Postoperative pain and analgesia administration in children after urological outpatient procedures

Opioid prescribing patterns and the effect of chronic kidney disease in pediatric urology population: A retrospective cohort analysis

BACKGROUND

Significant efforts have been undertaken to decrease opioid prescribing, but there is little research into patient-specific factors presenting as barriers in the pediatric surgical population. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be a safe and effective alternative to opioids for pain control, however, concerns about their impact on renal function limit their use in patients with chronic kidney disease (CKD). Data is limited on the interplay of CKD on opioid prescribing.

OBJECTIVE

We hypothesized that opioid reduction efforts were successful, but patients with CKD would be more likely to receive an opioid prescription than those without CKD.

STUDY DESIGN

A retrospective cohort study of patients ≤18 years old undergoing urologic surgery from 2014 to 2022 was performed. Patients were stratified by CKD diagnosis, determined by chart diagnosis and confirmed with CKiD U25 eGFR calculations, excluding those with normal eGFR or Stage 1 CKD. Patients without a documented CKD diagnosis and without preoperative renal function testing were presumed not to have CKD. Patients were propensity matched using the optimal full algorithm across 12 different variables. Outcomes of interest were discharge opioid prescriptions, non-opioid analgesic prescriptions, and unscheduled healthcare encounters (urology clinic visits within 5 days, emergency department visits, readmissions, or reoperations within 30 days).

RESULTS

10,604 patients were included. 603 patients (5.7 %) had a pre-existing CKD diagnosis; the majority were CKD stage 2 (77.8 %, 466 patients). A significant decrease in discharge opioid prescriptions was seen for patients with and without CKD. Patients with CKD had greater opioid exposure prior to surgery (17.2 %, 104 versus 2.8 %, 280, p = 0.04). Those with CKD were equally likely to be prescribed NSAIDs (p = 0.36) and opioids (p = 0.09) at discharge. Patients with CKD were more likely to present to the emergency department (ED) within 30 days of surgery (17.6 % versus 7.9 %, p = 0.007).

DISCUSSION

Similar proportions of patients with and without CKD received an opioid prescription at discharge. Patients with CKD were more likely to be exposed to opioids in-hospital earlier than non-CKD counterparts.

CONCLUSIONS

Multiple interventions and a dedicated postoperative opioid reduction protocol worked well, even in patients with CKD where there is concern about safely receiving NSAIDs. All-cause unplanned healthcare encounters did not differ significantly within groups with introduction of these interventions.

National Postoperative Opioid Prescribing Rates Following Pediatric Urology Procedures Before and After the 2018 American Academy of Pediatrics Challenge to Reduce Opioid Prescribing: A Claims Database Analysis

OBJECTIVE

To evaluate trends in opioid prescribing rates following pediatric urologic surgery.

METHODS

We queried the TriNetX Research database for patients under age 18 who underwent one of seven common pediatric urology procedures. We identified the proportion of patients that received an oral opioid prescription within 5days of surgery. The primary analysis evaluated the trend in postoperative opioid prescriptions using 3-month intervals from January 2010 to December 2022. We performed an interrupted time series analysis assessing trends in opioid prescribing patterns both before and after the American Academy of Pediatrics challenge.

RESULTS

Of the 81,644 pediatric urology procedures, 29,595 (36.2%) received a postoperative opioid prescription, including 29.8% of circumcisions, 25.8% of hydrocelectomies, 39.6% of hypospadias repairs, 42.7% of pyeloplasties, 42.8% of ureteral reimplants. For all procedures we observed rising rates of opioid prescribing, increasing by 0.9% per 3-month interval prior to the challenge statement release from 2010 to 2018. We observed an overall significant decrease in opioid prescribing by 2.2% per 3-month interval following the challenge statement release. Additionally, since 2018, there was a significant decrease in opioid prescribing in all of the race, ethnicity, and age cohorts.

CONCLUSION

Opioid prescribing following pediatric urology procedures has sharply decreased following the 2018 American Academy of Pediatrics challenge statement which underscores the value of cross-specialty quality improvement initiatives. Nonetheless, opioid prescribing remains high with potential racial or age disparities that warrant further investigation.

The diversity of hypospadias management in North America: a survey of pediatric urologists

PURPOSE

To determine trends in hypospadias management, including surgical techniques and perioperative care, by pediatric urologists in North America.

METHODS

An anonymous online survey was devised to assess approaches to hypospadias repair and management, including anesthetic considerations, catheter placement, choice of dressing, and postoperative antibiotic treatment. The survey was sent to all practicing members of the Societies for Pediatric Urology.

