An audit of postoperative analgesia after pyloromyotomy

The Association Between Opioid Use and Outcomes in Infants Undergoing Pyloromyotomy

PURPOSE

The purpose of this study was to describe the frequency and variation of opioid use across hospitals in infants undergoing pyloromyotomy and to determine the impact of opioid use on postoperative outcomes.

METHODS

A retrospective cohort study (2005-2015) was conducted by using the Pediatric Health Information System (PHIS) database, including infants (aged <6 months) with pyloric stenosis who underwent pyloromyotomy. Infants with significant comorbidities were excluded. Opioid use was classified as a patient receiving at least 1 opioid medication during his or her hospital stay and categorized as preoperative, day of surgery, or postoperative (≥1 day after surgery). Outcomes included prolonged hospital length of stay (LOS; ≥3 days) and readmission within 30 days.

FINDINGS

Overall, 25,724 infants who underwent pyloromyotomy were analyzed. Opioids were administered to 6865 (26.7%) infants, with 1385 (5.4%) receiving opioids postoperatively. In 2015, there was significant variation in frequency of opioid use by hospital, with 0%-81% of infants within an individual hospital receiving opioids (P < 0.001). Infants only receiving opioids on the day of surgery exhibited decreased odds of prolonged hospital LOS (odds ratio [OR], 0.85; 95% CI, 0.78-0.92). Infants who received an opioid on both the day of surgery and postoperatively exhibited increased odds of a prolonged hospital LOS (OR, 1.71; 95% CI, 1.33-2.20). Thirty-day readmission was not associated with opioid use (OR, 1.03; 95% CI, 0.93-1.14).

IMPLICATIONS

There is national variability in opioid use for infants undergoing pyloromyotomy, and postoperative opioid use is associated with prolonged hospital stay. Nonopioid analgesic protocols may warrant future investigation.

Acetaminophen for analgesia following pyloromyotomy: does the route of administration make a difference?

Background

During the perioperative care of infants with hypertrophic pyloric stenosis, an opioid-sparing technique is often advocated due to concerns such as postoperative hypoventilation and apnea. Although the rectal administration of acetaminophen is commonly employed, an intravenous (IV) preparation is also currently available, but only limited data are available regarding IV acetaminophen use for infants undergoing pyloromyotomy. The objective of the current study was to compare the efficacy of IV and rectal acetaminophen for postoperative analgesia in infants undergoing laparoscopic pyloromyotomy.

Methods

A retrospective review of the use of IV and rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy was performed. The efficacy was assessed by evaluating the perioperative need for supplemental analgesic agents, postoperative pain scores, tracheal extubation time, time in the postanesthesia care unit, time to oral feeding, and time to hospital discharge.

Results

The study cohort included 68 patients, of whom 34 patients received IV acetaminophen and 34 received rectal acetaminophen. All patients also received local infiltration of the surgical site with 0.25% bupivacaine. No intraoperative opioids were administered. There was no difference between the two groups with regard to postoperative pain scores, need for supplemental analgesic agents, time in the postanesthesia care unit, or time in the hospital. There was no difference in the number of children who tolerated oral feeds on the day of surgery or in postoperative complications.

Conclusion

Our preliminary data suggest that there is no clinical difference or advantage with the use of IV versus rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy.

Perioperative care of infants with pyloric stenosis

Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.

Ultrasound guided rectus sheath blockade compared to peri-operative local anesthetic infiltration in infants undergoing supraumbilical pyloromyotomy

Background:

Provision of appropriate analgesia for supraumbilical pyloromyotomy in infants is limited by concerns about sensitivity to opioids and other medication groups, due to immature metabolism. Local anesthetic infiltration and ultrasound guided rectus sheath blockade are two techniques commonly employed to provide perioperative analgesia. The aim of this review was to compare the quality of post-operative analgesia afforded by these two techniques.

Materials and Methods:

A retrospective chart analysis of hospital records of all patients who underwent supraumbilical pyloromyotomy at a tertiary pediatric hospital between March 2009 and February 2011. Analysis of the anesthetic technique employed and post-operative acetaminophen requirements were performed. Additional information as to time to first post-operative feed, any complications and time of discharge from the hospital were collected by reviewing the post-operative nursing notes.

Results:

A total of 30 patients underwent supraumbilical pyloromyotomy during this period. A total of 18 received local anesthetic infiltration at the end of the procedure and 12 patients underwent ultrasound guided pre-incisional rectus sheath block for post-operative analgesia. Patients who had post-operative local anesthetic infiltration had a median (range) of 2 (1-3) doses of acetaminophen in the first 24 h. In the group of patients who received a rectus sheath block, the median (range) number of doses of acetaminophen in the first 24 h was also 2 (1-3). There were no differences in time to first feed and time to hospital discharge between the groups. The volume of local anesthetic administered was significantly smaller in the group receiving analgesia via rectus sheath block.

Conclusion:

Local anesthetic infiltration and pre-incisional ultrasound guided rectus sheath block provide similar degrees of post-operative analgesia. There were no differences between the two groups in time for first post-operative feed and time to hospital discharge.

The ins and outs of pyloromyotomy: what we have learned in 35 years

PURPOSE/BACKGROUND

The aim of the study is to evaluate a large series of infantile hypertrophic pyloric stenosis (IHPS) patients treated by one pediatric surgeon focusing on their diagnostic difficulties and complications.

METHODS

From July 1969 to December 2003 (inclusive), the charts of 791 infants with IHPS were retrospectively reviewed.

