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Brennan MP, Webber AM, Patel CV, Chin WA, Butz SF, Rajan N. Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2024; 139:509-520. [PMID: 38517763 DOI: 10.1213/ane.0000000000006645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.
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Affiliation(s)
- Marjorie P Brennan
- From the Department of Anesthesiology, Pain and Perioperative Medicine, The George Washington University School of Medicine, Children's National Hospital, Washington, DC
| | - Audra M Webber
- University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Chhaya V Patel
- Department of Anesthesiology and Pediatrics, Emory School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Wanda A Chin
- Department of Anesthesiology and Perioperative Medicine, New York University Grossman School of Medicine, NYU Lagone Health, New York, New York
| | - Steven F Butz
- Department of Anesthesiology, Medical College of Wisconsin, Children's Wisconsin Surgicenter
| | - Niraja Rajan
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, Hershey Outpatient Surgery Center, Hershey, Pennsylvania
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Kim DH, Stybayeva G, Hwang SH. Efficacy and safety of perioperative ibuprofen for pain control after pediatric tonsillectomy: A systemic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2024; 184:112078. [PMID: 39178604 DOI: 10.1016/j.ijporl.2024.112078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 08/04/2024] [Accepted: 08/19/2024] [Indexed: 08/26/2024]
Abstract
OBJECTIVES To assess the safety and effectiveness of perioperative ibuprofen in pediatric tonsillectomy through a meta-analysis of relevant randomized controlled trials. METHODS We conducted a comprehensive review of studies available in PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases up to June 2024. This analysis compared perioperative ibuprofen administration to control groups (saline, acetaminophen, or opioids). Outcomes assessed were postoperative pain management, as indicated by the frequency of analgesic use, and morbidity rates, which included the incidence of postoperative nausea and vomiting and post-tonsillectomy hemorrhage (PTH). PTH was further categorized as primary (occurring on the day of operation) or secondary (occurring after the day of operation), and classified as type 1 (observed at home or evaluated in the emergency department without further intervention), type 2 (requiring readmission for observation), or type 3 (necessitating a return to the operating room for hemorrhage control). RESULTS This analysis included nine studies involving a total of 1545 patients. Incidences of primary PTH (OR = 1.0949, 95 % CI [0.4169; 2.8755], I2 = 0.0 %), secondary PTH (OR = 1.6433 95 % CI [0.7783; 3.4695], I2 = 0.1 %), and overall PTH (OR = 1.4296 95 % CI [0.8383; 2.4378], I2 = 0.0 %) were not significantly higher in the ibuprofen group than the control groups. Administration of ibuprofen led to a significant decrease in postoperative nausea and vomiting (OR = 0.4228 95 % CI [0.2500; 0.7150], I2 = 40.0 %) and frequency of postoperative analgesic uptake (OR = 0.4734 95 % CI [0.2840; 0.7893]; I2 = 19.8 %). There was no difference in bleeding by type between the ibuprofen and control groups. CONCLUSIONS Our meta-analysis demonstrated that administration of ibuprofen for pediatric tonsillectomy did not significantly increase the incidence of postoperative bleeding but did decrease postoperative emesis and improve pain control.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gulnaz Stybayeva
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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Koç O, Er N, Karaca Ç, Bilginaylar K. Comparison of the effects of submucosal hyaluronidase and dexamethasone on postoperative edema, pain, trismus, and infection following impacted third molar surgery. BMC Oral Health 2024; 24:1018. [PMID: 39215323 PMCID: PMC11365265 DOI: 10.1186/s12903-024-04729-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 08/09/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Limiting postoperative edema, pain, trismus, and infection is crucial for smooth healing. This prospective, controlled clinical trial investigated and compared the effectiveness of dexamethasone and hyaluronidase in relieving these complications. METHODS In groups Ia and IIa, 8 mg of dexamethasone and 150 IU of hyaluronidase were administered following the removal of impacted teeth, respectively. The contralateral sides (groups Ib and IIb) were determined as control groups. Edema, pain, trismus, and infection were clinically evaluated on the 1st, 2nd, 3rd, and 7th postoperative days. RESULTS 60 patients were enrolled in the study. Hyaluronidase provided significantly more edema relief than dexamethasone on the 1st, 2nd, 3rd, and 7th postoperative days (P = 0.031, 0.002, 0.000, and 0.009, respectively). No statistical difference was found between dexamethasone and hyaluronidase in VAS and rescue analgesic intake amount values for all time points. Hyaluronidase was more effective in reducing trismus than dexamethasone on the 2nd and 3rd postoperative days (P = 0.029, 0.024, respectively). Neither of the agents significantly increased the postoperative infection rate. CONCLUSIONS Hyaluronidase can be selected when postoperative excessive edema and trismus are anticipated. Dexamethasone may be a cost-effective option if postoperative pain control is merely targeted. TRIAL REGISTRATION This trial was registered in the Clinical Trials Protocol Registration and Results System (ClinicalTrials.gov identifier number: NCT05466604) on 20/07/2022.
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Affiliation(s)
- Onur Koç
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Hacettepe University, Sıhhiye, Ankara, Turkey.
| | - Nuray Er
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Hacettepe University, Sıhhiye, Ankara, Turkey
| | - Çiğdem Karaca
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Hacettepe University, Sıhhiye, Ankara, Turkey
| | - Kanİ Bilginaylar
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Final International University, Nicosia, Cyprus
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Alm F, Odhagen E, Sunnergren O, Nerfeldt P. Postoperative Analgesic Regimens and Their Satisfaction Rates-Data from the Swedish Quality Register for Tonsil Surgery. Laryngoscope 2024. [PMID: 39140262 DOI: 10.1002/lary.31691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/29/2024] [Accepted: 07/26/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE To describe postoperative analgesic regimens and patient-reported pain-related outcomes after tonsil surgery. METHODS Cohort study including perioperative data (n = 9274) and patient-reported outcome measures (n = 5080) registered in the Swedish Quality Register for Tonsil Surgery during 2023. RESULTS After tonsil surgery, 92.7% received at least paracetamol and a NSAID/COX inhibitor, while 6.8% received no NSAID/COX inhibitor. Opioids were prescribed after tonsillectomy to 62.9% of adults and less often to adolescents and children (13-17-year-olds: 48.2%, 6-12-year-olds: 8.8%, 0-5-year-olds: 4.0%). Clonidine was frequently prescribed to 0-5-year-olds after tonsillectomy (54.4%). Overall, 11.7% reported dissatisfaction with the pain treatment, with the highest dissatisfaction rate after tonsillectomy in adolescents (20.6%) and adults (20.0%), and the lowest after tonsillotomy in children (4.9-6.8%). The most common complaint among dissatisfied patients was analgesics not being sufficiently helpful. Adult patients who received addition of opioids were less dissatisfied with the pain treatment (15.9% vs. 25.9%, p < 0.001), but also reported more side effects (5.7% vs. 2.7%, p = 0.039), compared with patients who received only paracetamol and NSAID/COX inhibitors. CONCLUSION Tonsil surgery patients in Sweden receive various analgesic regimens. Although most are satisfied with pain treatment, there is room for improvement, particularly among adolescents and adults undergoing tonsillectomy. Paracetamol and a NSAID/COX inhibitor seem advisable as basic treatment. However, many patients need more effective treatment. The addition of opioids in adults results in greater satisfaction with pain treatment, but safety issues with opioid prescriptions must be taken into consideration. LEVELS OF EVIDENCE Level 4 Laryngoscope, 2024.