RESULTS

The survey was completed by 133 (34.5%) respondents. Hypospadias repair was overwhelmingly recommended between ages 6-12 months (89.5%). A local or regional anesthetic block (caudal, penile, pudendal, spinal) is performed nearly universally (96.2%). The majority of surgeons perform distal repairs outpatient (70.7%), while fewer perform outpatient staged repairs (47.4%) or redo surgery (33.8%). Nearly all respondents preferred either VicrylTM/DexonTM (50.4%) or MaxonTM/PDSTM (48.1%) for urethroplasty. All but one respondent leaves a stent for midshaft to proximal repairs whereas stenting for glanular repairs was split with 53.4% leaving a stent. Most surgeons (60.9-70.9%) prescribe postoperative antibiotics regardless of severity and the majority (72.9%) prescribe narcotics for analgesia.

CONCLUSIONS

Approaches to hypospadias repair are extremely varied such that there is a lack of consensus among pediatric urologists regarding most aspects of hypospadias management. Investigations comparing hypospadias practice patterns are necessary to develop a standard of care for this complex pediatric urologic entity.

Safety and Efficacy of Long-Acting Liposomal Bupivacaine Plus Bupivacaine Hydrochloride for Dorsal Penile Block During Ambulatory Pediatric Urologic Surgery

This study evaluates the tolerability and efficacy of preoperative dorsal penile nerve block with Exparel plus bupivacaine hydrochloride in children>6 years old undergoing ambulatory urologic surgery. We demonstrate that the drug combination is well-tolerated, with appropriate analgesic efficacy in the recovery room as well as at 48-hour and 10-14 day follow-up periods. These preliminary data justify the need to perform a prospective, randomized trial comparing Exparel plus bupivacaine hydrochloride to other common local anesthetic regimens used in pediatric urologic surgery.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

INTRODUCTION & OBJECTIVE

The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events.

METHODS

A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed.

RESULTS

1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter.

DISCUSSION

The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution.

CONCLUSIONS

The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Opioids and pediatric urology: A prospective study evaluating prescribing habits and patient postoperative pain and narcotic utilization

INTRODUCTION

Few pediatric urologists believe patients require a majority of the doses of opioids prescribed to them postoperatively. Seeking a better understanding of postoperative pain and analgesia in pediatric urology patients may help reduce opioid over prescription while still adequately managing postoperative pain.

OBJECTIVE

We sought to better understand: 1) the postoperative pain levels experienced by pediatric urology patients, 2) the factors that correlate with postoperative pain and number of opioids consumed following pediatric urologic procedures, and 3) the patients who do not require opioids after surgery.

STUDY DESIGN

Pediatric patients undergoing circumcision, inguinal hernia repair, orchidopexy, or hypospadias repair were eligible to participate. Patients were enrolled in the prospective cohort on the day of the procedure. For each of the first 7 postoperative days, patients' parents completed a text message-based questionnaire, quantifying their child's pain level and the doses of pain medication the child consumed.

RESULTS

165 participants were enrolled. 57 patients underwent circumcision, 54 underwent orchiopexy, 32 underwent hypospadias repair, and 22 underwent inguinal hernia repair. For all procedure types, pain scores (p < 0.01) and doses of oxycodone consumed were highest on postoperative day one and steadily declined thereafter. Overall, average 7-day pain score (2.02; 0.86-5.14) and doses of narcotics consumed (3.50; 0-5) were low. Patients in each surgical subgroup were prescribed narcotics in excess of what was consumed. There was an average excess of 10.9 doses (0-39.0) for hypospadias repair, 8.6 (1.0-30.0) for circumcision, 9.0 (3.0-21.0) for inguinal hernia repair, and 6.1 (0-22.0) for orchiopexy.

DISCUSSION

Overall, reported pain scores and number of narcotics consumed were low regardless of surgery type. Opioids were overprescribed regardless of surgery type.

CONCLUSIONS

Our findings indicate that level of pain and opioid use varies by procedure type, but that number of narcotics prescribed greatly exceeds number needed.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis

INTRODUCTION AND OBJECTIVE

Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events.

STUDY DESIGN

All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated.

RESULTS

438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04).

DISCUSSION

The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries.

CONCLUSIONS

Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

A Prospective Analysis of Opioid Use Following Outpatient Pediatric Urologic Surgery

OBJECTIVES

To examine our outpatient urologic surgery cohort for trends in opioid consumption, given the lack of consensus on opioid prescription after outpatient urologic procedures. While opioids have a role in multimodal post-operative analgesia, there is emerging data that they may not be routinely required after pediatric surgery.

