Efficacy of Analgesic Treatments to Manage Children's Postoperative Pain After Laparoscopic Appendectomy: Retrospective Medical Record Review

Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative

BACKGROUND

Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative.

METHODS

On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation.

RESULTS

In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001).

CONCLUSION

Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care.

STUDY TYPE

Quality improvement.

LEVEL OF EVIDENCE

Level III.

Pain-related hospitalization and emergency room visit following initial analgesic prescription after outpatient surgery

PURPOSE

Our study examined the association between outpatient postsurgical analgesic prescription and risk of insufficiently managed pain characterized by pain-associated hospital admission and emergency room (ER) visit.

METHODS

Eligible individuals were children 1-17 years of age who filled an incident analgesic following an outpatient surgery during 2013-2018. Pain-associated hospital admission or ER visit were measured within 30 days following the outpatient surgical procedure. A hierarchical multivariable logistic regression model with patients nested under prescribers was fitted to test the association between incident analgesic prescription and risk of having pain-associated hospital admission or ER visit.

RESULTS

Of 14 277 children meeting the inclusion criteria, 6224 (43.6%) received an incident opioid and 8053 (56.4%) received an incident non-opioid analgesic prescription respectively. There were a total of 523 (3.7%) children undergoing surgical procedures that had pain-related hospital admissions or ER visits with 5.1% initiated on non-opioid analgesics and 1.8% on opioid analgesics. The multilevel model indicated that initial opioid analgesic recipients were 32% less likely of having a pain-associated hospital admission or ER visit [aOR: 0.68 (95% CI: 0.3-0.8)].

CONCLUSION

Majority of postsurgical patients do not require additional pain management strategies. In the 3.7% of patients requiring additional pain management strategies, those initiated on non-opioid analgesics are more likely to have a pain-associated hospital admission or ER visit compared with their opioid recipient counterparts.

Pain Management Throughout Pediatric Laparoscopic Appendectomy: A Systematic Review

Opioid-related fatalities are a leading cause of accidental death in the United States. Appendicitis is a common cause of abdominal pain in children and adolescents. The management of pain throughout the laparoscopic appendectomy (LA) in the pediatric population is a critical concern. This study aimed to evaluate trends in analgesic use and patient satisfaction following LA, with a focus on reducing the reliance on opioids for pain management. From 2003 to 2023, 18258 articles were filtered for all types of analgesic use with LA. The publications were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 19 studies were included for analysis and review. The study included peer-reviewed experimental and observational studies involving individuals under 18 years. Pain management strategies varied across studies, involving a combination of analgesics, nerve blocks, and wound infiltrations. Analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids were administered before and after surgery. Some studies implemented patient-controlled analgesia (PCA) pumps. Other studies explored non-pharmacological interventions like magnetic acupuncture. The results showed a reduction in the need for postoperative analgesics in patients treated with LA, particularly when using non-opioid medications and novel analgesic techniques. Pediatric patients who received gabapentin reported lower opioid use, shorter hospital stays, and high satisfaction rates. However, the reliance on opioids remained significant in some cases, particularly among patients with peritonitis who required more morphine. Pain management in pediatric patients is multifaceted, involving preoperative and postoperative analgesics, nerve blocks, and PCA pumps. Efforts to improve pain management following pediatric LA while reducing opioid reliance are essential in the context of the ongoing opioid epidemic. The findings from this study highlight the potential benefits of non-opioid analgesics, nerve blocks, and alternative methods for managing postoperative pain in <18 appendectomy patients. Further research and standardization of pain management protocols are needed to ensure optimal patient outcomes and minimize the risk of opioid-related complications.

Ketorolac use and risk of bleeding after appendectomy in children with perforated appendicitis

BACKGROUND

Ketorolac is an opioid sparing agent commonly used in children. However, ketorolac may be avoided in children with peritonitis owing to a possible increased risk of bleeding.

METHODS

A retrospective cohort study of healthy children 2-18 years who underwent appendectomy for perforated appendicitis was performed using the Pediatric Health Information System (2009-2019). Multivariable logistic regression was used to evaluate the association between perioperative ketorolac use and postoperative blood transfusions within 30 days of surgery, adjusting for patient and hospital level factors. An interaction between ketorolac and ibuprofen was evaluated to identify synergistic effects.