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Affiliation(s)
- Fredrik Alm
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Odhagen
- Department of Otorhinolaryngology, Södra Älvsborgs Hospital, Borås, Sweden
- Department of Otorhinolaryngology -Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ola Sunnergren
- Department of Otorhinolaryngology -Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Oral Health, School of Health and Welfare, Jönköping University, Jönköping, Sweden
- Department of Otorhinolaryngology, Region Jönköping County, Jönköping, Sweden
- Department of Otorhinolaryngology-Head and Neck Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Pia Nerfeldt
- Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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So V, Radhakrishnan D, MacCormick J, Webster RJ, Tsampalieros A, Zitikyte G, Ripley A, Murto K. Does Celecoxib Prescription for Pain Management Affect Post-tonsillectomy Hemorrhage Requiring Surgery? A Retrospective Observational Cohort Study. Anesthesiology 2024; 141:313-325. [PMID: 38684054 DOI: 10.1097/aln.0000000000005032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Adenotonsillectomy and tonsillectomy (referred to as tonsillectomy hereafter) are common pediatric surgeries. Postoperative complications include hemorrhage requiring surgery (2 to 3% of cases) and pain. Although nonsteroidal anti-inflammatory drugs are commonly administered for postsurgical pain, controversy exists regarding bleeding risk with cyclooxygenase-1 inhibition and associated platelet dysfunction. Preliminary evidence suggests selective cyclooxygenase-2 inhibitors, for example celecoxib, effectively manage pain without adverse events including bleeding. Given the paucity of data for routine celecoxib use after tonsillectomy, this study was designed to investigate the association between postoperative celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery using chart-review data from the Children's Hospital of Eastern Ontario. METHODS After ethics approval, a retrospective single-center observational cohort study was performed in children less than 18 yr of age undergoing tonsillectomy from January 2007 to December 2017. Cases of adenoidectomy alone were excluded due to low bleed rates. The primary outcome was the proportion of patients with post-tonsillectomy hemorrhage requiring surgery. The association between a celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery was estimated using inverse probability of treatment weighting based on propensity scores and using generalized estimating equations to accommodate clustering by surgeon. RESULTS An initial patient cohort of 6,468 was identified, and 5,846 children with complete data were included in analyses. Median (interquartile range) age was 6.10 (4.40, 9.00) yr, and 46% were female. In the cohort, 28.1% (n = 1,644) were prescribed celecoxib. Among the 4,996 tonsillectomy patients, 1.7% (n = 86) experienced post-tonsillectomy hemorrhage requiring surgery. The proportion with post-tonsillectomy hemorrhage requiring surgery among patients who had a tonsillectomy and were or were not prescribed celecoxib was 1.94% (30 of 1,548; 95% CI, 1.36 to 2.75) and 1.62% (56 of 3,448; 95% CI, 1.25 to 2.10), respectively. Modeling did not identify an association between celecoxib prescription and increased odds of post-tonsillectomy hemorrhage requiring surgery (odds ratio = 1.4; 95% CI, 0.85 to 2.31; P = 0.20). CONCLUSIONS Celecoxib does not significantly increase the odds of post-tonsillectomy hemorrhage requiring surgery, after adjusting for covariates. This large pediatric cohort study of celecoxib administered after tonsillectomy provides compelling evidence for safety but requires confirmation with a multisite randomized controlled trial. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Vincent So
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dhenuka Radhakrishnan
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Johnna MacCormick
- Department of Otolaryngology Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard J Webster
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Allyson Ripley
- University of Western Ontario, Faculty of Medicine, London, Ontario, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Hart K, Medvecz AJ, Vaidya A, Dusetzina S, Leech AA, Wiese AD. Opioid and non-opioid analgesic regimens after fracture and risk of serious opioid-related events. Trauma Surg Acute Care Open 2024; 9:e001364. [PMID: 39021730 PMCID: PMC11253739 DOI: 10.1136/tsaco-2024-001364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/31/2024] [Indexed: 07/20/2024] Open
Abstract
Background Non-opioid analgesics are prescribed in combination with opioids among patients with long bone fracture to reduce opioid prescribing needs, yet evidence is limited on whether they reduce the risk of serious opioid-related events (SOREs). We compared the risk of SOREs among hospitalized patients with long bone fracture discharged with filled opioid prescriptions, with and without non-opioid analgesics. Design We identified a retrospective cohort of analgesic-naïve adult patients with a long bone fracture hospitalization using the Merative MarketScan Commercial Database (2013-2020). The exposure was opioid and non-opioid analgesic (gabapentinoids, muscle relaxants, non-steroidal anti-inflammatory drugs, acetaminophen) prescriptions filled in the 3 days before through 42 days after discharge. The outcome was the development of new persistent opioid use or opioid use disorder during follow-up (day 43 through day 408 after discharge). We used Cox proportional hazards regression with inverse probability of treatment weighting with overlap trimming to compare outcomes among those that filled an opioid and a non-opioid analgesic to those that filled only an opioid analgesic. In secondary analyses, we used separate models to compare those that filled a prescription for each specific non-opioid analgesic type with opioids to those that filled only opioids. Results Of 29 489 patients, most filled an opioid prescription alone (58.4%) or an opioid and non-opioid (22.0%). In the weighted proportional hazards regression model accounting for relevant covariates and total MME, filling both a non-opioid analgesic and an opioid analgesic was associated with 1.63 times increased risk of SOREs compared with filling an opioid analgesic only (95% CI 1.41 to 1.89). Filling a gabapentin prescription in combination with an opioid was associated with an increased risk of SOREs compared with those that filled an opioid only (adjusted HR: 1.84 (95% CI1.48 to 2.27)). Conclusions Filling a non-opioid analgesic in combination with an opioid was associated with an increased risk of SOREs after long bone fracture. Level of evidence Level III, prognostic/epidemiological. Study type Retrospective cohort study.