METHODS

Data on opioid use was prospectively collected over 16 months via post-operative telephone calls to caregivers of patients undergoing outpatient urologic surgery. Patient characteristics, surgery type, analgesia, and opioid prescription and usage information were recorded. Patients were prescribed as needed oxycodone and scheduled acetaminophen and ibuprofen for 48 hours, then as needed. The relationships between the log mean of the number of opioid doses used and age, type of surgery, race, and opioid prescription were modelled using negative binomial regression with robust standard errors.

RESULTS

265 patients were included. They were predominantly male with median age 2.6 years. The mean number of opioid doses prescribed per patient was 5.8 (SD 2.8, range 3-20). Over half of patients used no opioids, and mean opioid use was one dose. Those prescribed >5 doses took on average 3.4 times more doses compared to those prescribed >5 (p=0.0003), and this was the only factor significantly associated with amount of opioid used.

CONCLUSIONS

Our findings suggest that opioids are over-prescribed after outpatient pediatric urologic surgery, with 95% of patients having leftover medication and 54% not using any opioids at all. While opioid requirements were low across all sub-cohorts, patients who were prescribed more opioid doses used significantly more doses.

Children undergoing outpatient complex penile surgery and hypospadias repair may not require opioid analgesics

BACKGROUND/PURPOSE

Pain control is important after penile surgery, and opioid use should be minimized as able. We sought to describe our experience performing complex penile surgeries with vs without post-operative opioids.

METHODS

A retrospective review of penile surgeries, including 3998 between 2009 and 2019. We identified patients <8 years who underwent outpatient penile surgery requiring either penile degloving or hypospadias repair. Patients who were or were not prescribed opioids were matched 1:1 by age and type of penile surgery. Primary outcomes of interest were pain-related encounters, delayed opioid prescription, and predictors of pain.

RESULTS

200 children were identified, 100 per group, with mean age 1.3 ± 0.8 years. 48% were penile degloving procedures, 31% hypospadias repairs with catheters, and the remaining 21% hypospadias repairs without catheters. Perioperative features were comparable between groups(p > 0.05). 59% of patients without opioids had an impromptu post-operative encounter vs 41%, and 20% had an associated pain complaint vs 9%(p = 0.026). Two patients in both groups received delayed opioid prescription(p = 1.00). The presence of a catheter (OR 2.9) and no opioid prescription (OR 2.6) were independent predictors for pain complaint.

CONCLUSIONS

Patients discharged without an opioid were more likely to contact a provider postoperatively and were more likely to endorse pain complaint (number needed to treat: 9).

Follow up of pain reported by children undergoing outpatient surgery using a smartphone application: AlgoDARPEF multicenter descriptive prospective study

ABSTRACT

In pediatric patients, pain remains the most common complaint after surgery. This French multicenter epidemiological study (AlgoDARPEF) aimed to evaluate the use of a smartphone application (App) to assess the duration and severity of pain experienced by children undergoing outpatient surgery. Children below 18 years of age scheduled for an elective outpatient procedure in one of the participating centers were eligible. Parents were invited to provide daily information for 10 days regarding their child's pain and comfort via a smartphone App using the Parents' Postoperative Pain Measure - Short Form (PPPM-SF). Children over 6 years old could also provide self-assessments of pain using a Numerical Rating Scale (NRS-11). Data regarding pain medication, preoperative anxiety, postoperative nausea and vomiting, and parent satisfaction were also analyzed. Repeated-measures analyses of variance (ANOVAs) were used to compare the self- and hetero-assessments of pain. Eleven centers participated in the study, and 1,573 patients were recruited. Forty-nine percent of parents (n = 772) actually used the App at least once. In all surgeries, the average pain rating on the PPPM-SF scale did not exceed 3/10 throughout the follow-up period, as well as for the four main surgical specialties. Age, visceral surgery, and preoperative anxiety ≥ 4/10 were identified as independent risk factors for experiencing at least one episode of pain ≥ 4/10 during the first 48 postoperative hours. While these findings indicated that postoperative pain management appears to be satisfactory in the families who used the App, some improvements in anxiety management are suggested. This study shows that inviting parents to use a smartphone App to assess and report the quality of postoperative management in pediatric patients, provides useful information. A continuous report is possible, regarding pain and adverse events, over a postoperative ten days period, by a self-reporting or a parent's contribution. Future studies should investigate the ability of live data collection using an App to ensure fast, efficient interactions between patients and physicians.

