The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery—A quality improvement project

Abstract

Pain management following pediatric tonsillectomy and adenotonsillectomy surgery is challenging and traditionally involves perioperative opioids. However, the recent national opioid shortage compelled anesthesiologists at Bellevue Surgery Center to identify an alternative perioperative analgesic regimen that minimizes opioids yet provides effective pain relief. We assembled an interdisciplinary quality improvement team to trial a series of analgesic protocols using the Plan-Do-Study-Act cycle.Initially, we replaced intraoperative morphine and acetaminophen (M/A protocol) with intraoperative dexmedetomidine and preoperative ibuprofen (D/I protocol).However, when results were not favorable, we rapidly transitioned to intraoperative ketorolac and dexmedetomidine (D/K protocol). The following measures were evaluated using statistical process control chart methodology and interpreted using Shewhart's theory of variation: maximum pain score in the postanesthesia care unit, postoperative morphine rescue rate, postanesthesia care unit length of stay, total anesthesia time, postoperative nausea and vomiting rescue rate, and reoperation rate within 30 days of surgery. There were 333 patients in the M/A protocol, 211 patients in the D/I protocol, and 196 patients in the D/K protocol. With the D/I protocol, there were small increases in maximum pain score and postanesthesia care unit length of stay, but no difference in morphine rescue rate or total anesthesia time compared to the M/A protocol. With the D/K protocol, postoperative pain control and postanesthesia care unit length of stay were similar compared to the M/A protocol. Both the D/I and D/K protocols had reduced nausea and vomiting rescue rates. Reoperation rates were similar between groups. In summary, we identified an intraoperative anesthesia protocol for pediatric tonsillectomy and adenotonsillectomy surgery utilizing dexmedetomidine and ketorolac that provides effective analgesia without increasing recovery times or reoperation rates. K E Y W O R D S analgesics, anesthesia, dexmedetomidine, ketorolac, quality improvement, tonsillectomy | 683 FRANZ et Al.

<p>Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study</p>

“…in pediatric patients through the use of regional anesthesia and non-opioid medications for various surgical procedures. 8,11,12 Our pilot study utilized an opioid-sparing technique for intraoperative and postoperative analgesia that included 4 medications dextromethorphan, acetaminophen, dexmedetomidine, and ketamine. At our institution, preoperative acetaminophen and intraoperative dexmedetomidine are frequently administered, but the use of the other two medications (dextromethorphan and ketamine) was unique additions to the perioperative regimen.…”

“…To our knowledge, this is the first study describing the combined use of dextromethorphan, acetaminophen, ketamine and dexmedetomidine to manage pain for pediatric patients undergoing otolaryngologic procedures. Although the use of ketorolac has been utilized for pediatric otolaryngological procedures without a reported increase of postoperative bleeding, 11,38,39 a lack of consensus remains due to institutionally dependent tonsillar bleeding rates and differing perceptions among otolaryngologists regarding risk factors and causes of post tonsillectomy hemorrhage. Of note, the pediatric otolaryngologists within our institution preferred to exclude ketorolac in the current study due to conflicting evidence regarding the potential risk of bleeding.…”

“…9,10 To date, these techniques have been successful in managing pain following various surgical procedures in pediatric patients. 8,[11][12][13] The current pilot studies outline a non-opioid technique using a combination of adjunctive agents (acetaminophen, dextromethorphan, ketamine and dexmedetomidine) with analgesic effects in a cohort of children undergoing adenoidectomy. We hypothesized that this technique would provide intraoperative analgesia, postoperative pain management, and facilitate performance of this surgical procedure without the need for perioperative opioids.…”

Postoperative Analgesia Protocol: A Resident‐Led Effort to Standardize Opioid Prescribing Patterns

“…A rapidly growing body of research has demonstrated multiple strategies for reducing postoperative opioid prescriptions, including reducing pill counts, inclusion of nonopioid alternatives, focused patient and provider education as well as preoperative medication regimes. 17‐24 However, within academic medical centers, the nearly 135,000 residents training across all specialties frequently serve as the primary prescribers of postoperative pain control regimens 3,15,25,26 . Resident physicians rarely receive formal training in opioid prescription management and most report low levels of comfort with prescribing these medications 3 .…”

<p>The United States Drug Enforcement Administration and Prescription Opioid Production Quotas: An End Game of Eradication?</p>

“…11 Other subsequent commentaries and studies have confirmed the challenges associated with treating inpatients' pain due to the APQ reductions, [12][13][14][15][16][17][18] including those addressing treating children perioperatively and postoperatively. 19,20 Up to this point, reports of APQ reduction-related shortages of oral opioids are only anecdotal, with numerous reports from patients on social media. In these cases, the patients (generally suffering from chronic non-cancer pain) report that their pharmacies have "run out" of medications that they have taken for many years, although these patients have not been privy to whether these lacks of availability are due to APQ reductions or other supplyside issues within their own pharmacies.…”