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Martin LD, Franz AM, Rampersad SE, Ojo B, Low DK, Martin LD, Hunyady AI, Flack SH, Geiduschek JM. Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Paediatr Anaesth 2023; 33:699-709. [PMID: 37300350 DOI: 10.1111/pan.14705] [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: 01/16/2023] [Revised: 04/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.
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Affiliation(s)
- Lynn D Martin
- Department of Anesthesiology & Pain Medicine and Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Amber M Franz
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sally E Rampersad
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Bukola Ojo
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Daniel K Low
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Lizabeth D Martin
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Agnes I Hunyady
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sean H Flack
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeremy M Geiduschek
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
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Misurac JM, Grinsell MM, Narus JH, Mason S, Kallash M, Andreoli SP. NSAID-associated acute kidney injury in hospitalized children - a prospective Pediatric Nephrology Research Consortium study. Pediatr Nephrol 2023; 38:3109-3116. [PMID: 36943469 DOI: 10.1007/s00467-023-05916-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) in children has serious short-term and long-term consequences. We sought 1) to prospectively describe NSAID-associated AKI in hospitalized children; 2) to determine if NSAID-associated AKI was more severe in younger children < 5 years; and 3) to follow outcomes after hospitalization for NSAID-associated AKI. METHODS This was a prospective, multi-center study in hospitalized children 1 month to 18 years. Parents/guardians were given a brief questionnaire to determine the dosing, duration, and type of NSAIDs given. Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria were used to stage AKI severity. Patients with other causes of AKI were excluded (e.g., other nephrotoxins, sepsis, malignancy, etc.). RESULTS We identified 25 patients with NSAID-associated AKI, accounting for 3.1% of AKI. All 25 had AKI upon hospital presentation. The median age was 15.5 years, and 20/25 (80%) had volume depletion. Median duration of NSAID use was 2 days, and 63% of patients took the normal recommended NSAID dose. Median hospital length of stay was 4 days, and none required dialysis. At the most recent estimated glomerular filtration rate (eGFR) after discharge (available in 17/25 patients), only 4/17 (24%) had eGFR ≥ 90 ml/min/1.73 m2, and 13/17 (76%) had eGFR 60 to < 90 ml/min/1.73 m2, indicative of abnormal kidney function. CONCLUSIONS NSAID-associated AKI usually occurs with recommended NSAID dosing in the setting of dehydration. Follow-up after AKI showed a substantial rate of CKD. Therefore, we recommend that NSAIDs should not be used in dehydrated children. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Jason M Misurac
- Division of Pediatric Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, 200 Hawkins Dr, Iowa City, IA, 52242, USA.
- Department of Pediatrics, Pediatric Nephrology, Indiana University Medical Center, Indianapolis, IN, USA.
| | - Matthew M Grinsell
- Division of Pediatric Nephrology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - JoAnn Hansen Narus
- Division of Pediatric Nephrology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Sherene Mason
- Division of Pediatric Nephrology, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Mahmoud Kallash
- Division of Pediatric Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sharon P Andreoli
- Department of Pediatrics, Pediatric Nephrology, Indiana University Medical Center, Indianapolis, IN, USA
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Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs 2022; 24:603-655. [PMID: 36053397 PMCID: PMC9592650 DOI: 10.1007/s40272-022-00514-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
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Affiliation(s)
- Victoria C. Ziesenitz
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany ,grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland
| | - Tatjana Welzel
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.411544.10000 0001 0196 8249Pediatric Rheumatology and Autoinflammatory Reference Center, University Hospital Tuebingen, Tuebingen, Germany
| | - Madelé van Dyk
- grid.1014.40000 0004 0367 2697Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide, SA Australia
| | - Patrick Saur
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Gorenflo
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Johannes N. van den Anker
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.239560.b0000 0004 0482 1586Division of Clinical Pharmacology, Children’s National Hospital, Washington DC, USA ,grid.416135.40000 0004 0649 0805Intensive Care and Department of Pediatric Surgery, Sophia Children’s Hospital, Rotterdam, The Netherlands