Postoperative pediatric urology opioid prescriptions at a tertiary academic medical center

INTRODUCTION

Opioid abuse is a public health crisis, and often this starts postoperatively. Limited data are available on pediatric urology practitioners. We examined the likelihood of postoperative opioid prescriptions in our practice.

OBJECTIVE

To determine rates of post-operative opioid prescriptions following urologic surgery in a tertiary academic center, and to identify what factors are related to opioid prescriptions.

STUDY DESIGN

We retrospectively reviewed opioid prescriptions for children who underwent a procedure in the operating room between 1/1/17 and 12/31/19. We collected data on gender, age, surgeon, procedure, length of stay, ethnicity, race, and whether opioids had been used pre-operatively. We grouped procedures into five categories: minor penile surgery, cystoscopic procedures, scrotal surgery, hypospadias repair/penoplasty, and pyeloplasty/ureteral reimplant. Multivariable logistic regression was used to determine odds ratios (OR) of opioid prescriptions.

RESULTS

1102 procedures had data available. 14.2% (n = 156) received opioid prescriptions. Using minor penile surgery as a baseline, scrotal surgery increased the odds of an opioid by 1.42; hypospadias, pyeloplasty, and other procedures reduced the odds by 0.53, 0.55, and 0.54, respectively (no patient received opioids for endoscopic procedures). Ambulatory procedures had a lower rate of opioids (0.40), and age was a major factor, with the odds of a prescription increasing by a factor of 1.45 per year of age. Since January of 2017, the opioid prescription rate has decreased from 18% in 2017 to 7.7% in 2019.

DISCUSSION

We found a relatively low rate of opioid prescribing in our pediatric patients, mostly in older children undergoing penile and scrotal procedures. Our rate was comparable to several other institutions that have examined their prescription rates in surgical patients. Heightened awareness has resulted in decreased opioid usage over time (to 6.9%). Limitations included the retrospective nature of our study, which did not allow us to assess whether pain control was adequate or if the opioids prescribed were used by patients. Opioids are rarely needed in pediatric patients.

CONCLUSIONS

85.8% of post-operative pediatric urology patients at our institution were not provided with prescription opioids. Factors associated with a higher likelihood of receiving a prescription were increasing age and scrotal surgery.

Postoperative opioid-free ureteroscopy discharge: A quality initiative pilot protocol

BACKGROUND

Opioids are commonly prescribed after ureteroscopy. With an increasing adoption of ureteroscopy for management of urolithiasis, this subset of patients is at high risk for opioid dependence. We sought to pilot an opioid-free discharge protocol for patients undergoing ureteroscopy for urolithiasis.

MATERIALS AND METHODS

A prospective cohort study was performed of all patients undergoing ureteroscopy for urolithiasis and compared them to a historical control group. An opioid-free discharge protocol was initiated targeting all areas of surgical care from June 20th, 2019 to September 20th, 2019 as part of an institutional quality improvement initiative. Demographic and surgical data were collected as were morphine equivalent doses (MEDs) prescribed at discharge, postoperative measures including phone calls, clinic visits, and emergency room visits for pain.

RESULTS

Between October 1st, 2017 and February 1st, 2018, a total of 54 patients who underwent ureteroscopy were identified and comprised the historical control cohort while 54 prospective patients met the inclusion criteria since institution of the quality improvement initiative. There were no statistically significant differences in baseline patient demographics or surgical characteristics between the 2 patient groups. Total 37% of the intervention group had a preexisting opioid prescription versus 42.6% of the control group with no difference in preoperative MED (p = 0.55). The intervention group had a mean MED of 12.03 at discharge versus 110.5 in the control cohort (p ≤ 0.001). At discharge 3.7% of the intervention group received an opioid prescription versus 88.9% of the control group (p < 0.001). Overall, there was no difference in postoperative pain related phone calls (p = 1.0) or emergency room visits (p = 1.0).

CONCLUSIONS

An opioid-free discharge protocol can dramatically reduce opioid prescription at discharge following ureteroscopy for urinary calculi without affecting postoperative measures such as phone calls, clinic visits, or subsequent prescriptions.

The impact of patient age and procedure type on postoperative opioid use following ambulatory pediatric urologic procedures

PURPOSE

The aim of this study is to determine whether patient age and procedure type are associated with duration of opioid use in pediatric patients undergoing ambulatory urologic procedures.

METHODS

We retrospectively reviewed pediatric patients who underwent outpatient urologic procedures from 2013 to 2017. At postoperative visits, parents reported the number of days their child took opioid pain medication. Factors associated with duration of opioid use were evaluated using negative binomial regression models.