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Affiliation(s)
- Kyle Hart
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew J Medvecz
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Avi Vaidya
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stacie Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashley A Leech
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew D Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Butkus JM, Sagalow ES, Alfonsi S, Riordan J, Zhan T, McGettigan B, Fisher K, Rosen D, Boon M, Huntley C. Prednisone Decreases Opioid Use in Adults Undergoing Benign Oropharyngeal Surgery. Otolaryngol Head Neck Surg 2024; 170:405-413. [PMID: 37702155 DOI: 10.1002/ohn.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/09/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE This study sought to analyze the efficacy and safety of postoperative prednisone to reduce reliance on opioids in adult benign oropharyngeal surgery. STUDY DESIGN Prospective cohort study. SETTING Single tertiary-care facility. METHODS Patients undergoing tonsillectomy (T), tonsillectomy and adenoidectomy (T&A), and/or modified uvulopalatopharyngoplasty (UPPP) from December 2020 to January 2023 received the standard of care postoperative management. A prednisone taper was dependent on surgeon preference. Cohorts were based on the prescription of postoperative steroids. Patients completed a survey to assess opioid usage, pain scores, and steroid compliance. RESULTS Seventy-two patients were included. The nonsteroid cohort (N = 29) received an average of 467 ± 94.1 morphine milligram equivalents (MME), and the steroid cohort (N = 43) received an average of 285 ± 128 MME (P < 0.001). The nonsteroid cohort consumed 1.62 times more opioids than the steroid cohort (P < 0.002). There were no significant differences in complication or refill rates between treatment groups. There were no significant differences in pain scores on the day of surgery or postoperative days 1, 5, or 10 (P = 0.34, P = 0.66, P = 0.62, and P = 0.22, respectively). Patients undergoing T&A (p = 0.019) or who had current psychiatric medication use (P < 0.006) consumed significantly more opioids. Patients who received a total opioid prescription of >300 MME (40 5-mL doses of 5 mg/5 mL liquid oxycodone) consumed 2.27 times more postoperative opioids than patients with opioid prescriptions ≤300 MME (P < 0.001). CONCLUSION Patients who did not receive steroids consumed 1.62 times more postoperative opioids compared to those who completed a steroid taper. Corticosteroid use was not associated with changes in pain scores, refill rates, or complication rates and may be considered in a multimodal approach to pain management in adults undergoing benign oropharyngeal surgery, although further study is warranted.
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Affiliation(s)
- Joann M Butkus
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Emily S Sagalow
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Samuel Alfonsi
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jacob Riordan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tingting Zhan
- Department of Biostatistics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian McGettigan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kyle Fisher
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Rosen
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Amin SN, Thompson T, Wang X, Goldklang S, Martin LD, Low DKW, Parikh SR, Sie KC, Dahl JP. Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative. Otolaryngol Head Neck Surg 2024; 170:610-617. [PMID: 37747042 PMCID: PMC10841103 DOI: 10.1002/ohn.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/21/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Postoperative pain is the most common morbidity associated with tonsillectomy. Opioids are frequently used in multimodal posttonsillectomy analgesia regimens; however, concerns regarding respiratory depression, drug-drug interactions, and medication misuse necessitate responsible opioid stewardship among prescribing surgeons. It is unclear if intentionally reducing opioid prescription doses negatively affects the patient experience. METHODS A quality improvement team reviewed all posttonsillectomy opioid prescriptions at a pediatric ambulatory surgery center between January and June 2021 (preintervention, 163 patients). Following this review, we performed an opioid education session for surgeons and studied opioid prescribing habits between July and December 2021 (Plan-Do-Study-Act [PDSA] 1, 152 patients). We then implemented a standardized prescription protocol of 7 doses of oxycodone per patient and again reviewed prescriptions between January and June 2022 (PDSA 2, 178 patients). The following measures were evaluated: initial number of opioid doses prescribed, need for refills, 7-day emergency department (ED) visits, and readmissions. RESULTS Each intervention reduced the average number of initial oxycodone doses per patient (12.2 vs 9.2 vs 6.9 doses, P < .001). There were no changes in the rate of refill requests, 7-day ED visits, and readmissions, by descriptive or Statistical Process Control analyses. DISCUSSION In 2 PDSA cycles, we achieved a 43% reduction in the number of doses of oxycodone prescribed following tonsillectomy. We did not observe any increased rates in balancing measures, which are surrogates for unintentional effects of PDSA changes, including refills, ED presentations, and readmission rates. IMPLICATIONS FOR PRACTICE Directed provider education and standardized posttonsillectomy prescription protocols can safely decrease postoperative opioid prescribing. Further PDSA cycles are required to consider even fewer opioid prescription doses.
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Affiliation(s)
- Shaunak N Amin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Trey Thompson
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Xing Wang
- Department of Biostatistics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Samantha Goldklang
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel K-W Low
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Sie
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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Coviello C, Sivam SK. Considerations for Functional Nasal Surgery in the Obstructive Sleep Apnea Population. Facial Plast Surg 2023; 39:642-647. [PMID: 37328151 DOI: 10.1055/a-2111-9255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023] Open
Abstract
Obstructive sleep apnea (OSA) and nasal obstruction are common in the general population and frequently treated by otolaryngologists and facial plastic surgeons. Understanding the appropriate pre-, peri-, and postoperative management of OSA patients undergoing functional nasal surgery is important. OSA patients should be appropriately counseled in the preoperative period on their increased anesthetic risk. In OSA patients who are continuous positive airway pressure (CPAP) intolerant, the role of drug-induced sleep endoscopy should be discussed with the patient, and depending on the surgeon's practice may prompt referral to a sleep specialist. Should multilevel airway surgery be indicated, it can safely be performed in most OSA patients. Surgeons should communicate with the anesthesiologist regarding an airway plan given this patient population's higher propensity for having a difficult airway. Given their increased risk of postoperative respiratory depression, extended recovery time should be given to these patients and the use of opioids as well as sedatives should be minimized. During surgery, one can consider using local nerve blocks to reduce postoperative pain and analgesic use. After surgery, clinicians can consider opioid alternatives such as nonsteroidal anti-inflammatory agents. Neuropathic agents, such as gabapentin, require further research in their indications for managing postoperative pain. CPAP is typically held for a period of time after functional rhinoplasty. The decision on when to restart CPAP should be individualized to the patient based on their comorbidities, OSA severity, and surgical maneuvers performed. More research would provide further guidance in this patient population to shape more specific recommendations regarding their perioperative and intraoperative course.
