Anesthesia in the News
  • Toward Opioid-free Pediatric Procedures

    A pediatric surgery center developed a protocol that eliminated opioids for one of its highest-volume and most painful surgeries, tonsillectomy and adenoidectomy. 

    Since the facility opened in 2010, anesthesia providers at Seattle Children’s Bellevue Clinic and Surgery Center had utilized multi-modal analgesia to minimize pain and perioperative opioid use, including regional anesthesia for a large number of protocols. Despite this deliberate and cautious practice, this standalone pediatric clinic and ambulatory surgery facility caring for over 4,000 surgical patients annually, saw an increase in opioid use in 2017 with fully 84% of its young surgical patients receiving intraoperative opioids in the final month of that year.

    Colliding crises

    As related in the original clinical research report published in the March 2021 issue of the journal Anesthesia & Analgesia, the anesthesia team at the Center had already been exploring the efficacy of potential perioperative opioids alternatives when two nationwide developments converged in early 2018 to add further impetus to their quest.

    First, a national shortage of intravenous opioids hit, which caused health care systems to alter protocols in order to conserve supplies. At the same time, the national opioid crisis had seen overdose fatalities eclipse the number of deaths due to motor vehicle accidents. Further, recognition was growing of the role that routine post-operative opioid use played as a gateway to opioid misuse disorder.

    First steps and success

    In response, the Bellevue team developed a new standardized protocol that eliminated intraoperative opioids for one of the Center’s highest-volume and most painful surgeries, tonsillectomy and adenoidectomy.  Following close collaboration and extensive team discussion, they elected to replace intraoperative morphine and acetaminophen with dexmedetomidine and ibuprofen.

    The early results were noteworthy. The new protocol had reduced perioperative opioid administration for tonsillectomy and adenoidectomy without compromising effective analgesia. The promising outcomes from this initial step prompted the Team to expand the use of dexmedetomidine at the Center. The anesthesia colleagues started to incorporate dexmedetomidine into other surgeries while continuing to take opportunities to expand the use of the opioid-sparing analgesics already employed at the center such as nonsteroidal anti-inflammatory agents and regional anesthesia.

    By the start of 2019, the Team decided to remove opioids from all standardized intraoperative anesthesia protocols.

    Results by the numbers

    During the Team’s 18-month quality improvement project, 10,948 surgeries were performed at the Center, with 10,733 cases included in the subsequent analyses. Between December 2017 and June 2019, intraoperative opioid administration at the Center decreased from 84% to 8%, and postoperative morphine administration declined from 11% to 6% using opioid-sparing analgesics such as dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia.

    Postoperative nausea and vomiting rescue rate decreased, while maximum postoperative pain scores, total anesthesia minutes, and total post-anesthesia care unit minutes remained stable per control chart analyses.  Even costs improved as the alternative combination of medications used were less costly. Annual intraoperative analgesic costs declined from $85,000 in 2017 to $12,000 in 2019, largely due to reduced intravenous acetaminophen administration.

    Since starting this initiative, more than 6,000 pediatric patients at the Center have undergone surgery without opioids during their procedure.

    Caveats and future plans

    Notwithstanding their quality improvement project success, the authors do note that despite removing opioids from all standardized protocols, “there are several surgeries that are not protocolized.”  Thus, the Center’s “intraoperative opioid administration rate has not yet reached zero.”

    Next, they relate that among the obstacles they encountered in implementing the project were “team member participation in standardized protocols and recovery nurse apprehension about eliminating intraoperative opioids.” The Team adds that they surmounted these challenges “using technology, data, communication, education, time and a culture that emphasizes willingness to change.”

    Finally, “and most importantly,” the research team states that they have minimal data on post-discharge pain and opioid use for the first week following surgery, but that the exploration of whether there was a change in home opioid administration once intraoperative opioids were replaced with dexmedetomidine represents the next phase of their ongoing quality improvement initiative.

    Review in detail each of the steps your colleagues took “In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.” Anesth Analg. 2021 Mar 1;132(3):788-797 at