RESULTS

805 patients were included: 320 infants (39.8%), 430 children (53.4%), and 55 adolescents (6.8%). Overall mean length of opioid use was 1.7 (± 2.6) days. On average, infants used opioids for the shortest duration: 1.5 (± 2.3) days, followed by children: 1.7 (± 2.5) days, and adolescents: 3.1 (± 4.6) days. In adjusted models, adolescents used opioids for 85.2% longer (95% CI 13.1-161.8%; p < 0.001) than children and infants used opioids for 19.4% shorter duration (95% CI 0.4-34.7%; p = 0.05) than children. Each 1-year increase in age was associated with 6.1% increased duration of opioid use (95% CI 3.9-8.5%; p < 0.0001). Patients who underwent circumcision, hypospadias repair, and penile reconstruction took opioids for 75.9% (95% CI 42.6-117.1%; p < 0.001), 144.2% (95% CI 76.4-238.0%; p < 0.001), and 126.7% (95% CI 48.8-245.3%; p < 0.001) longer respectively than patients who underwent inguinal procedures.

CONCLUSIONS

Increasing age, circumcision, hypospadias repair, and penile reconstruction are associated with increased duration of opioid use.

Effects of Three Different Doses of Dexmedetomidine and Ropivacaine on Analgesia and the Stress Response in Hypospadias Surgery: A Randomized Trial

Objective: This study was designed to investigate the effects of three different doses of dexmedetomidine in caudal blocks on postoperative stress and pain after pediatric urethroplasty. Methods: A total of 160 children who underwent elective urethroplasty were enrolled in this study. They were randomly divided into four groups: groups D1, D2, and D3, in which the patients were injected respectively with a mixed solution of 1, 1.5, or 2 μg kg^-1 of dexmedetomidine and 0.25% ropivacaine into the sacral canal; and group R, in which the patients were injected with 0.25% ropivacaine into the sacral canal. Cortisol and interleukin-6 (IL-6) levels within 24 h, the incidence of adverse events in the circulatory system during surgery, onset time of the caudal block, duration of postoperative analgesia, the incidence of agitation during recovery, and other anesthetic adverse reactions were observed and recorded. Results: Compared with group R, cortisol and IL-6 levels in groups D1, D2, and D3 decreased within 24 h after the operation (T2-T6). The incidence of intraoperative hypertension, tachycardia, and shivering during the recovery period decreased, the onset time of the caudal block decreased, and the duration of postoperative analgesia increased (p < 0.01). Compared with group D1, the duration of postoperative analgesia increased in groups D2 and D3 (p < 0.01). Compared with groups D1 and D2, the incidence of excessive sedation and bradycardia in group D3 increased (p < 0.05). Conclusion: The administration of 1.5 μg kg^-1 of dexmedetomidine appears to be most feasible in accelerating the onset of the caudal block, reducing stress and inflammation, stabilizing the circulation, increasing the duration of postoperative analgesia, and reducing anesthesia- and operation-associated adverse events.

Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery

BACKGROUND

Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain.

OBJECTIVES

As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures.

METHODS

We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure).

RESULTS

Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p < 0.01). There was significant variation in opioid prescribing patterns by provider (p < 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries.

CONCLUSIONS

Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.

Parental Assessment of Pain Control Following Pediatric Circumcision: Do Opioids Make a Difference?

OBJECTIVE

To determine whether a postoperative prescription for opioids affects parental assessment of pain control following pediatric circumcision.

METHODS

This postoperative survey assessed the parental assessment of pain control in 199 patients, ages<18 years undergoing circumcision. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 2018 to January 2020. Postoperative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for postoperative analgesia based on the surgical preference. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric circumcision as poor or inadequate based on the postoperative analgesic regimen.

RESULTS

Of the 502 surveys sent, the response rate was 40% (199/502) of those who received the survey email, and 64% (199/308) for those who opened the email. Between the opioid and nonopioid groups, there was no difference in, race/ethnicity (Caucasian; 28% vs 37%; P = .43) or insurance status (insured; 51% vs 45%; P = .44). The proportion of parents who rated their child's pain as poor or inadequately controlled following circumcision was relatively rare:5.5% and 1.1% in the nonopioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following circumcision were 61% and 53% in the nonopioids and opioid groups, respectively.

CONCLUSION

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

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.

Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative

INTRODUCTION

Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms.

OBJECTIVE

To measure the efficacy of a quality improvement initiative aimed to reduce post-operative opioids for pain management in a large pediatric surgical cohort.