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Affiliation(s)
- Caitlin Coviello
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Sunthosh Kumar Sivam
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
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Sagalow ES, Estephan LE, Kumar AT, Hwang M, Krein H, Heffelfinger R. Recovery Benefit With Total Intravenous Anesthesia in Patients Receiving Rhinoplasty. Otolaryngol Head Neck Surg 2023; 169:489-495. [PMID: 36906818 DOI: 10.1002/ohn.319] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE The aim was to evaluate the difference in recovery when comparing total intravenous anesthesia (TIVA) to inhalational gas anesthesia in patients receiving rhinoplasty. STUDY DESIGN Retrospective review. SETTING Postoperative anesthesia care unit (PACU). METHODS Patients who received a functional or cosmetic rhinoplasty at a single academic institution between April 2017 and November 2020 were included. Inhalational gas anesthesia was in the form of sevoflurane. Phase I recovery time, which was defined as the time it took a patient to reach ≥9/10 on the Aldrete scoring system was recorded, as well as the usage of pain medication in the PACU. The postoperative course and incidence of postoperative nausea and vomiting (PONV) were also collected. RESULTS Two hundred and two patients were identified with 149 (73.76%) who received TIVA and 53 (26.24%) who received sevoflurane. For the patients who received TIVA, the average recovery time was 101.44 minutes (standard deviation [SD]: 34.64) compared to an average recovery time of 121.09 minutes (SD: 50.19) for patients who received sevoflurane leading to a difference of 19.65 minutes (p = 0.002). Patients who received TIVA experienced less PONV (p = 0.001). There were no differences in the postoperative course including surgical or anesthesia complications, postoperative complications, hospital or Emergency Department admissions, or administration of pain medication (p > 0.05 for all). CONCLUSION When utilizing TIVA over inhalational anesthesia, patients undergoing rhinoplasty had significantly increased benefits in terms of reduced phase I recovery times and decreased incidence of PONV. TIVA was demonstrated to be a safe and efficacious method of anesthesia for this patient population.
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Affiliation(s)
- Emily S Sagalow
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Leonard E Estephan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ayan T Kumar
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michelle Hwang
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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11
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Balakrishnan K, Faucett EA, Villwock J, Boss EF, Esianor BI, Jefferson GD, Graboyes EM, Thompson DM, Flanary VA, Brenner MJ. Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do. CURRENT OTORHINOLARYNGOLOGY REPORTS 2023; 11:201-214. [PMID: 38073717 PMCID: PMC10707492 DOI: 10.1007/s40136-023-00467-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 01/31/2024]
Abstract
Purpose of review To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls. Recent findings Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity. Summary Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.
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Affiliation(s)
- Karthik Balakrishnan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Erynne A. Faucett
- Department of Otolaryngology-Head and Neck Surgery, University of CA-Davis , Sacramento, USA
| | - Jennifer Villwock
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Brandon I. Esianor
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gina D. Jefferson
- Department of Otolaryngology-Head and Neck Surgery, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Dana M. Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| | - Valerie A. Flanary
- Division of Pediatric Otolaryngology, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael J. Brenner
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan medical School, 1500 East Medical Center Drive, 48108 Ann Arbor, MI, USA
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12
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Sivaraj LBM, Basco WT, Heavner SF, Lopes SS, Rolke LJ, Shi L, Truong K. Outpatient Opioid Dispensing Patterns for SC Medicaid Children 1-36 Months Old. Matern Child Health J 2023; 27:1043-1050. [PMID: 36939951 DOI: 10.1007/s10995-023-03621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVES We sought to identify the most common diagnostic categories linked to dispensed opioid prescriptions among children 1-36 months old and changes in patterns over the years 2000 to 2017. METHODS This study used South Carolina's Medicaid claims data of pediatric dispensed outpatient opioid prescriptions between 2000 and 2017. The major opioid-related diagnostic category (indication) for each prescription was identified using visit primary diagnoses and the Clinical Classification System (AHRQ-CCS) software. The variables of interest were the rate of opioid prescriptions per 1,000 visits for each diagnostic category and the relative percentage of opioid prescriptions assigned to each category compared to all categories. RESULTS Six major diagnostic categories were identified; Diseases of the respiratory system (RESP), Congenital anomalies (CONG), Injury (INJURY), Diseases of the nervous system and sense organs (NEURO), Diseases of the digestive system (GI), and Diseases of the genitourinary system (GU). The overall rate of dispensed opioid prescriptions per category declined significantly for four diagnostic categories throughout the study period, RESP by 15.13, INJURY by 8.49, NEURO by 7.33, and GI by 5.93. Two categories increased during the same time, CONG (by 9.47) and GU (by 6.98). RESP was the most prevalent category linked to a dispensed opioid prescription within 2010-2012 (almost 25%) but CONG was the most prevalent by 2014 (17.77%). CONCLUSIONS FOR PRACTICE Among Medicaid children 1-36 months old, annual dispensed opioid prescription rates declined for most major diagnostic categories (RESP, INJURY, NEURO, and GI). Future studies should explore alternatives to current opioid dispensing practices for GU and CONG cases.
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Affiliation(s)
| | - William T Basco
- Department of Pediatrics, The Medical University of South Carolina, Charleston, SC, USA
| | - Smith F Heavner
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA.,CURE Drug Repurposing Collaboratory Critical Path Institute, Tucson, Arizona, USA.,Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, USA
| | - Snehal S Lopes
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Laura J Rolke
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Khoa Truong
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA.
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13
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Statman BJ. Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2. Anesth Prog 2023; 70:37-48. [PMID: 36995961 PMCID: PMC10069535 DOI: 10.2344/anpr-70-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/27/2023] [Indexed: 03/31/2023] Open
Abstract
Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.
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14
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Butkus JM, Awosanya S, Scott ER, Perlov N, Hannikainen P, Tekumalla S, Armache M, Stewart M, Willcox T, Chiffer R. Multimodal Analgesia and Patient Education Reduce Postoperative Opioid Consumption in Otology. Otolaryngol Head Neck Surg 2023. [PMID: 36939618 DOI: 10.1002/ohn.229] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/08/2022] [Accepted: 11/23/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study sought to validate alternative pain management strategies that can reduce reliance on opioids for postoperative pain management in otology. STUDY DESIGN Prospective cohort study. SETTING Single tertiary-care facility. METHODS Adult patients who underwent outpatient otologic surgery from September 2021 to July 2022 were randomized into treatment cohorts. The opioid monotherapy cohort received a standard opioid prescription. The multimodal analgesia cohort received the same opioid prescription, prescriptions for acetaminophen and naproxen, and additional pain management education with a flyer on discharge. All patients completed a questionnaire 1 week after surgery to evaluate opioid usage and pain scores. RESULTS Eighty-six patients completed the study. The opioid monotherapy cohort (n = 42) and multimodal analgesia cohort (n = 44) were prescribed an average of 42.1 ± 20.4 morphine milligram equivalents (MME) and 38.4 ± 5.7 MME, respectively (p = 0.373). Four patients (9.52%) in the opioid monotherapy cohort required opioid refills compared to 1 patient (2.27%) in the multimodal analgesia cohort (p = 0.156). Multivariate analysis demonstrated that the multimodal analgesia cohort consumed significantly fewer opioids on average than the opioid monotherapy cohort (11.9 ± 15.9 MME vs 22.8 ± 28.0 MME, respectively). There were no significant differences in postoperative rehospitalizations (p = 0.317) or Emergency Department visits (p = 0.150). Pain scores on the day of surgery, postoperative day (POD) 1, POD3, and POD7 were not significantly different between cohorts (p = 0.395, 0.896, 0.844, 0.765, respectively). CONCLUSION The addition of patient education, acetaminophen, and naproxen to postoperative opioid prescriptions significantly reduced opioid consumption without affecting pain scores, refill rates, or complication rates after otologic surgery.