RESULTS

Overall, 55,603 children with perforated appendicitis underwent appendectomy and 82.3% (N = 45,769) received ketorolac. Of those, 32% (N = 14,864) also received ibuprofen. Receipt of a blood transfusion was infrequent (N = 189, 0.3%). On multivariable logistic regression analysis, perioperative ketorolac administration was associated with decreased odds of a blood transfusion (OR 0.53, 95% CI: 0.35-0.79). However, children receiving ketorolac and ibuprofen were more likely to require a blood transfusion (OR 1.99, 95% CI: 1.42-2.79). In a subset of children receiving ketorolac, each additional day of ketorolac was associated with an increase odds of blood transfusion (OR 1.39, 95% CI: 1.30-1.49).

CONCLUSION

Perioperative ketorolac alone is not associated with an increased risk of significant bleeding in children undergoing appendectomy for perforated appendicitis. However, use of both ketorolac and ibuprofen during hospitalization was associated with increased risk of bleeding, although precise timing of administration of these medications was unable to be determined. Extended ketorolac use was also associated with increased risk of bleeding requiring blood transfusion.

LEVEL OF EVIDENCE

Level III.

Ketorolac Administration After Colorectal Surgery Increases Anastomotic Leak Rate: A Meta-Analysis and Systematic Review

Objective

This meta-analysis aimed to evaluate whether ketorolac administration is associated with an increased anastomotic leak rate after colorectal surgery.

Methods

The literature was searched using the Web of Science, Embase, and PubMed databases, and the search ended on May 31, 2020. The Newcastle–Ottawa Scale was used to assess methodological quality. Statistical heterogeneity was assessed using the Chi-square Q test and I² statistics. Subgroup analysis was performed, and Egger's test was used to assess publication bias.

Results

This meta-analysis included seven studies with 400,822 patients. Our results demonstrated that ketorolac administration after surgery increases the risk of anastomotic leak [OR = 1.41, 95% CI: 0.81–2.49, Z = 1.21, P = 0.23]. Low heterogeneity was observed across these studies (I² = 0%, P = 0.51). The results of subgroup analysis showed that the use of ketorolac in case–control and retrospective cohort studies significantly increased the risk of anastomotic leak (P < 0.05). Furthermore, the subgroup analysis revealed that ketorolac use increased anastomotic leak rate in patients in the United States and Canada, and ketorolac plus morphine use did not increase anastomotic leak rate in Taiwanese patients (P < 0.05). No significant publication bias was observed (P = 0.126). Moreover, the analysis of risk factors related to anastomotic leak rate indicated that the total use of ketorolac did not increase the risk of anastomotic leak similar to the control group (P > 0.05).

Conclusion

The meta-analysis indicates that the use of ketorolac increases the risk of anastomotic leak after colorectal surgery.

Systematic Review Registration

PROSPERO, identifier CRD42020195724.

The impact of intravenous acetaminophen pricing on opioid utilization and outcomes for children with appendicitis

BACKGROUND

In 2014, the price of intravenous acetaminophen more than doubled. This study determined whether increased intravenous acetaminophen cost was associated with decreased utilization and increased opioid use for children undergoing appendectomy.

METHODS

A multicenter retrospective cohort study using the Pediatric Health Information System database between 2011 and 2017 was performed. Healthy children 2 to 18 years undergoing appendectomy at 46 children's hospitals in the United States were identified. Intravenous acetaminophen use, opioid use, and pharmacy costs were assessed. Multivariable mixed-effects modeling was used to determine the association between postoperative opioid use, intravenous acetaminophen use, and postoperative length-of-stay.