STUDY DESIGN

Patients undergoing ambulatory pediatric urologic surgery at a tertiary children's hospital between July 2016 to June 2019 were analyzed. Structured physician peer-to-peer comparisons, electronic health record redesign and a standardized pain management protocol were implemented. Rate of opioid prescriptions per month, utilization of non-opioid analgesia, unplanned encounters in the emergency department and/or office during implementation were aggregated. Opioid doses and prescribed opioid days before and after protocol implementation were analyzed. A subcohort, from October-December 2018 was administered a patient-reported outcome questionnaire focused on pain management and return to baseline activity.

RESULTS

A total of 6684 consecutive outpatient urologic cases were included (median age = 3.3 years old (IQR 0.9-9.2) and 92.3% male). Comparing 6 months pre-intervention and the post-intervention latest 6 month intervals, opioid prescription rate decreased from 43.9% to 2.3% (p < 0.001). Additionally, non-opioid analgesia with ketorolac increased from 30.7% to 50.6% (p < 0.001). Concurrently, no differences in the rate of office visits within 5 days, overall ED visits, ED visits for pain or for bleeding within 30 days after implementation were identified. Between October to December 2018, 373 cases were performed and a Patient-Reported Outcome (PRO) questionnaire was completed for 128 of those patients (34%). Families reported a low patient pain score of 3.7 (SD 2.4) and a rapid postoperative recovery time of a median 2 (IQR 1-4) days to full resumption of pre-operative level of activity. High satisfaction with opioid reduction in post-operative pain management was reported (median score of 10 (IQR 8-10)).

CONCLUSION

Opioid prescriptions and utilization may be minimized without increasing unplanned encounters or adversely affecting quality of life. The QI framework utilized in this process can be implemented to reduce opioid exposure in other surgical patient populations.

Structured opioid-free protocol following outpatient hypospadias repair - A prospective SQUIRE 2.0-compliant quality improvement initiative

BACKGROUND

Prescription opioids have been extensively to manage postoperative pain in children. A growing body of evidence from the adult literature, suggests however, that healthcare providers may be prescribing far more opioids than required, with some studies demonstrating equivalent post-operative pain and clinical outcomes with their omission.

OBJECTIVE

The objectives of this prospective study were to assess the current heterogeneity of practice in post-operative opioids prescription following day case hypospadias surgery, to establish a streamlined discharge protocol, and to reduce the use of post-operative opioid prescription by 30% within a 4 month period through the use of systemic forcing functions and education.

STUDY DESIGN

This prospective study was approved by the Quality Improvement (QI) sub-committee of the hospital's Research and Ethics Board (REB) and was compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines. Recruited parents (n = 84) were contacted for telephone interview following a combined intervention of education and omission of post-operative opioids from the discharge prescription. A mixture of qualitative and quantitative techniques were employed including an initial process analysis to assess current opioid use, the creation of balancing measures, and the creation of Plan-Do-Study-Act cycles. Age, procedure, post-operative outcomes and opioid prescription data were recorded over a period of 6 months in 2019.

RESULTS

Initial measures in our process analysis demonstrated significant institutional practice variation amongst our 84 post-intervention patients. Our process and fidelity measures confirmed 100% information provision. Following the point of intervention, there was a significant and sustained drop in opioid prescription, with an absolute reduction of 35%, and a relative reduction of 56%. There was no significant difference in patient age, pain scores, or outcomes pre- and post-intervention.

DISCUSSION

We have shown in this study that a sustainable decrease in post-operative opioid prescriptions following hypospadias surgery is possible. We managed to achieve a relative reduction 56% which is comparable to other specialties, however, did it within a quality improvement framework to ensure fidelity and no adverse balancing measures. We also managed to reduce the number of doses prescribed in those receiving opioids post-intervention at week 9.

CONCLUSION

Our study demonstrates opioids can be safely omitted in hypospadias cohorts without any adverse clinical outcomes or balancing measures. We recommend that opioids be used extremely judiciously in this population in order to minimize exposure in children.

First national survey on opioids prescribing practices of Canadian pediatric surgeons

PURPOSE

Prescription opioid misuse has become a public health concern globally. In Canada, little is known about the national prescription patterns in children. The purpose of the present study was to evaluate the opioid prescribing practices of pediatric surgeons in Canada.

METHODS

Following ethical approval, an electronic questionnaire was administered to all pediatric surgeons currently practicing in Canada. Questions included surgeon practice information, patterns of opioid prescription at discharge based on the type of surgery, type of opioid prescribed, and availability of training for surgeons/families.

