PAPS -Perioperative Opioid Use In Paediatric Inguinal Hernia Patients- A Systematic Review And Retrospective Audit Of Practice - Isabel Hageman

First, we have for um our first presentation of the event and first from Paps, we have Doctor Isabelle Hageman. She's gonna, uh we're gonna watch her video from her presentation on perioperative opioid use in pediatric inguinal hernia patients. And then Todd is gonna start out with some commentary after that and start the con uh start the conversation. So let's get started with that video. Hi, my name is Isabel Hackerman and I will be presenting a retrospective audit on perioperative opioid use in pediatric surgical patients. Opioids play an important role in perioperative pain management in pediatric surgical patients. They can have serious side effects and increase the risk for resentation to the emergency department and future opioid misuse. Also, there are no procedure-specific guidelines for opiate use like there are in adults. We aim to explore opiate use in inguinal hernia patients at the Royal Children's Hospital in Melbourne, Australia. The subjects were pediatric patients that underwent an inguinal hernia repair between May and December 2019. They were excluded if they underwent another procedure simultaneously or had an allergy or contraindication for opioids. The data was extracted from the departmental database and electronic medical record and and collected in redcap. The primary outcome was opioid use in the postoperative period, and secondary outcomes for opioid prescription and discharge, intraoperative opioid use, and non-opioid analgesia use, and all doses were converted to oral morphine equivalents. 150 patients were included in the final analysis and were mostly premature males with the median age of 3 months, and nearly everyone was opioid naive. Median length of stay was 23.6 hours and duration of surgery was 41 minutes. The majority had general anesthesia with the addition of a regional block. 20% of patients received opioids intraoperatively, which was mostly fentanyl. Post-operatively, 17% received opioids, which was mostly fentanyl in the PACU and oxycodone thereafter. 33% of patients received opioids during their entire hospital stay and were significantly older than patients who didn't receive opioids. No patients received an opiate prescription at discharge. We found that increasing age increased the risk for postoperative and total opiate use, and there was also a significant association between female sex and total opioid use. Surprisingly, preoperative paracetamol did not reduce opioid use, nor did it lower the doses in patients that did receive opioids. Addition of regional blocks significantly lowered postoperative opiate use, and general anesthesia was found to be a risk for total, but not postoperative opioid use. So, opioids play a limited role in the pain regimens at the RCH contrary to other parts of the world. Older age and female sex are factors that increased the rates of opioid use, while addition of a regional block reduced it. We found a wide variation in doses in patients that did receive opioids, which might be because pain assessment is difficult in young patients. We also found that patients with regional anesthesia only had much lower doses than in patients with general anesthesia, with or without the addition of a regional. In conclusion, adequate use of neur actual techniques, reliable pain assessment tools, and pediatric procedure-specific perioperative opioid prescribing guidelines may help improve the quality and safety of care in this vulnerable population. Thank you. All right. Well, thank you, Doctor Hageman, for that, that presentation. Um, I see why it was one of the finalists. I think that this highlights a big point that doesn't just relate to hernias, but the fact is, one of the big changes I've seen in my practice over the last decade is I used to give everybody narcotics after surgery, and I can't remember the last time I prescribed narcotics. So, this is a big Uh, slice of the pie, uh, of all the different procedures we do, just demonstrating how we really don't need to give what we used to. There were some questions I had for you. Uh, number one, the length of stay, the average length of stay was 24 hours, about. Um, is that, is that because, I mean, do you routinely admit your hernias? Uh, because our length of stay is probably an hour. Uh, unless it's, uh, a preemie that fit the criteria for risk of apnea to stay overnight. So that was, that was my one question. Uh, another question I had is, um, I think it's fantastic you do the regional blocks. You said it in some patients. Um, are you doing any of these under spinal, uh, without any general anesthesia? Um, I'll tell you what I was totally shocked about. Men are wimps. Yet, the females had the higher need for pain control. That totally shocked me cause I would have thought the exact opposite. Um, and, uh, and I also wanna talk about lap versus open, if, if that was, if there's any lap, and if you saw a difference. So, phenomenal paper. This, this is why this is gonna be a great day. It is, I would have never seen this paper had, had we not had uh an event like this to bring everyone together. So thank you for presenting that. So, uh, Doctor Hageman, why don't you respond and then we can open up to the gallery for discussion. Um, thank you, Todd, for your commentary. Um, to answer your first question in terms of, um, length of stay, it's true that most of the patients, they don't actually, uh, they aren't actually admitted, but I think that the median was high due to a number of Yeah, preemies and um uh children that were already admitted to the hospital and then had inguinal hernia