RESULTS

Overall, 110,019 children undergoing appendectomy were identified, with 22.5% (N = 24,777) receiving intravenous acetaminophen. Despite the 2014 price increase, intravenous acetaminophen use increased from 3% in 2011 to 40.1% in 2017 (P < .001), but at a significantly reduced rate. After 2014, adjusted median pharmacy charges decreased from $3,326.5 (interquartile range: $1,717.5-$6,710.8) to $3,264.1 (interquartile range: $1,782.8-$5,934.7, P < .001) for children who received intravenous acetaminophen. In 94,745 children staying ≥1 day after surgery, postoperative opioid use decreased from 73.6% in 2011 to 58.6% in 2017 (P < .001). Use of intravenous acetaminophen alone compared to opioids alone after surgery resulted in similar predicted mean postoperative length-of-stay.

CONCLUSION

In children undergoing appendectomy, intravenous acetaminophen use continued to rise, but at a slower rate after a price increase. Furthermore, adjusted pharmacy charges were lower for children receiving intravenous acetaminophen, possibly secondary to a concurrent decrease in postoperative opioid use. These findings suggest intravenous acetaminophen may be more broadly used regardless of perceived costs to minimize opioid use after surgery.

Children's Opioid Use at Home After Laparoscopic Appendectomy

BACKGROUND

To combat the opioid epidemic, prescribers need accurate information about pediatric home opioid requirements to manage acute pain after surgery. Current opioid use estimates come from retrospective surveys; this study used medication adherence technology (eCAP) to track home opioid use.

PURPOSE

To describe children's pain treatment at home after laparoscopic appendectomy, and to compare self-reported opioid analgesic use to eCAP data and counts of returned pills.

DESIGN

Prospective exploratory and descriptive study METHODS: A convenience sample of 96 patients, 10-17 years of age, from a single urban nonprofit children's hospital consented to self-report pain treatment in 14-day diaries and use eCAP to monitor prescribed opioid use at home after laparoscopic appendectomy.

RESULTS

Patients were prescribed 5-45 opioid-containing pills (mean ± standard deviation 15 ± 7.2). Of 749 opioid-containing pills prescribed to 49 patients who returned data, 689 pills were dispensed, 167.5 were used for the reason prescribed, 488 were returned to families for disposal, and 53.5 were missing. The majority of the 49 patients were opioid naïve (72%), Caucasian (64%), and male (56%), with a mean age of 14 years. Patients used 6.6 ± 6.3 opioid-containing pills by pill count and 5.6 ± 5.1 by self-report, a significant difference (p = .004). Unreported eCAP-enabled pill bottle openings typically occurred on weekends.

CONCLUSION

Medication adherence technology (eCAP) is a more rigorous method than self-report to estimate opioid needs and detect early opioid misuse. Additional rigorously designed studies of postoperative opioid use are needed to guide opioid prescribing.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

Opioid Prescription Patterns for Children Following Laparoscopic Appendectomy

OBJECTIVE

To describe variability in and consequences of opioid prescriptions following pediatric laparoscopic appendectomy.

SUMMARY BACKGROUND DATA

Postoperative opioid prescribing patterns may contribute to persistent opioid use in both adults and children.

METHODS

We included children <18 years enrolled as dependents in the Military Health System Data Repository who underwent uncomplicated laparoscopic appendectomy (2006-2014). For the primary outcome of days of opioids prescribed, we evaluated associations with discharging service, standardized to the distribution of baseline covariates. Secondary outcomes included refill, Emergency Department (ED) visit for constipation, and ED visit for pain.

RESULTS

Among 6732 children, 68% were prescribed opioids (range = 1-65 d, median = 4 d, IQR = 3-5 d). Patients discharged by general surgery services were prescribed 1.23 (95% CI = 1.06-1.42) excess days of opioids, compared with those discharged by pediatric surgery services. Risk of ED visit for constipation (n = 61, 1%) was increased with opioid prescription [1-3 d, risk ratio (RR) = 2.46, 95% CI = 1.31-5.78; 4-6 d, RR = 1.89, 95% CI = 0.83-4.67; 7-14 d, RR = 3.75, 95% CI = 1.38-9.44; >14 d, RR = 6.27, 95% CI = 1.23-19.68], compared with no opioid prescription. There was similar or increased risk of ED visit for pain (n = 319, 5%) with opioid prescription [1-3 d, RR = 1.00, 95% confidence interval (CI) = 0.74-1.32; 4-6 d, RR = 1.31, 95% CI = 0.99-1.73; 7-14 d, RR = 1.52, 95% CI = 1.00-2.18], compared with no opioid prescription. Likewise, need for refill (n = 157, 3%) was not associated with initial days of opioid prescribed (reference 1-3 d; 4-6 d, RR = 0.96, 95% CI = 0.68-1.35; 7-14 d, RR = 0.91, 95% CI = 0.49-1.46; and >14 d, RR = 1.22, 95% CI = 0.59-2.07).