RESULTS

Fifty-eight questionnaires were completed (response rate: 84%) by surgeons from 8 out of 8 Canadian provinces with pediatric surgery coverage. 33% of responders prescribed opioids (most commonly morphine) for day surgeries and 73% of Pediatric Surgeons prescribed opioids for major surgeries. Most responders (84%) declared that at their institution there was no formal training for residents/fellows in pain control and opioid prescribing. Similarly, 57% reported no education for families about opioids at discharge.

CONCLUSION

This first national survey on opioid prescribing practices across Canada reveals that opioids were prescribed to pediatric patients following a broad range of minor and major surgical procedures. Moreover, there seems to be a lack of education for surgeons and families about opioid use.

TYPE OF STUDY

Descriptive, cross-sectional, practice survey.

LEVEL OF EVIDENCE

Level 5.

Opioid utilization is minimal after outpatient pediatric urologic surgery

INTRODUCTION

There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution.

MATERIALS AND METHODS

After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use.

RESULTS

Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups.

DISCUSSION AND CONCLUSIONS

Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.

Postoperative pain management for circumcision; Comparison of frequently used methods

Objective

To determine the ideal method for postoperative pain management after circumcision by comparing the most frequently used different methods like; dorsal penile block, caudal epidural block, subcutaneous ring block, intravenous paracetamol and intravenous tramadol HCl.

Methods

Between May 1^st 2015 to May 1^st 2016, 500 children between 2-10 year old were circumcised at the department of pediatric surgery of Istanbul Medipol University Health Care Practice & Research Center Sefakoy Hospital. Five groups were formed according to postoperative analgesia methods which were planned to be compared; Group-I. penile block, Group-II. Caudal epidural block, Group-III. subcutaneous ring block, Group-IV as intravenous paracetamol and Group-V as intravenous tramadol HCl. In order to evaluate the postoperative pain levels of children, Children's Hospital Eastern Ontario Pain Scale (CHEOPS) was filled at 30, 60, 120, 180 minutes after circumcision by a researcher who does not know which method was applied.

Results

No significant difference is found between the groups (p>0.05). In the statistical analysis, no significant difference was found in the effect of analgesia methods on CHEOPS scores between 30, 60, 120 and 180 minutes (p>0.05). In parallel with this result, no significant difference was found in the effect of heart beat rates and respiration rate averages between 30, 60, 120 and 180 minutes (p>0.05).

Conclusion

It has been shown that none of the five method has any superiority in reducing pain after circumcision and that all five methods can be used. However, we think that side effects of regional anesthesia and systemic analgesic applications should not be ignored.

A Societies for Pediatric Urology survey of opioid prescribing practices after ambulatory pediatric urology procedures

INTRODUCTION

Opioid dependence and abuse has been declared a national public health emergency, and overprescribing of opioids after surgery has been identified as a driving factor. To date, opioid prescribing after pediatric urology ambulatory surgery has not been well-described.

OBJECTIVE

The study's objective was to assess pediatric urologists' practices in prescribing opioids for routine ambulatory procedures.

STUDY DESIGN

A 23-question survey was created, including eight case vignettes describing routine procedures (orchiopexy, hydrocele repair, circumcision) across three age groups (8 months, 3 years, 13 years). Multiple choice questions asked about typical opioid type and duration for each case. Respondent attitudes and practice types were also evaluated. The survey was administered through the Societies for Pediatric Urology.

RESULTS

Of the 102 respondents, 48% reported prescribing postoperative opioids for all cases described (Figure 1). Fourteen percent reported prescribing no opioids for all cases. Longer prescription duration was associated with older age (p = 0.003). Acetaminophen-hydrocodone was prescribed most commonly, while a few respondents reported prescribing acetaminophen-codeine. North Central and Southeastern respondents were more likely to prescribe opioids for all cases described (p = 0.003). The majority of respondents work in academic settings and had >10 years in practice. Only 16% believe that their patients take the majority of opioids prescribed, while only 35% provide education to their patients on proper disposal.

DISCUSSION

There is significant variability in reported opioid prescribing practices after ambulatory procedures amongst pediatric urologists. Only 16% of respondents believe that patients take the majority of opioids prescribed, and only 14% reported never prescribing opioids for these procedures. There is an opportunity for guidelines and standardization of care for postoperative analgesia in this patient population. Given that overprescribing can lead to abuse and misuse, further work needs to be done to establish postoperative analgesia needs and to educate providers and families on proper prescribing and disposal.

CONCLUSION

Pediatric urologists report prescribing opioids frequently after routine ambulatory procedures in infants, children, and adolescents despite believing that patients do not take the majority of the prescribed medication.