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Affiliation(s)
- Joann M Butkus
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Samiat Awosanya
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth Reilly Scott
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Natalie Perlov
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paavali Hannikainen
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sruti Tekumalla
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maria Armache
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew Stewart
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas Willcox
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rebecca Chiffer
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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15
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Thal AG, Ahmed S, Kim S, Yang CJ, Gao Q, Gangar M, Mehta V. Assessing Impact: Implementing an Opioid Prescription Protocol in Otolaryngology. J Patient Saf 2022; 18:e992-e998. [PMID: 35093975 PMCID: PMC11221781 DOI: 10.1097/pts.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A lack of guidance for pain control after otolaryngology surgery can lead to overprescription of opioids. We implemented a postoperative site-specific opioid prescription protocol and analyzed the impact on opioid prescriptions. METHODS This is a retrospective cohort study. A postoperative opioid prescription protocol was implemented within our otolaryngology department at a tertiary academic medical center on January 1, 2020. Retrospective chart review was completed for all patients undergoing otolaryngology surgery from November 1, 2019, to February 29, 2020 (2 months before and after initiation of intervention; n = 1070). The primary outcome was change in the amount of opioid prescribed for the preintervention and postintervention cohorts. Unplanned contact related to pain and opioid refills were tracked to assess pain control. RESULTS A total of 940 cases were included; adult and pediatric data were analyzed separately. There were 489 pediatric cases, 250 preintervention and 239 postintervention. There was a significant decrease in the amount of opioid prescribed per pediatric patient in the postintervention cohort (2.7 versus 0.32 morphine milligram equivalents, P = 0.02), and 99% of patients were not prescribed opioids at all. There was no significant change in unplanned contact, and no refills were required. There were 451 adult cases, 200 preintervention and 251 postintervention. There was no statistically significant decrease in the amount of opioid prescribed per adult patient (56.8 versus 51.7 morphine milligram equivalents, P = 0.23). There was no significant increase in unplanned contact or refills. CONCLUSIONS A postoperative opioid prescribing protocol can reduce the amount of opioid prescribed without increasing unplanned contact or opioid refills.
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Affiliation(s)
- Arielle G. Thal
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
| | - Sadia Ahmed
- Albert Einstein College of Medicine, The Bronx, New York
| | - Stanley Kim
- Albert Einstein College of Medicine, The Bronx, New York
| | - Christina J. Yang
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
| | - Qi Gao
- Albert Einstein College of Medicine, The Bronx, New York
| | - Mona Gangar
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
| | - Vikas Mehta
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
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16
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Go BC, Go CC, Chorath K, Moreira A, Rajasekaran K. Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review. World J Otorhinolaryngol Head Neck Surg 2022; 8:107-117. [PMID: 35782401 PMCID: PMC9242426 DOI: 10.1002/wjo2.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/30/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Management of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients. Methods Pubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30-day outcomes. Results A total of five studies representing 592 patients (MMA, n = 275; non-MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. Conclusion MMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient.
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Affiliation(s)
- Beatrice C. Go
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Cammille C. Go
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Kevin Chorath
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Alvaro Moreira
- Department of Pediatrics, Division of NeonatologyUniversity of Texas Health‐San AntonioSan AntonioTexasUSA
| | - Karthik Rajasekaran
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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17
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Esce AR, Meiklejohn DA. Ibuprofen prescription following adult tonsillectomy reduces postoperative opioid use. Am J Otolaryngol 2022; 43:103436. [PMID: 35429845 DOI: 10.1016/j.amjoto.2022.103436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/02/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Based on a 2018 American Academy of Otolaryngology - Head and Neck Surgery survey, an average of 37 tablets of opioid medication, or about a week's worth of medication, were prescribed after adult tonsillectomy. Nearly 15% of patients will still be taking opioids one year after an initial weeklong prescription, according to data from the Centers for Disease Control and Prevention. Non-steroidal anti-inflammatory medications have traditionally been avoided in adult tonsillectomy patients due to concern for increased bleeding risk from platelet dysfunction, despite little evidence supporting this claim. This study sought to demonstrate that ibuprofen prescriptions after tonsillectomy could be a safe and effective way to reduce postoperative opioid use. METHODS This study was a retrospective chart review of patients undergoing tonsillectomy with one surgeon over three years. Half of the patients received a prescription for postoperative opioid medications and were counseled against taking ibuprofen. The other half of patients were prescribed ibuprofen following surgery and only provided with opioid analgesia as a rescue medication. The New Mexico Prescription Monitoring System was used to verify opioid prescriptions. Descriptive statistics and logistic regression were used to analyze the data. RESULTS Ninety-nine patients were included in analysis, with 53 in the first group that did not receive ibuprofen and 46 in the second group that did receive ibuprofen. There was no difference in the bleeding rate between the two groups. Significantly fewer patients in the ibuprofen group filled postoperative opioid prescriptions when compared to the group that did not receive ibuprofen (40% vs. 96.2%, p < 0.0001, OR = 0.02). CONCLUSION Ibuprofen is a safe and effective analgesic following adult tonsillectomy and significantly reduces the proportion of patients who must fill a postoperative opioid prescription.
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Affiliation(s)
- Antoinette R Esce
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, MSC10 5610, University of New Mexico, Albuquerque, NM 87131, United States of America.
| | - Duncan A Meiklejohn
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, MSC10 5610, University of New Mexico, Albuquerque, NM 87131, United States of America
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18
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Chang MT, Lalakea ML, Shepard K, Saste M, Munoz A, Amoils M. Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery. Otolaryngol Head Neck Surg 2022; 167:657-663. [PMID: 35015583 DOI: 10.1177/01945998211071116] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. STUDY DESIGN Retrospective cohort study. SETTING County hospital otolaryngology practice. METHODS A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. RESULTS We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 (P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased (P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased (P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. CONCLUSION Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.
