An Opioid-free Anesthesia Protocol for Pediatric Strabismus Surgery: A Quality Improvement Project

Abstract

Introduction: This quality improvement (QI) project tracks a series of 2 Plan-Do-Study-Act (PDSA) cycles as we standardized and refined an ambulatory pediatric anesthesia strabismus protocol. We aimed to provide effective pain relief, reduce postoperative nausea and vomiting (PONV) rates, and be cost-efficient while minimizing perioperative opioids over 5 years. Methods: We used statistical process control (SPC) charts to analyze real-world data captured from the medical record. We chose the following outcome and process measures to evaluate effectiveness: postoperative morphine rescue rate, maximum pain score in the postanesthesia care unit (PACU), and PONV rescue rate. We also used 2 balancing measures: postoperative length of stay (LOS) and total anesthesia time. We standardized our anesthesia protocol for our first PDSA cycle (April 2017) by removing intraoperative intravenous acetaminophen and utilizing fentanyl only. For the second PDSA cycle (January 2019), we replaced intraoperative fentanyl with dexmedetomidine. Results: There was a total of 325 pediatric strabismus repair surgeries performed between April 2015 and July 2020. There was no special cause variation detected in the SPC charts for the family of measures chosen to measure effectiveness: postoperative morphine rescue rate, maximum pain score in the PACU, or the PONV rescue rate. The PONV rescue rate was 0 with the removal of opioids. Also, there was no special cause variation for the balancing measures: postoperative LOS or total anesthesia time. Conclusions: Throughout 2 PDSA cycles, this QI project enabled our team to standardize an opioid-free and cost-efficient anesthesia protocol for pediatric strabismus surgery over 5 years.

Reducing Opioid Prescriptions after Common Outpatient Pediatric Urologic Surgeries: A Quality Improvement Assessment

“…10,11 Examples of similar quality improvement projects organized in other subspecialty fields have had similar aims and efficacy of decreased opioid medication consumption. [12][13][14][15] Utilizing these principles after deciding to proceed with the AAP's challenge statement, we reviewed our department's baseline dose administration for common urologic outpatient procedures (circumcision, orchiopexy, and IHR) before the initiation of our project. We also reviewed our state's prescribing laws to inform all levels of prescribing providers (surgeon, resident physician, and advanced practice provider) and any changes that may affect our prescribing patterns.…”

“…10,11 Examples of similar quality improvement projects organized in other subspecialty fields have had similar aims and efficacy of decreased opioid medication consumption. 12–15…”

Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative

“…20,21 Built on these principles, the team previously developed opioid-sparing techniques that significantly reduce perioperative opioids for surgery. 22–25…”

“…20,21 Built on these principles, the team previously developed opioid-sparing techniques that significantly reduce perioperative opioids for surgery. [22][23][24][25] After a review of pediatric ERP elements, the ASC leadership committed to a plan to (1) improve existing ERP elements and (2) implement missing ERP elements deemed appropriate for the surgical population. The preparation phase started July 1, 2020 and ended January 24, 2021.…”

Improved postoperative recovery profile in pediatric oral rehabilitation with low-dose dexmedetomidine as an opioid substitute for general anesthesia: a randomized double-blind clinical trial

“…However, there is inadequate data to establish an outcome [ 9 ]. Recently, there has been a trend towards use opioid-free anesthesia in pediatric ambulatory procedures [ 10 11 12 ]. An ideal opioid-free anesthetic agent should be rapid in onset and offset, with smooth emergence, minimal cardiovascular effects, and a predictable response.…”