CONCLUSIONS

There was substantial variation in opioid prescribing patterns. Opioid prescription duration increased risk of ED visits for constipation, but not for pain or refill.

Fewer postoperative opioids are associated with decreased duration of stay for children with perforated appendicitis

BACKGROUND

The impact of postoperative opioid use on outcomes for children with perforated appendicitis is unknown.

METHODS

A retrospective cohort study was performed using the Pediatric Health Information System database from 2005 to 2015. Children 2 to 18 years with perforated appendicitis who underwent an appendectomy were identified. Postoperative day analgesic use was categorized as nonopioid analgesia alone, opioids (with or without nonopioid analgesia), or no analgesics. The impact of postoperative opioid use on postoperative duration of stay and 30-day readmission was evaluated using multivariable mixed-effects regression analysis.

RESULTS

Overall, 47,726 children with perforated appendicitis were identified. On postoperative day 1, 17.7% received nonopioid analgesia alone, 77.6% received opioids, and 4.7% received no analgesics. On adjusted analysis, postoperative day 1 opioid use was associated with a 0.75-day (95% confidence interval: 0.54-0.96) increased postoperative duration of stay. Starting opioids after postoperative day 1 was associated with 2.21 days (95% confidence interval: 1.90-2.51) longer postoperative duration of stay. Among children who received opioids on postoperative day 1, continued use of opioids after postoperative day 1 was associated with a 1.88 day (95% confidence interval: 1.77-1.98) longer postoperative duration of stay. Postoperative day 1 opioid use did not significantly affect 30-day readmission.

CONCLUSION

Early and continued postoperative opioid use is associated with prolonged postoperative duration of stay in children undergoing appendectomy for perforated appendicitis. Minimizing opioid use, even on postoperative day 2, may result in a decreased postoperative duration of stay.

Prescription vs. consumption: Opioid overprescription to children after common surgical procedures

BACKGROUND

In the setting of a national opioid epidemic there are concerns about routine overprescription of opioids postoperatively in both children and adults, which introduces excess opioids into the community.

PURPOSE

We sought to examine current opioid prescribing practices by surgeons and consumption of prescribed opioids by pediatric surgical patients following discharge.

METHODS

Starting in January 2017 we began an emailed survey for all postoperative patients in a 23-hospital system about the opioids they were prescribed and consumed following discharge. They were then asked if their pain was controlled. Responses of pediatric patients (age 10-18) were examined.

FINDINGS

Data from 277 patients were analyzed. After surgical procedures, patients were prescribed significantly more opioids (given in hydrocodone 5 mg equivalents) than they consumed: for appendectomy (median 10 vs. 2) cholecystectomy (12 vs. 5), hernia repair (20 vs. 14), tonsillectomy (30 vs. 17), sinus surgery (30 vs. 5), septoplasty (27 vs. 9.5), knee arthroscopy (30 vs. 12.5), open reduction and internal fixation (ORIF) of the hand and wrist (20 vs. 8.5), and ORIF of the foot and ankle (27 vs. 13.5). The majority (84%) of patients agreed or strongly agreed with the statement that their pain was controlled. Of patients with excess opioids, 64% reported keeping them in their home.

CONCLUSIONS

Providers prescribed more opioid tablets than were used by patients. Despite using fewer tablets, patients reported good pain control. Current prescribing practices contribute to excess opioids in the community and represent an opportunity to alter the current epidemic.

LEVEL OF EVIDENCE

III.

Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients

BACKGROUND

Opioid misuse is a public health crisis in the United States. This study aimed to evaluate the discharge opioid prescription practices for pediatric simple appendectomy patients.

METHODS

A retrospective review of pediatric appendectomy patients at a tertiary children's hospital was conducted from October 2016 to January 2018. Only patients with simple appendicitis were included. Written opioid prescriptions were found in the electronic medical record (EMR) or through a statewide prescription monitoring database. All dosing data were converted to oral morphine equivalents (OMEs). Analysis of variance and logistic regression were used.

RESULTS

During the study, 590 patients underwent appendectomy, of which 371 (62.9%) were diagnosed as having simple acute appendicitis. The majority of patients were prescribed an opioid analgesic (62.5%). Demographics were similar between those who received opioids and those who did not. The OME prescribed per day (range 0.2 to 3.4 mg/kg/day) was highly variable as was duration of prescription (1 to 30 days). Odds of emergency department visit were 3.3 times higher (95% CI 1.3-8.2) in those who received opioids.

CONCLUSION

Postdischarge prescription practices for pediatric appendectomy are highly variable. Two-thirds of patients who received narcotics had a higher rate of complications. Greater scrutiny is required to optimize opioid stewardship.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Effect of a Scenario-tailored Opioid Messaging Program on Parents' Risk Perceptions and Opioid Decision-making

OBJECTIVES

Poor parental understanding of prescription opioid risks is associated with potentially dangerous decisions that can contribute to adverse drug events (ADE) in children and adolescents. This study examined whether an interactive Scenario-tailored Opioid Messaging Program (STOMP) would (1) enhance opioid risk perceptions and (2) improve the safety of parents' decision-making.

MATERIALS AND METHODS

In total, 546 parents were randomized to receive the STOMP versus control information and 516 completed the program. A baseline survey assessed parents' opioid risk knowledge, perceptions, and preferences for pain relief versus risk avoidance (Pain Relief Preference). Parents then made hypothetical decisions to give or withhold a prescribed opioid for high-risk (excessive sedation) and low-risk (no ADE) scenarios. The STOMP provided immediate feedback with specific risk and guidance information; the control condition provided general information. We reassessed knowledge, perceptions, and decision-making up to 3 days thereafter.

RESULTS

Following the intervention, the STOMP group became more risk avoidant (Pain Relief Preference, mean difference -1.27 [95% confidence interval, -0.8 to -1.75]; P<0.001) and gained higher perceptions of the critical risk, excessive sedation (+0.56 [0.27 to 0.85]; P<0.001). STOMP parents were less likely than controls to give a prescribed opioid in the high-risk situation (odds ratio, -0.14 [-0.24 to -0.05]; P=0.006) but similarly likely to give an opioid for the no ADE situation (P=0.192).

DISCUSSION

The STOMP intervention enhanced risk perceptions, shifted preferences toward opioid risk avoidance, and led to better decisions regarding when to give or withhold an opioid for pain management. Scenario-tailored feedback may be an effective method to improve pain management while minimizing opioid risks.

Association Between Acute Pain and Hemodynamic Parameters in a Postoperative Surgical Intensive Care Unit

I conducted a prospective repeated-measure study in the general surgery intensive care unit to investigate the associations among acute postoperative pain, analgesic therapy, and hemodynamic parameters. I selected 33 patients and recorded 84 episodes of pain. I measured intensity of pain and hemodynamic parameters after patients were transferred from the postanesthesia care unit to the general surgery intensive care unit, immediately before analgesic therapy and at 15, 30, and 45 minutes after analgesic therapy. Acute pain increased systolic (SBP), diastolic (DBP), and mean arterial blood pressure (MAP); pulse rate (PR); and arterial oxygen saturation. Fifteen minutes after analgesic therapy, SBP and PR decreased, and DBP, MAP, and oxygen saturation increased. Thirty minutes after therapy, SBP, MAP, and PR decreased, and DBP and oxygen saturation increased. Forty-five minutes after therapy, SBP, MAP, and PR decreased, and DBP and oxygen saturation increased. I saw no significant hemodynamic parameter changes during postoperative episodes of pain.