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Affiliation(s)
- Michael T Chang
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA.,Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - M Lauren Lalakea
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Kimberly Shepard
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Micah Saste
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Amanda Munoz
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Misha Amoils
- Division of Otolaryngology-Head and Neck Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
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19
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Kirubalingam K, Nguyen P, Klar G, Dion JM, Campbell RJ, Beyea JA. Opioid Prescriptions Following Otologic Surgery: A Population-Based Study. Otolaryngol Head Neck Surg 2021; 167:141-148. [PMID: 34582291 DOI: 10.1177/01945998211045364] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine postoperative opioid-prescribing patterns following otologic surgery. STUDY DESIGN Retrospective population-based descriptive study. SETTING All hospitals in the Canadian province of Ontario. METHODS Of all patients with advanced ear surgery between July 1, 2012, and March 31, 2019, 7 cohorts were constructed: tympanoplasty with or without ossiculoplasty (n = 7812), atticotomy/limited mastoidectomy (n = 1371), mastoidectomy (n = 3717), semicircular canal occlusion (SCO; n = 179), stapedectomy (n = 2735), bone-implanted hearing aid insertion (n = 280), and cochlear implant (n = 2169). Prescriptions filled for narcotics postoperatively were calculated per morphine milligram equivalent (MME) opioid dose. Multivariable regression was used to determine predictors of higher opioid doses. RESULTS The mean ± SD MMEs prescribed were as follows: tympanoplasty with or without ossiculoplasty, 246.77 ± 1380.78; atticotomy/limited mastoidectomy, 283.32 ± 956.10; mastoidectomy, 280.56 ± 1018.50; SCO, 328.61 ± 1090.86; stapedectomy, 164.64 ± 657.18; bone-implanted hearing aid insertion, 326.11 ± 1054.66; and cochlear implant, 200.87 ± 639.93. SCO (odds ratio [OR], 1.69 [95% CI, 1.16-2.48]) and mastoidectomy (OR, 1.50 [95% CI, 1.36-1.66]) were associated with higher opioid doses than tympanoplasty-ossiculoplasty. Asthma (OR, 1.24 [95% CI, 1.12-1.38]), chronic obstructive pulmonary disease (OR, 1.29 [95% CI, 1.12-1.47]), myocardial infarction (OR, 1.33 [95% CI, 1.05-1.68]), diabetes (OR, 1.22 [95% CI, 1.08-1.39]), and substance-related and addictive disorders (OR, 2.59 [95% CI, 1.67-4.00]) were associated with higher opioid doses prescribed. Overall MME prescribed by year demonstrates a sharp drop from 2017-2018 to 2018-2019. CONCLUSION This large comprehensive population study provides insight into the prescribing patterns following otologic surgery. The large amounts prescribed and substantial variation require further study to determine barriers that limit good opioid-prescribing stewardship in the postoperative period.
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Affiliation(s)
| | - Paul Nguyen
- ICES Queen's, Queen's University, Kingston, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - Joanna M Dion
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | | | - Jason Atkins Beyea
- Otolaryngology-Head and Neck Surgery, School of Medicine, Queen's University, Kingston, Canada.,ICES Queen's, Queen's University, Kingston, Canada
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20
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Wang JJ, Rubin SJ, Devaiah AK, Faden DL, Salama AR, Edwards HA. Long-Term Opioid Use in Post-Surgical Management of Patients With Head and Neck Cancer. Ann Otol Rhinol Laryngol 2021; 131:844-850. [PMID: 34521247 DOI: 10.1177/00034894211045771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study aims to identify clinical and socioeconomic factors associated with long-term, post-surgical opioid use in the head and neck cancer population. METHODS A single center retrospective study was conducted including patients diagnosed with head and neck cancer between January 1, 2014 and July 1, 2019 who underwent primary surgical management. The primary outcome measure was continued opioid use 6 months after treatment completion. Both demographic and cancer-related variables were recorded to determine what factors were associated with prolonged opioid use. Univariate analysis was performed using chi-squared test for categorical variables and 2-sample t-test for continuous variables. Multivariate analysis was performed using logistic regression. RESULTS A total of 359 patients received primary surgical management. Forty-five patients (12.53%) continued to take opioids 6 months after treatment completion. Using univariate analysis, patients less than 65 years of age (P = .0126), adjuvant chemoradiation (n = 25, P < .001), and overall length of hospital stay (8.60 ± 8.58 days, P = .0274) were significantly associated with long term opioid use. Multivariate logistic regression showed that adjuvant chemoradiation (OR = 3.446, 95% CI [1.742, 6.820], P = .0004) and overall length of hospital stay (OR = 0.949, 95% CI [0.903, 0.997], P = .0373) to be significantly associated with opioid use 6 months after head and neck cancer treatment. CONCLUSION Long-term postoperative opioid use in head and neck cancer patients is significantly associated with adjuvant chemoradiation, and patients with longer length of hospital stay. Therefore, future research should focus on interventions to better manage opioid use during the acute treatment period to decrease long-term use.
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Affiliation(s)
- Judy J Wang
- Boston University School of Medicine, Boston, MA, USA.,Department of Otolaryngology-Head & Neck Surgery, Boston Medical Center, Boston, MA, USA
| | - Samuel J Rubin
- Boston University School of Medicine, Boston, MA, USA.,Department of Otolaryngology-Head & Neck Surgery, Boston Medical Center, Boston, MA, USA
| | - Anand K Devaiah
- Boston University School of Medicine, Boston, MA, USA.,Department of Otolaryngology-Head & Neck Surgery, Boston Medical Center, Boston, MA, USA
| | - Daniel L Faden
- Boston University School of Medicine, Boston, MA, USA.,Department of Otolaryngology-Head & Neck Surgery, Boston Medical Center, Boston, MA, USA
| | - Andrew R Salama
- Department of Oral and Maxillofacial Surgery, Boston Medical Center, Boston, MA, USA
| | - Heather A Edwards
- Boston University School of Medicine, Boston, MA, USA.,Department of Otolaryngology-Head & Neck Surgery, Boston Medical Center, Boston, MA, USA
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21
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Ayoub NF, Choby G, Turner JH, Abuzeid WM, Raviv JR, Thamboo A, Ma Y, Chandra RK, Chowdhury NI, Stokken JK, O’Brien EK, Shah S, Akbar N, Roozdar P, Nayak JV, Patel ZM, Hwang PH. Assessment of Opioid Use and Analgesic Requirements After Endoscopic Sinus Surgery: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2021; 147:811-819. [PMID: 34351376 PMCID: PMC8343514 DOI: 10.1001/jamaoto.2021.1839] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/21/2021] [Indexed: 02/01/2023]
Abstract
Importance The opioid epidemic has generated interest in optimizing opioid prescribing after common surgeries. Recent studies have shown a broad range of analgesic prescription patterns following endoscopic sinus surgery (ESS). Objective To compare the efficacy of different analgesic regimens after ESS. Design, Setting, and Participants This multi-institutional, nonblinded randomized clinical trial was conducted at 6 tertiary centers across the US and Canada and included participants who underwent ESS for acute or chronic rhinosinusitis. The study was conducted from March 2019 to March 2020, and the data were analyzed in November to December 2020. Interventions All participants received acetaminophen, 650 mg, as the first-line analgesic. From there, patients were randomized to either oxycodone rescue (oxycodone, 5 mg, as second-line therapy) or ibuprofen rescue (ibuprofen, 600 mg, as second-line therapy, with oxycodone, 5 mg, reserved for breakthrough pain). Main Outcomes and Measures Baseline characteristics and disease severity were collected at enrollment. Medication logs, pain scores, and epistaxis measures were collected until postoperative day 7. The primary outcome was the postoperative visual analog scale score for pain. Brief Pain Inventory Pain Severity and Pain Interference Scores were also collected. Results A total of 118 patients were randomized (62 [52.5%] oxycodone rescue, 56 [47.5%] ibuprofen rescue; mean [SD] age, 46.7 [16.3] years; 44 women [44.0%]; 83 White [83.0%], 7 Black [7.0%], and 7 Asian individuals [7.0%]). After exclusions for loss to follow-up and noncompliance, 51 remained in the oxycodone rescue group and 49 in the ibuprofen rescue group. The groups had similar demographic characteristics and disease severity. Thirty-two (63%) in the oxycodone rescue group had adequate pain management with acetaminophen only, while 19 (37%) consumed at least 1 oxycodone dose. In the ibuprofen rescue group, 18 (16%) required only acetaminophen, 28 (57%) used only acetaminophen and ibuprofen, and the remaining 13 (26%) consumed 1 or more oxycodone doses. The groups had similar average acetaminophen (9.69 vs 7.96 doses; difference, 1.73; 95% CI, -1.37 to 4.83) and oxycodone (1.89 vs 0.77 doses; difference, 1.13; 95% CI, -0.11 to 2.36) use. Both groups had similar postoperative visual analog scale scores. A subanalysis that compared opioids users with nonusers showed clinically significant lower pain scores in nonusers at multiple postoperative points. Conclusions and Relevance In this randomized clinical trial, most patients who underwent ESS could be treated postoperatively using a nonopioid regimen of either acetaminophen alone or acetaminophen and ibuprofen. Ibuprofen as a second-line therapy did not reduce overall narcotic consumption, but the overall narcotic use was low in both groups. Trial Registration ClinicalTrials.gov Identifier: NCT03783702.
