Opioid Use in Pediatric Surgery

We, I think all now recognize the importance of the opioid problem and certainly in our earlier polling, it even seemed that it was a very high rate of people doing the right thing. However, when you actually look at data that's been published in recent years, not everybody is plugged in. So I do think it's worth going through again. This was two days ago for my Buffalo News newspaper, the opioid crisis may be over according to a county administrator. But the experts disagree. Uh, you do a laparoscopic appendectomy for acute appendicitis, five hours later, you're ready to discharge. What do you send them home on? All right, I'm going to move on. That's Because because we we did it the first part. I know I know we we practiced, right? I this question is irrelevant. So, is that so, okay. Are you really 100% with that? Our our group is because we we had an intervention. We really did. With someone who wasn't uh No, no, no, we we just as a group got together and decided we were going to do this and The question is then they're going to come back and you can't call in the narcotics. So what do you do? Say that again? The the question has been in previous years when we talk about opioids that if you risk the chance of sending them home with nothing, they're going to get the call in about four hours or 3:00 in the morning that you have to write them a script. And you can't do that, right? Is that what you're saying? Saying it's well, it's It's it's harder to do that now, right? Right, it's harder to do that. They have to come back to the hospital. You say come back to the ED, I guess, but we have not had that problem for acute appendicitis. The same question about umbilical. Do you put them on schedule? Yes, every four hours alternating alternating yeah, when they're awake alternating acetaminofen and ibuprofen. So, um, so let me Julie Rios is going to be giving a talk here and actually I was looking for your title to introduce you, but I'll do it later. Um, but she's one of our um gynecologists here at Cincinnati Children's. You take care of adult patients. Correct. What about is what's happening in adults? Are you giving less narcotics to the adults? I give less narcotics to the adults. Um, so I also use try to use acetaminofen and ibuprofen and then I will send them home with a few of the narcotics separate. So it's not linked to the ibuprofen kind of as breakthrough. So if you get that call in the middle of the night, they have something that they can use as breakthrough, but it's only for one or two days. So you give a few. I give a few and it's just the oxycodone by itself. So I let's people chat in the group. I'm very curious what people are doing in other countries with narcotics, okay? Let's keep going. Can I ask, can I ask a question? How how many people are using total in these kids? Like give them a dose of total before they wake them up? I always do. I'm a big fan of total. I have some data on that too a little bit later, so. Sorry. Oh, no. Thunder stealer. Uh looks like for umbilical hernia repairs, it's either just acetaminofen or the combo. But the background here is over the past 18 years, 9,000 children and adolescents have died from this. Uh mortality rate has increased threefold, mostly males, but even in kids zero to four, there's a 7% death rate from kids getting opioids and 25% of those have been homicides. 81% are adolescent. The heroin death uh death rate has increased 400 485% and opioids almost twofold. This is an uh uh 2018 publication. Mac, Kurt Heist just wrote Kurt Heist, for those of you don't know from Atlanta, has talked to us before in this event about about enhanced recovery. He says the RTS, what's RTS? Return to system. The return to system, that's total Atlanta term because I don't think the the return to system or coming back to the hospital or call backs are the same for those with or without opioids, if the Tylenol motrin dosings are scheduled and given in advance. Kurt, thanks for that. That's uh Thank you, Kurt. Uh so here's some data again, not just audience. So here's a study looking at 06 to 14 and again maybe we've gotten past that now, but 68% of those patients were prescribed opioids. Uh and the adult general surgeons tended to give more than the pediatric surgeons. Uh and the opioid group has uh increased ED visits for constipation. And I I know I've seen that. So, some data from our Umbilico reflecting rethinking back to our own uh results. I'm sorry that small. This is 12 to 15 data. Uh 4,000 umbilical hernias, 52% received post op opioids is a post to our data which was zero in our vote right here, right? Zero. Oh, here. Here in the vote. Yeah. Um, six years old or older tended to get a get more opioids than younger kids and Southern US was more problematic than Northeast. And again the duration less than three days was 50%. Four to 10 days was almost 50% and greater than 10 days 4%. So again recent years have shown this to still be a real problem. Um This was a a small study led by David Rosteen and Sarah Cairo at our place in Buffalo. Uh just published uh earlier this year where this is the intervention Todd. So we we looked at how much uh pain medicine we gave for simple things like appendectomy and then we did an intervention where we educated everybody including nurses, anesthesiologist the whole hospital. And then we remeasured again after the intervention. This is more of a you can do it slide. So here is our early the first post-op orders, use of APAP as acetaminofen again, ibuprofen, ketorolac, morphine, and then a combination of hydrochlorine and acetaminofen and um the blue is after the intervention. You can see that uh dramatic chain increases in non opioids or narcotics. It was interesting that morphine didn't change. Yeah, I saw that. Now is that recorded because it was given in the operating room? Like by that was given by anesthesia probably. No, this is post stop surgeon ordering. Okay. So you can imagine maybe an early post stop one dose or something like that. Yeah. Uh then this just sort of restates those same information and shows P values to what was significant in their change. And this is now a discharge, pre-intervention and post-intervention. So pre-intervention, 84% of our patients got narcotic at discharge for an appendectomy down to 7%. Uh 31% got acetaminofen up to 94%. 