Safety of perioperative ketorolac administration in pediatric appendectomy

BACKGROUND

Recent studies in adults undergoing gastrointestinal surgeries show an increased rate of complications with the use of ketorolac. This calls into question the safety of ketorolac in certain procedures. We sought to evaluate the impact of perioperative ketorolac administration on outcomes in pediatric appendectomy.

METHODS

The Pediatric Health Information System database was queried for patients aged 5-17 y with a primary diagnosis of appendicitis and a primary procedure of appendectomy during the period 2010-2014. Patients with procedures suggesting incidental appendectomy, those records with data quality issues, deaths, and extracorporeal membrane oxygenation were excluded. Variables recorded included age, sex, race, ethnicity, discharge year, complex chronic conditions, geographic region, intensive care unit admission, mechanical ventilation, and whether appendicitis was coded as complicated. The exposure variable was ketorolac administration on the day of or day after operation. The primary outcomes of interest were any surgical complications during the initial encounter, postoperative length of stay (LOS), total cost for the initial visit, any readmission to ambulatory, observation, or inpatient status within 30 d, and readmission with a diagnosis of peritoneal abscess or other postoperative infection or with transabdominal drainage performed.

RESULTS

A total of 78,926 patients were included in the analysis cohort. Mean age was 11.4 y (standard deviation 3.3 y), the majority were males (61%), White (70%), and non-Hispanic (65%). Few had a complex chronic condition (3%) or required mechanical ventilation (2%) or an intensive care unit admission (1%). Patients with complicated appendicitis comprised 28% of the cohort. Most (73%) received ketorolac on postoperative day 0-1; those with complicated appendicitis were more likely to receive ketorolac. In all, 2.6% of the cohort had a surgical complication during the index visit, 4.3% were readmitted within 30 d, and 2% had a postoperative infection or transabdominal drainage (1% in the uncomplicated group and 5% in the complicated group). Median postoperative LOS was 1 d and mean cost was $9811 ± $9509. On bivariate analysis, ketorolac administration was associated with a decrease in same-visit surgical complications (P = 0.004) and cost ($459 decrease, P < 0.001) but was not associated with readmission, postoperative LOS, or postoperative infection. On multivariate analysis, ketorolac administration was associated with a significant decrease in any complication (adjusted odds ratio 0.89, 95% confidence interval 0.80-0.99) and cost (analysis of variance P < 0.001) but was not associated with readmission, postoperative LOS, or postoperative infection.

CONCLUSIONS

Based on a large, contemporary data set from children's hospitals, ketorolac administration in the immediate postoperative period after appendectomy for appendicitis is common and was not associated with an increase in postoperative LOS, postoperative infection, or any-cause 30-d readmission. Ketorolac was, however, independently associated with a lower overall rate of postoperative complications and cost in this population.

A Single Perioperative Injection of Dexamethasone Decreases Nausea, Vomiting, and Pain after Laparoscopic Donor Nephrectomy

Background. A single dose of perioperative dexamethasone (8–10 mg) reportedly decreases postoperative nausea, vomiting, and pain but has not been widely used in laparoscopic donor nephrectomy (LDN). Methods. We performed a retrospective cohort study of living donors who underwent LDN between 2013 and 2015. Donors who received a lower dose (4–6 mg)  (n = 70) or a higher dose (8–14 mg) of dexamethasone (n = 100) were compared with 111 donors who did not receive dexamethasone (control). Outcomes and incidence of postoperative nausea, vomiting, and pain within 24 h after LDN were compared before and after propensity-score matching. Results. The higher dose of dexamethasone reduced postoperative nausea and vomiting incidences by 28% (P = 0.010) compared to control, but the lower dose did not. Total opioid use was 29% lower in donors who received the higher dose than in control (P = 0.004). The higher dose was identified as an independent factor for preventing postoperative nausea and vomiting. Postoperative complication rates and hospital stays did not differ between the groups. After propensity-score matching, the results were the same as for the unmatched analysis. Conclusion. A single perioperative injection of 8–14 mg dexamethasone decreases antiemetic and narcotic requirements in the first 24 h, with no increase in surgical complications.