol 2020; 87:634-636. [PMID: 33331754 DOI: 10.23736/s0375-9393.20.15270-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Pablo Ingelmo
- Department of Anesthesiology, Montreal Children's Hospital, McGill University, Montreal, QC, Canada -
| |
Collapse
|