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Affiliation(s)
- Noel F. Ayoub
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Garret Choby
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Justin H. Turner
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology, Vanderbilt Health, Nashville, Tennessee
| | - Waleed M. Abuzeid
- Division of Rhinology and Skull Base Surgery, Department of Otolaryngology–Head & Neck Surgery, University of Washington, Seattle
| | - Joseph R. Raviv
- Division of Otolaryngology–Head and Neck Surgery, NorthShore University Health System, Chicago, Illinois
| | - Andrew Thamboo
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yifei Ma
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Rakesh K. Chandra
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology, Vanderbilt Health, Nashville, Tennessee
| | - Naweed I. Chowdhury
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology, Vanderbilt Health, Nashville, Tennessee
| | - Janalee K. Stokken
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Erin K. O’Brien
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Sharan Shah
- Department of Otolaryngology–Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Nadeem Akbar
- Department of Otolaryngology–Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Pooya Roozdar
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Jayakar V. Nayak
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Zara M. Patel
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Peter H. Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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22
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McCoul ED, Barnett ML, Brenner MJ. Reducing Opioid Prescribing and Consumption After Surgery-Keeping the Lock on Pandora's Box. JAMA Otolaryngol Head Neck Surg 2021; 147:819-821. [PMID: 34351391 DOI: 10.1001/jamaoto.2021.1846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Edward D McCoul
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Associate Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
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23
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Go BC, Go CC, Chorath K, Moreira A, Rajasekaran K. Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review. Otolaryngol Head Neck Surg 2021; 166:820-831. [PMID: 34372726 DOI: 10.1177/01945998211032910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. DATA SOURCES A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov. REVIEW METHODS All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. RESULTS A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. CONCLUSION With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.
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Affiliation(s)
- Beatrice C Go
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cammille C Go
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Chorath
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alvaro Moreira
- Department of Pediatrics, Division of Neonatology, University of Texas Health-San Antonio, San Antonio, Texas, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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24
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Gray BM, Vandergrift JL, Weng W, Lipner RS, Barnett ML. Clinical Knowledge and Trends in Physicians' Prescribing of Opioids for New Onset Back Pain, 2009-2017. JAMA Netw Open 2021; 4:e2115328. [PMID: 34196714 PMCID: PMC8251502 DOI: 10.1001/jamanetworkopen.2021.15328] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/29/2021] [Indexed: 12/28/2022] Open
Abstract
Importance Opioid musculoskeletal pain overprescribing was widespread in the mid-2000s. The degree to which prescribing changed as awareness of the danger grew among physicians with different levels of clinical knowledge remains unstudied. Objective To compare the association of clinical knowledge with opioid prescribing from 2009 to 2011 when prescribing peaked nationally with 2015 to 2017 when guidelines shifted away from opioid prescribing. Design, Setting, and Participants This cross-sectional study included 10 246 midcareer general internal medicine physicians in the United States who saw patients who were Medicare beneficiaries with Part D enrollment from 2009 to 2017. Main Outcomes and Measures Any opioid prescription and high dosage or long duration (HDLD) (>7 days or >50 daily morphine milligram equivalents) opioid prescriptions filled within 7 days of applicable visits for new low back pain concerns. Associations between opioid prescribing for new low back pain concerns during outpatient visits and clinical knowledge measured by prior year American Board of Internal Medicine (ABIM) Maintenance of Certification examination performance were estimated using serial cross-sectional logit regressions. Regression covariates included yearly examination quartile (ie, knowledge quartile) interacted with 3-year group dummies (ie, early: 2009-2011; middle: 2012-2014; late: 2015-2017), state and year dummies, physician, practice, patient characteristics, and state opioid regulations. Results Of the 55 387 low back pain visits included in this study, 37 185 (67.1%) were visits with female patients, 41 978 (75.8%) were with White patients, and the mean (SE) age of patients was 76.2 (<0.01) years. The rate of opioid prescribing was 21.6% (11 978) for any opioid prescription and 17.6% (9759) for HDLD prescriptions. From 2009 to 2011, visits with physicians in the highest and lowest knowledge quartiles had similar adjusted opioid prescribing rates with a 0.5 (95% CI, -1.9 to 3.0) percentage point difference. By 2015 to 2017, visits with physicians in the highest knowledge quartile prescribed opioids less frequently that physicians in the lowest knowledge quartile (4.6 percentage point difference; 95% CI, -7.5 to -1.8 percentage points). Visits in which HDLD opioids were prescribed showed no difference in the early period but showed a difference in the late period when comparing physicians in the highest and lowest knowledge quartiles (early period: difference -0.1; 95% CI, -2.4 to 2.2 percentage points; late period difference: 4.8; 95% CI, -7.4 to -2.1 percentage points). Conclusions and Relevance In this cross-sectional study, when the standard of care shifted away from routine opioid prescribing, physicians who performed well on an ABIM examination were less likely to prescribe opioids for back pain than physicians who performed less well on the examination.