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Lizardo RE, Langness S, Davenport KP, Kling K, Fairbanks T, Bickler SW, Grabowski J. Ketorolac does not reduce effectiveness of pleurodesis in pediatric patients with spontaneous pneumothorax. J Pediatr Surg 2015; 50:2035-7. [PMID: 26385568 DOI: 10.1016/j.jpedsurg.2015.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/24/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Antiinflammatory medications are thought to reduce the effectiveness of pleurodesis performed for the treatment of spontaneous pneumothorax. We reviewed our experience with children undergoing video-assisted thorascopic surgery (VATS) with pleurodesis for pneumothorax to determine if ketorolac administration influences patient outcomes. METHODS A retrospective review of patients who underwent VATS pleurodesis for spontaneous pneumothorax from 2009 to 2013 at a pediatric hospital was performed. Length of stay, radiographic pneumothorax resolution prior to discharge, and ipsilateral recurrence rates were compared in patients who did and did not receive perioperative ketorolac. RESULTS Over a 50-month period, 51 patients underwent VATS with mechanical pleurodesis for spontaneous pneumothorax. The average age was 15.5years, and 76% were male. Ketorolac was administered to 26/51 patients. There were no differences in average length of stay (11.3 vs 10.9days, p=0.36), incidence of residual pneumothorax at discharge (22/41 vs 19/41, p=0.48), or ipsilateral recurrence (5/10 vs 5/10, p=1). CONCLUSIONS Despite the intrinsic antiinflammatory properties of ketorolac, our data suggests that its use for patients undergoing pleurodesis for spontaneous pneumothorax does not detrimentally influence the outcomes of surgery. Therefore, we conclude that ketorolac can be used for pain control in this population. Large-scale studies are warranted to validate these findings.
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Affiliation(s)
- Radhames E Lizardo
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA.
| | - Simone Langness
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Katherine P Davenport
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Karen Kling
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Timothy Fairbanks
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Stephen W Bickler
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Julia Grabowski
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Nonsteroidal anti-inflammatory drugs are an important cause of acute kidney injury in children. J Pediatr 2013; 162:1153-9, 1159.e1. [PMID: 23360563 DOI: 10.1016/j.jpeds.2012.11.069] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Revised: 11/08/2012] [Accepted: 11/21/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To characterize nonsteroidal anti-inflammatory drug (NSAID)-associated acute kidney injury (AKI) in children. STUDY DESIGN We conducted a retrospective chart review of children diagnosed with AKI through the use of International Classification of Diseases, Ninth Revision diagnosis code 584.5 or 584.9 from January 1999 to June 2010. Medical records were reviewed to confirm the diagnosis of AKI and to quantify NSAID administration. Pediatric RIFLE criteria were used to codify AKI. Patients were not classified as having NSAID-associated AKI if they had a diagnosis explaining AKI or comorbid clinical conditions predisposing to AKI development. RESULTS Patients (N=1015) were identified through International Classification of Diseases, Ninth Revision screening. Twenty-one children had clinical, laboratory, and radiographic studies suggesting NSAID-associated acute tubular necrosis and 6 had findings suggesting NSAID-associated acute interstitial nephritis, representing 2.7% (27 of 1015) of the total cohort with AKI and 6.6% when excluding complex patients with multifactorial AKI. Children with NSAID-associated AKI had a median (range) age of 14.7 years (0.5-17.7 years); 4 patients (15%) were <5 years old. Fifteen of 20 children (75%) for whom dosing data were available received NSAIDs within recommended dosing limits. Patients<5 years old were more likely to require dialysis (100% vs 0%, P<.001), intensive care unit admission (75% vs 9%, P=.013), and a longer length of stay (median 10 vs 7 days, P=.037). CONCLUSIONS NSAID-associated AKI accounted for 2.7% of AKI in this pediatric population. AKI typically occurred after the administration of correctly dosed NSAIDs. Young children with NSAID-associated AKI may have increased disease severity.
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Abstract
The accurate assessment and effective treatment of acute pain in children in the hospital setting is a high priority. During the past 2 to 3 decades, pediatric pain management has gained tremendous knowledge with respect to the understanding of developmental neurobiology, developmental pharmacology the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. A wide range of medications is available to treat a variety of pain types. This article provides an overview of the most common analgesic medications and techniques used to treat acute pain in children.
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Affiliation(s)
- F Wickham Kraemer
- University of Pennsylvania, School of Medicine, Department of Anesthesiology and Critical Care, Philadelphia, PA 19104, USA.
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