surgery as one of the reasons they were admitted to the hospital. So I think that kind of um was the reason why the median was a little bit higher, but generally, all the elective inguinal hernia patients, they only get admitted for a couple of hours and uh and they straight after from the PACU they go home. OK. And then your second question, um, about the regionals and the spinal, I think. Yeah, do you, do you do any under spinal anesthesia? Yeah, yeah, there's a couple in the spinal anesthesia, um, but I don't think I, um, actually did a sub-analysis on that specifically because it was too small to, uh, to see the, the sample, um, the differences in sample sizes. But yeah, that happens a lot and it was found that general, um, anesthesia was, was a, was a risk factor for opioid use in general. So I think, uh, we are definitely moving towards more, uh, spinals only. I, yeah, I have to, oh, go ahead, go ahead. No, no, no, no, go ahead. Well, I do have to say I never knew. I think I'm way behind the times, as always. I'm like the slowest in the world to learn things, but this spinal anesthesia thing was new to me over the last month. Um, one of our anesthesiologists, Matthew Mitchell in Akron. Uh, has been doing our cases that way. I can't believe they don't need a general. There's no PACU. There's just wide awake, you operate, and they don't move and they go home. I'm like, this is gonna change pediatric surgery. Um, so, yeah. Yeah, I think definitely in the very, very young, uh, young, uh, sorry? Oh, yeah, I think in the very young children especially, it's easy to do a spinal because they don't really get, I mean, of course, they're crying and stuff, but it's not like it's an older child that's really experiencing all the potentially traumatic, uh, things for. From being in the OR and being operated upon and if it's, if it's a baby, um, then, uh, because the, the median age was 3 months, so then I think, uh, yeah, it's very, it's ideal because especially in these young children is when you wanna be careful with the narcotics. Um, I, I totally screwed up and took us over way over time. Let me give 10 seconds to anyone on the panel that wants to make a comment. Yama, go ahead. So, the, how do you, how, how did you select three groups? I mean, uh, general anesthesia and, uh, all the, uh, regional, and the, the, the general anesthesia and the regional. How did you choose three groups? And that's the number 1. Number 2 question is, uh, the opioid usage amount is related to the length of operation. Did you do laparoscopic hernia repair in your group? Thank you, Yama for your questions. Um, no, all patients were open, inguinal hernia patients and um, Uh, I did do an analysis to see whether there was an association between length of stay and opiate use and there wasn't, but it could also be that it, it's the relatively small sample size, and not necessarily of all patients cause there's 150 patients, but in general, there's such a small sample of these patients that actually receive opioids that it's almost impossible to do an analysis on that small group and then looking at their length of stay. Um, and in terms of the selection of the three groups, it was a retrospective audit review, so we just looked, yeah, in retrospectively which patients received general, which only is final, which both, so we didn't select beforehand. Yeah, it's, uh, very nice, uh, elegant study. Thank you very much for your information. Thank you. So, um, yeah, so I was, uh, sorry, we do have a little few more minutes left. Um, if anyone else wants to make a comment, we, um, There was a, a question from uh the audience. Does anyone here on the panel have a comment or question? Sophie or Rebecca? Yeah, I have one question. Was there any education done kind of on an institutional level around opioid prescription and kind of direction around that? There wasn't at the time, uh, and there wasn't really before, um, but it was, um, a couple of years, I think 2 or 3 years before this study that um the opioids were placed on, uh, the, the, the, the warnings around opioids and on which level of narcotics they were, was changed in Australia. And so I think that might have influenced definitely the, the use of opioids in, in, in the RCH yeah. There, there was a comment from Paul Lasti. It says, he has a question about the, the difference in the gender sexual dimorphism, uh, with narcotic requirements. How is this critically appraised? Um, I guess, again, the same question I had. It's just interesting to see that there was a difference in, in, in sexual, uh, in, in gender. Yeah, I honestly find that super interesting because this is such a young population. So it's interesting to see that even in this young population, females have higher opioid dose requirements than males, because in the older populations, um, the theory could be that men are wimps. But they don't like to say anything about it, so, so females will say, hey, I'm in pain, can I get some painkillers? But in this very young group of patients where there's no verbal communication on whether or not they're in pain, it is especially interesting to see that they, the females have higher requirements, and I'm not really sure why this is, honestly. OK, that's very interesting. Any other final comments or questions? Ma'am, we're ahead of schedule. That never happens. All right, uh, Doctor Hageman, phenomenal paper. Thank you for this, and I, I, I, we hope to see some follow-up papers because I think we are, we need to stop, uh, giving so much narcotics and truly understand how we can optimize, uh, pain control after surgery. Laparoscopy is gonna probably be a good, good element of that. But, all right, uh, Ellen, thank you so much.