58 got ibuprofen went up to 86%. Mirallax automatically at discharge dropped from 77 to 47 as we had less problems with constipation. It's amazing. So, um Kurt uh uses Gatin too. Do you guys use that at all? Uh I don't, but I I anybody in the room could comment on that. I'm interested. Dan. I don't personally use it but we're able to to uh from Cinci let's pass it around. Vonman from Cincinnati says that uh we use Gabba here. This is Mark Wolken. We we use Gabba extensively uh in Atlanta. Uh you know, Kurt, Kurt got us started on that, but it's uh really remarkable how it's changed the pain management for the kids and even for the kids that have had major operations when you give a dose preoperatively and continue it post op, the it's really remarkable how well they do. Can you tell us how it's dosed? So we we're using basically 300 milligrams TID in uh in the in the bigger kids. Uh and then uh I I want I I I don't I'm not going to say our dose publicly. it's in the order set. So I I don't know what it is for the smaller kids. I Kurt Kurt can text it in or type it in. So Dr. Hest responded for the Gabapentin dose in the younger kids, 5 milligrams per kilo per dose TID for three to five days. What about in kids who are NPO? You continue to give it to them even if they're NPO. Well, as part of our ERAS protocol, we have very short NPO times. Yeah, they're NPO if they want to be. I mean, one of the challenges with Gabba though in some of the younger kids, it's it's a large volume in the liquid form to get the right dose in, but it hasn't been a it hasn't been a terrible problem. Has has has it helped in operations like pectus repair? And have you seen a decrease? So I I I think but we do we're doing multiple things in the pectus patients. We're also doing uh doing intercostal nerve blocks and some things like that. Uh we just we just now I think we I think we're finally got our cryoprobe. I don't think we've used it yet. Uh we're going to do some of that as well. But for example in my bariatric patients, we, you know, it used to be the first night there usually kind of miserable and we went from postop day one discharge about 20% of the time till now 50 plus percent of the time we can get them home on the first postop day. Frederick Scola. And we use Gapatin as well. It mainly with our pectus protocol and found it to be helpful, but there are multiple other aspects of the protocol. Just out of curiosity does uh are you using that in adults, Julie? Uh did you change the way you manage patients post operatively or not formally yet? I don't know if I really formally did. I mean most of mine is laparoscopic surgery. so most of patients go home the same day. Fully out before we leave the OR, so trying to make sure the patients are doing well. From a open standpoint, if I do an open case, I've used a lot of tap blocks um with anesthesia and most of my patients go home post op day one. Tap blocks. Who here is using uh can you explain what a tap block is? Cuz So essentially it's a um medicine that goes in uh intercally into the um they essentially give numbing medicine and it's a catheter that stays in that essentially numbs the abdominal uh wall and essentially allows them to get up, move, um they'll pass gas that same day because they're not really using any narcotic medication and we just schedule ibuprofen and Tylenol with it. Uh and we have a question uh from Dr. Gray, Fabian Gray. Anyone using IV Tylenol and are you having trouble with your hospitals letting you use it? Occasionally and yes. I use it, we use it quite a bit. It's acron Cincinnati, I don't know here too. I'm getting the nods about here too. Yes. I I'm going to make uh IV Tylenol is is very expensive as everybody knows and I know I'm involved with I guess I'm one of the IV Tylenol police in our hospital along with our P&T committee. But we have what we where we've loosened up is in places where it's appropriate in our cardiac ICU and the NIU and some places like that. But the reality is that it's no more or less efficacious than perrectum Tylenol. So, unless you if your patient has a rectum that and it can be administered that way. I mean it's it's it's literally cents versus a lot a very well it's a lot of money, but the the other piece the other confounding factor is that we've actually softened up on it a little bit because it is now much cheaper than it was. It used to be hundreds of dollars a dose and I think it's maybe 20 or 30 a dose. But the reality is that it's perrectum works just as well with the same bioavailability. prospective randomized trials? I I don't know. I I don't know. My Max calling me out on whether it's class A evidence. Yeah, big news. Well, I know there's some kinetic stuff that the pharmacists show me in the in the pharmacy in the pharmacy literature about bioavailability.