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Affiliation(s)
- Bradley M. Gray
- American Board of Internal Medicine, Philadelphia, Pennsylvania
| | | | - Weifeng Weng
- American Board of Internal Medicine, Philadelphia, Pennsylvania
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25
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Dahm V, Lui JT, Liepins R, Chen JM, Le TN, Arnoldner C, Lin VYW. Is otologic surgery contributing to the opioid epidemic? J Otolaryngol Head Neck Surg 2021; 50:38. [PMID: 34158125 PMCID: PMC8220669 DOI: 10.1186/s40463-021-00521-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background The opioid epidemic is a significant public health crisis challenging the lives of North Americans. Interestingly, this problem does not exist to the same extent in Europe. Surgeons play a significant role in prescribing opioids, especially in the context of post-operative pain management. The aim of this study was to compare the post-surgical prescribing patterns of otologists comparing Canada and Austria. Methods An online questionnaire was sent to 33 Canadian and 32 Austrian surgeons, who perform otologic surgery on a regular basis. Surgeons were asked to answer some questions about their background as well as typical prescribing patterns for postoperative pain medication for different ear surgeries (cochlear implant, stapedotomy, tympanoplasty). In addition, surgeons were asked about the typical use of local anesthetics for pain control at the end of a procedure. Otologists gave an estimate how confident they were that their therapy and prescriptions provide sufficient pain control to their patients. Results Analysis of the returned questionnaires showed that opioids are more commonly prescribed in Canada than in Austria. Nonsteroidal anti-inflammatory drugs are used for postoperative pain more regularly after ear surgery in Austria, as opposed to Canada. Some of the prescribed drugs by European otologists are not available in North America. The use of local anesthetics at the end of surgery is not common in Austria. Surgeons´ confidence that the prescribed pain medication was sufficient to control postoperative symptoms was higher in the group not prescribing opioids than in the group that did routinely prescribe opioids. Conclusion Prescribing patterns differ substantially between the two evaluated countries. This data suggests an opportunity to reduce opioid prescriptions after otologic surgeries. Studies to evaluate pain after these operations as well as efficacy of analgesics following ear surgery are an important next step. Graphical abstract ![]()
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Affiliation(s)
- Valerie Dahm
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Justin T Lui
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Rudolfs Liepins
- Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Joseph M Chen
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Trung N Le
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Vincent Y W Lin
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
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26
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Basco WT, Ward RC, Taber DJ, Simpson KN, Gebregziabher M, Cina RA, McCauley JL, Lockett MA, Moran WP, Mauldin PD, Ball SJ. Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010-2017. Int J Pediatr Otorhinolaryngol 2021; 143:110636. [PMID: 33548590 DOI: 10.1016/j.ijporl.2021.110636] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. PATIENTS AND METHODS Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. RESULTS There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. CONCLUSIONS Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.
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Affiliation(s)
- William T Basco
- Pediatrics, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA.
| | - Ralph C Ward
- Public Health Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - David J Taber
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Kit N Simpson
- Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Mulugeta Gebregziabher
- Public Health Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Robert A Cina
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Jenna L McCauley
- Psychiatry and Behavioral Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Mark A Lockett
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - William P Moran
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Sarah J Ball
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
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27
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Rubin S, Wulu JA, Edwards HA, Dolan RW, Brams DM, Yarlagadda BB. The Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology Surgeries. Otolaryngol Head Neck Surg 2021; 164:781-787. [PMID: 33588624 DOI: 10.1177/0194599820987454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Determine whether opioid prescriber patterns have changed for tonsillectomy, parotidectomy, and thyroidectomy after implementation of the Massachusetts Prescription Awareness Tool (MassPAT). STUDY DESIGN Retrospective cohort study. SETTING Single-center tertiary care hospital. METHODS Patients were included if they received tonsillectomy, parotidectomy, or thyroid surgery at Lahey Hospital and Medical Center (Burlington, Massachusetts) between October 1, 2015, and October 1, 2019. Prescribing patterns were compared prior to implementation of MassPAT, October 1, 2015, to October 14, 2016, to postimplementation of MassPAT, October 15, 2016, to October 1, 2019. Quantity of opioids prescribed was described using total morphine milligram equivalents (MME). Data were analyzed using univariate analysis, multivariate analysis, and trend line using line of best fit. RESULTS A total of 737 subjects were included in the study. There was a downward trend in the quantity of opioids prescribed for all 3 surgeries during the study period. There was a significant difference in the quantity of opioids prescribed pre- and postimplementation of MassPAT for tonsillectomy (647.70 ± 218.50 MME vs 474.60 ± 185.90 MME, P < .001), parotidectomy (241.20 ± 57.66 MME vs 156.70 ± 72.99 MME, P < .001), and thyroidectomy (171.20 ± 93.77 MME vs 108.50 ± 63.84 MME, P < .001). There was also a decrease in the number of patients who did not receive opioids for thyroidectomy pre- and post-MassPAT (7.56% vs 24.14%). CONCLUSION We have demonstrated that there is an association with state drug monitoring programs and decrease in the amount of opioids prescribed for acute postoperative pain control for common otolaryngology surgeries.
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Affiliation(s)
- Samuel Rubin
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Jacqueline A Wulu
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Heather A Edwards
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Robert W Dolan
- Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - David M Brams
- Division of General Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Bharat B Yarlagadda
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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28
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Katz AP, Misztal C, Ghiam MK, Hoffer ME. Changes in Single-Specialty Postoperative Opioid Prescribing Patterns in Response to Legislation: Single-Institution Analysis Over Time. Otolaryngol Head Neck Surg 2021; 164:774-780. [PMID: 33528299 DOI: 10.1177/0194599820986577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine changes in the prescriptions of postoperative opioids in response to Florida state legislation restricting the number of days for which these medications could be prescribed to 3 days in most circumstances or 7 days at provider discretion. STUDY DESIGN A retrospective review was performed for all patients undergoing 7 common outpatient otolaryngology surgical procedures. SETTING Single-institution academic center in Florida. METHODS Query of the state's online prescription drug monitoring program was used to compare prescription habits 3 months before and after the law and then again 1 year later. RESULTS A total of 561 patients were identified meeting criteria. The number of days that opioids were prescribed decreased significantly, from 6.42 to 4.48 to 3.03 days. There was a significant decrease in the proportion of patients receiving any postoperative opioid prescription, from 0.80 to 0.52 to 0.32. The total morphine milligram equivalents prescribed decreased from 28.4 before the law to 18.4 at 1 year after. CONCLUSIONS Legislative restrictions on the length of opioid prescriptions were associated with significant decreases in the proportion of patients receiving any opioids, the number of days that opioids were prescribed, and the total morphine milligram equivalents 3 months after the law went into effect, with even more dramatic changes at the 1-year time point. We opine that these changes are due to providers learning that many procedures do not require postoperative opioids and therefore increasingly considering and utilizing nonopioid alternatives in this setting.
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Affiliation(s)
- Andrew P Katz
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA
| | - Carly Misztal
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA
| | - Michael K Ghiam
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA
| | - Michael E Hoffer
- Department of Otolaryngology, Miller School of Medicine, The University of Miami, Miami, Florida, USA.,Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, Florida, USA
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