Pediatric postoperative opioid prescribing and the opioid crisis

PURPOSE OF REVIEW

The purpose of this review is to explore the effects of the opioid crisis on pediatric patients in the postoperative setting and provide recommendations for well-tolerated opioid prescribing practices.

RECENT FINDINGS

Opioid overdoses have increased among all age groups, predominantly related to overprescribing and accessibility of opioids in the home. Adverse risks of prescribed opioids include respiratory depression, gastrointestinal distress, accidental ingestion, intentional misuse, new chronic use, diversion to another user, and overdose. Well-tolerated opioid prescribing practices include multimodal pain management; prescribing guided by patient need; risk assessment for potential misuse; and comprehensive patient and family education on risks, safe storage, and disposal practices. Evolving state laws will affect varying institutional policies; thus, providers must ensure their prescribing practices are current and compliant.

SUMMARY

All age groups have been affected by the opioid crisis, including children and adolescents. When managing postoperative pain, clinicians must balance appropriate pain management with well-tolerated opioid stewardship to minimize harm related to postoperative care.

Opiate Exposure and Predictors of Increased Opiate Use After Ureteroscopy

Objective: Kidney stone formers are at risk for opioid dependence. The aim of this study is to describe opiate exposure and determine predictors of prolonged opiate use among kidney stone formers after surgery. Materials and Methods: A retrospective review was performed among patients who underwent ureteroscopy for upper tract stone disease. Prescription data were ascertained from a statewide prescribing database. Demographic data and surgical factors were collected from the electronic medical record. Predictors of additional postsurgery prescriptions filled within 30 days and persistent opiate use 60 days after ureteroscopy were determined. Results: Among 208 patients, 127 (61%) had received preoperative opiate prescriptions within 30 days before surgery. Overall, 12% (n = 25) of patients required an additional opiate prescription within 30 days after ureteroscopy, and 7% (n = 14) of patients continued to use opiate medications more than 60 days postoperatively. Patients continuing to use opiates long-term were not chronic opiate users. For both outcomes, preoperative opiate exposure, including number of prescriptions, days prescribed, and unique providers had significant associations (all p < 0.05). Additionally, younger age (p = 0.049) was associated with obtaining an additional opiate prescription within 30 days. Lower BMI (p = 0.02) and higher ASA score (p = 0.03) were predictors of continued opiate use more than 60 days after ureteroscopy. Conclusions: The majority of stone formers have had opiate exposure before surgery, often from multiple providers. Approximately 1 in 8 stone formers who undergo ureteroscopy require additional opiate prescriptions within 30 days. A small but significant population receive opiates beyond the immediate postoperative period.

Opioid-prescribing patterns, storage, handling, and disposal in postoperative pediatric urology patients

BACKGROUND

Emerging research on surgeons and the opioid epidemic have focused on the adult population. Consequently, little is known regarding opioid-prescribing practices in the pediatric population. The goal of this study is to examine postoperative opioid-prescribing and consumption patterns, as well as storage and disposal trends for specific pediatric urologic procedures.

STUDY DESIGN

Patients undergoing surgery associated with specified Current Procedural Terminology codes were retrospectively identified, and details regarding opioid medications were obtained through our pharmacy database. Patients' guardians were contacted two weeks postoperatively to determine opioid usage. Opioids were prescribed at a standard dosing of 0.1 mg/kg per dose or the equivalent.

RESULTS

Of the 171 identified patients, 117 patients were successfully contacted, with 67 (39%) completing telephone surveys. The 3 most common pediatric urology procedures were inguinal hernia repair (N = 39), circumcision (N = 27), and cystoscopy (N = 16). Across all procedures, there was an average excess of 9.8 doses prescribed, corresponding to an overprescription rate of 64%. Of the patients prescribed opioids, 41 (62%) had leftover opioid medication two weeks postoperatively. Thirty-two of 41 (78%) patients did not dispose of their leftover medication. Only 13 patients received perioperative counseling on appropriate storage and disposal of opiates.

DISCUSSION

Prescribing practices for an array of pediatric urologic procedures are non-standardized and often generously excessive. We show universal overprescribing for all our reviewed urologic procedures. Sixty-two percent of pediatric urology patients did not use their entire prescribed opiate, leaving a significant pool of medicine within the pediatric family home. Given the low incidence of perioperative education, unsurprisingly a majority of our patients improperly handled and disposed off excess opioid medication.

CONCLUSION

There is general overprescription of postoperative opioids and poor perioperative opioid education in the pediatric urology population.