Opioid stewardship in pediatric surgery: Approaching zero

Calderon, Thais; Hedges, Elizabeth A.; Livingston, Michael H.; Gitzelmann, Christopher A.; Pegoli, Walter; Wakeman, Derek

doi:10.1016/j.jpedsurg.2020.08.035

Cited by 7 publications

(6 citation statements)

References 19 publications

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“…Indeed, other authors have shown that MIS approaches at least in non-cancer pediatric surgical cases promoted opioid stewardship postoperatively, given the smaller incisions, and achieved more adequate pain control at discharge. 16,17 Patients in our series who underwent MIS resection of WT appeared to require fewer morphine equivalents postoperatively compared to open procedures, although this different was not statistically significant. As expected, the rate of epidural use was significantly lower in MIS approaches compared to open procedures, with no MIS patients receiving an epidural.…”

Section: Discussionmentioning

confidence: 64%

“…Indeed, other authors have shown that MIS approaches at least in non-cancer pediatric surgical cases promoted opioid stewardship postoperatively, given the smaller incisions, and achieved more adequate pain control at discharge. 16,17 When defining the ideal WT patient for MIS resection, clearly those scenarios warranting neoadjuvant chemotherapy are most appealing. This study adds novel evidence that calculating WT volumes, both for radical nephroureterectomies and nephron-sparing resections, can reveal opportunities to maintain better therapy timelines with equivalent oncologic fidelity through MIS approaches.…”

Section: Discussionmentioning

confidence: 99%

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Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors

McKay

Ghani

Crane

et al. 2022

The American Surgeon

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Background The Children's Oncology Group recommends upfront resection of Wilms tumor (WT), however, unique scenarios warrant neoadjuvant chemotherapy and delayed resection. We hypothesized that in the context of neoadjuvant chemotherapy, minimally invasive surgery (MIS) to resect WT achieves equivalent oncologic fidelity and better maintains therapy schedules. Methods A retrospective analysis of WT treated between 2010-2021 at a free-standing children's hospital was performed. Patient and disease specific characteristics were collected, and pre-resection tumor volumes (TV) were calculated. Impact of MIS or open resection on oncologic fidelity and time to resume chemotherapy was analyzed. Results For the study period, 62 patients were treated for 65 WT, and 14 patients (22.6%) received neoadjuvant chemotherapy to treat 17 WT (26.2%): 7 Stage I (all predisposition syndromes), 2 stage III, 7 stage IV, and 1 stage V (bilateral). MIS was utilized to resect 6 WT from 5 patients. For partial nephrectomy, pre-resection TV was 0.38 ml if MIS and 10.38 ml if open ( P = .025). For radical nephrectomy, pre-resection TV was 31.58 ml if MIS and 175.00 ml if open ( P = .101). No significant differences between surgical approach were detected regarding pathologic variables or survival. Epidural use was significantly greater with open procedures ( P = .001). Length of stay was 2.00 days after MIS compared to 6.00 for open resection ( P = .004). Time to resume chemotherapy was 7.00 days after MIS versus 27.00 for open ( P = .004). Conclusion After neoadjuvant chemotherapy for WT, MIS partial and radical nephrectomies achieved equivalent oncologic fidelity, reduced epidural use and post-operative stays, and better maintained adjuvant therapy timelines when compared to open resections.

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Section: Discussionmentioning

confidence: 64%

“…Indeed, other authors have shown that MIS approaches at least in non-cancer pediatric surgical cases promoted opioid stewardship postoperatively, given the smaller incisions, and achieved more adequate pain control at discharge. 16,17 When defining the ideal WT patient for MIS resection, clearly those scenarios warranting neoadjuvant chemotherapy are most appealing. This study adds novel evidence that calculating WT volumes, both for radical nephroureterectomies and nephron-sparing resections, can reveal opportunities to maintain better therapy timelines with equivalent oncologic fidelity through MIS approaches.…”

Section: Discussionmentioning

confidence: 99%

Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors

McKay

Ghani

Crane

et al. 2022

The American Surgeon

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“…Multiple other studies in umbilical and inguinal hernia repair have demonstrated a majority achieve adequate pain control without any opioid use. 26,27 As a result of these studies, the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee published recommendations an opioid-free recovery be used for common pediatric surgical procedures. 10 However, we do not yet know the implications this recommendation may have on postoperative pain control and representations to care.…”

Section: Discussionmentioning

confidence: 99%

Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children’s Hospital

Stephenson,

Krinock,

Vasquez

et al. 2024

J Patient Saf

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Objectives Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. Methods We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. Results A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed (P < 0.0001), prescriptions filled (P = 0.009), and opioid doses taken (P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call (P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. Conclusions Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.

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“… 3 , 8 Our team previously demonstrated that general surgery procedures can be performed in children with minimal to no opioid prescribing at discharge. 25 Standardizing nonopioid pain control methods preserved length-of-stay goals while minimizing opioid prescribing at discharge. In addition, the low rate of postoperative antibiotic prescribing is concordant with national pediatric appendicitis guidelines.…”

Section: Discussionmentioning

confidence: 99%

Value Added from Same-day Discharge after Appendectomy for Children with Simple Appendicitis

Juviler

Wilson

Livingston

et al. 2023

Pediatric Quality &Amp; Safety

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Introduction: Same-day discharge of children after appendectomy for simple appendicitis is safe and associated with enhanced parent satisfaction. Our general pediatric surgeons aimed to improve the rate of same-day discharge after appendectomy for simple appendicitis. Methods: We implemented a clinical practice guideline in September 2019. A surgeon-of-the-week service model and the urgent operating room started in November 2019 and January 2020, respectively. Data for children with simple appendicitis from our academic medical center were gathered prospectively using National Surgical Quality Improvement Program-Pediatric. Patient outcomes before intervention implementation (n = 278) were compared with patients following implementation (n = 264). Results: The average monthly percentage of patients discharged on the day of surgery increased in the postimplementation group (32% versus 75%). Median postoperative length of stay decreased [16.5 hours (interquartile range, 15.9) versus 4.4 hours (interquartile range, 11.7), P < 0.001], and the proportion of patients discharged directly from the postoperative anesthesia care unit increased (22.8% versus 43.6%; P < 0.001). There were no differences in balancing measures, including the return to the emergency department and readmission. Fewer children were discharged home on oral antibiotics after implementation (6.8% versus 1.5%, P = 0.002), and opioid prescribing at discharge remained low (2.5% versus 1.1%, P = 0.385). Conclusions: Using quality improvement methodology and care standardization, we significantly improved the rate of same-day discharge after appendectomy for simple appendicitis without impacting emergency department visits or readmissions. As a result, our health care system saved 140 hospital days over the first 21 months.

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Opioid stewardship in pediatric surgery: Approaching zero

Cited by 7 publications

References 19 publications

Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors

Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors

Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children’s Hospital

Value Added from Same-day Discharge after Appendectomy for Children with Simple Appendicitis

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