RESULTS

There were 647 (82%) males and 144 (18%) females; mean age was 38 days, median 51 (range 7 days-10 months). When ultrasonography (US) was routinely used (1990), the age at diagnosis decreased to <40 days. The mean weight before and after routine US was 3.2 kg, median 3 (range 1.5-6). Twenty-five (3.1%) were premature at diagnosis, mean age 49 days, median 56, (range 1-3 months) and mean weight 2.5 kg, median 2.3 (range 1.5-3.2). Eighty-one (10%) had a positive family history. Forty-four (5%) were non-Caucasians. Seventy-five (9 %) had other medical conditions, anomalies and/or associated findings. Sixty (7%) patients had abnormal preoperative electrolytes. Ten (1.2%) pylorics occurred after newborn operations. Of the entire total (791) who were treated, there were 13 (1.7%) not operated on. All operations were done open initially through one of two right upper quadrant incisions, and then through an upper midline incision under general endotracheal anesthesia; 14 (1.7 %) had concomitant procedures. Prophylactic antibiotics (from 1982) decreased the wound infection rate to 3.9%. There were a total of 87 (10%) complications which included 9 (1.1%) intraoperative, (including mistaken diagnoses) 78 (9%) postoperative: 59 (2%) early (<1 month) and 19 (2.4%) late (>1 month). The 13 (1.6%) postoperative transfers (12 from non-pediatric surgeons) had 16 (18%) complications (including 1 death); five (33%) requiring reoperation (4 incomplete, 1 perforation). There were two deaths.

CONCLUSIONS

IHPS should be considered in any vomiting infant. US allows earlier diagnosis. Serious complications are uncommon and avoidable, but recognizable and easily corrected. Higher surgeon volume of pyloromyotomies (>14 per year) is associated with fewer complications.

Impact of spinal anesthesia for open pyloromyotomy on operating room time

PURPOSE

When pyloromyotomy for hypertrophic pyloric stenosis (HPS) is performed under general anesthesia, metabolic abnormalities and fluid deficits coupled with residual anesthetics may increase the risk of postoperative apnea, thereby, prolonging operating room time and delaying extubation. Spinal anesthesia has been found to reduce the rate of postoperative apnea in high-risk infants. The aim of the study was to evaluate the effect of spinal vs general anesthesia on operating room time in infants undergoing open pyloromyotomy.

METHODS

Data for 60 infants who underwent pyloromyotomy under spinal (n = 24) or general (n = 36) anesthesia at a tertiary pediatric medical center were derived from the computerized database. Primary outcome measures were total operating room time, procedure duration, anesthesia release time, wake-up time, and anesthesia control time (anesthesia release plus wake-up). Nonparametric Mann-Whitney test was used for statistical analysis, and Levene's test was used to assess the equality of variances in samples; P <or= .05 was considered significant.

RESULTS

Mean total operating room time was 50.9 (12.1) minutes in the spinal anesthesia group and 69.5 (26.8) minutes in the general anesthesia group (P = .001). Corresponding values for mean wake-up time were 3.6 (2.9) and 17.2 (25.3) minutes (P < .001), and for mean anesthesia control time, 13.2 (6.7) and 28.5 (24.6) minutes (P < .001). There were no between-group differences in procedure duration or anesthesia release time. On Levene's test, between-group differences were significant for total operating time and wake-up time (P = .01 for both).

CONCLUSIONS

The use of spinal anesthesia for open pyloromyotomy in infants with HPS shortens the operating room time by reducing the wake-up time.

Regional anaesthetic techniques for neonatal surgery: indications and selection of techniques

The goal of neonatal care is to optimise the outcome of term and preterm infants with minimal suffering. Neonates are rare patients for the anaesthetist, therefore personal and even global experiences are limited. This chapter focuses on strategies for dealing with common clinical situations, e.g. heel lancing, obtaining vascular access, circumcision, hernia repair and pyloric stenosis, as well as major neonatal surgery. With the exception of heel lancing, regional techniques are useful in all cases. However, a careful risk-benefit analysis is mandatory, especially when considering more invasive techniques such as epidural catheters.

The effectiveness and safety of spinal anaesthesia in the pyloromyotomy procedure

BACKGROUND

Hypertrophic pyloric stenosis is a relatively common disorder of the gastrointestinal tract in infancy, causing projectile vomiting and metabolic abnormalities. Surgical management in the form of pyloromyotomy under general anaesthesia has been reported as safe for relieving the obstructed bowel. A number of studies have demonstrated the advantages of spinal anaesthesia over general anaesthesia in high risk infants undergoing minor infraumbilical surgery. The purpose of this study was to evaluate spinal anaesthesia as an alternative option to general anaesthesia in infants undergoing pyloromyotomy.

METHODS

Twenty-five infants undergoing pyloromyotomy under spinal anaesthesia were studied. Haemodynamic and respiratory parameters were noted before performing the spinal block, 5 min after the spinal block, and every 10 min after performing the spinal block; for a total period of 30 min. The spinal block was performed using spinal isobaric bupivacaine 0.5%, 0.8 mg.kg-1. Blood pressure, heart rate, respiratory rate and oxygen saturation values were recorded.

RESULTS

The sensory levels achieved ranged between T3-T5 thoracic segments within 6-8 min and were sufficient to perform surgery in 23 cases. There were no statistically significant differences in the oxygen saturation, systolic blood pressure and respiratory rate compared with before the spinal block and after 5, 10, 20 and 30 min.

CONCLUSIONS

This study proposes that spinal anaesthesia is an alternative option to general anaesthesia in infants undergoing pyloromyotomy, and should be considered in infants undergoing pyloromyotomy.