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Stokes SC, Theodorou CM, Brown EG, Saadai P. Variations in Perceptions of Postoperative Opioid Need for Pediatric Surgical Patients. JAMA Surg. 2021;156(9):885–887. doi:10.1001/jamasurg.2021.2076
Postoperative opioid medications may result in prolonged opioid use in children and contribute to the nationwide epidemic.1 Despite efforts to decrease pediatric postoperative opioid prescriptions,2 wide variation in prescribing habits remains.3 Understanding stakeholders’ beliefs regarding postoperative pain management is critical to develop opioid reduction interventions.
An anonymous, 16-question survey was distributed via email to pediatric surgeons, postanesthesia care unit (PACU) nurses, and surgical residents between May and July 2020. The survey evaluated the perceived duration of postoperative opioid need on a 0- to 5-day scale as well as practices in discussing alternative pain management strategies and inquiring about prior opioid use on a Likert scale. The institutional review board at the University of California, Davis approved the administration of the survey with a waiver of written informed consent. Return of a completed survey constituted informed consent. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Statistical analysis was performed using Kruskal-Wallis and χ2 tests, with 2-sided significance set at P < .05. Statistical analysis was performed in Minitab, version 19.2020.2.0 (Minitab, LLC).
Surveys were completed by 6 pediatric surgeons (100% response), 31 of 107 PACU nurses (29% response), and 26 of 48 surgical residents (54% response). Pediatric surgeons believed patients of all ages required opioids for 0 days after all operations (Table 1). This was significantly shorter than the need estimated by PACU nurses, who estimated a need of 1 to 2 days for patients aged 1 to 5 years (laparoscopic cholecystectomy: 2 days, P = .002; laparoscopic appendectomy: 1 day, P = .005; laparoscopic inguinal hernia repair: 1 day, P = .003; and open umbilical hernia repair: 2 days, P = .001; open inguinal hernia repair: 2 days, P = .001), 2 days for patients aged 6 to 12 years (laparoscopic cholecystectomy: 2 days, P = .004; laparoscopic appendectomy: 2 days, P = .003; laparoscopic inguinal hernia repair: 2 days, P = .002; open umbilical hernia repair: 2 days, P = .001; and open inguinal hernia repair: 2 days, P = .001), and 2 to 3 days for patients aged 13 to 17 years (laparoscopic cholecystectomy: 2 days, P = .001; laparoscopic appendectomy: 2 days, P = .002; laparoscopic inguinal hernia repair: 2 days, P = .001; open umbilical hernia repair: 3 days, P = .001; and open inguinal hernia repair: 3 days, P = .001).
Similar to pediatric surgeons, surgical residents believed that patients aged 1 to 5 years required opioid treatment for 0 days (laparoscopic cholecystectomy: 0 days, P = .08; laparoscopic appendectomy: 0 days, P = .19; laparoscopic inguinal hernia repair: 0 days, P = .15; open umbilical hernia repair: 0 days, P = .25; and open inguinal hernia repair: 0 days, P = .11). For patients aged 6 to 12 years, surgical residents estimated children would require 0.5 to 1 day of opioid treatment, which was not statistically different from pediatric surgeons’ estimates (laparoscopic cholecystectomy: 1 day, P = .16; laparoscopic appendectomy: 0.5 days, P = .18; laparoscopic inguinal hernia repair: 1 day, P = .13; open umbilical hernia repair: 0.5 days, P = .15; and open inguinal hernia repair: 1 day, P = .09). For patients aged 13 to 17 years, surgical residents believed children would require opioid treatment for 1.5 to 2 days, which was significantly longer than pediatric surgeons’ estimates (laparoscopic cholecystectomy: 2 days, P = .03; laparoscopic appendectomy: 1.5 days, P = .02; laparoscopic inguinal hernia repair: 1 day, P = .006; open umbilical hernia repair: 1.5 days, P = .006; and open inguinal hernia repair: 2 days, P = .003).
Postanesthesia care unit nurses discussed alternative pain management strategies and inquired about prior opioid use most frequently across all age groups (Table 2). For patients aged 13 to 17 years, 27 of the 31 PACU nurses (87%) discussed alternative pain management strategies always or most of the time compared with 11 of the 26 of surgical residents (42%) and 2 of the 6 pediatric surgeons (33%) (P = .001). Also, for patients aged 13 to 17 years, 23 PACU nurses (74%) reported asking about patients’ prior experience with opioids always or most of the time compared with 7 surgical residents (27%) and none of the pediatric surgeons (P < .001).
We found significant variation among pediatric surgeons, PACU nurses, and surgical residents in beliefs around pediatric postoperative opioid requirements and in practices of discussing pain management strategies and prior opioid use. Before this survey, residents and nurses had not received formal education on pediatric opioid-free pain control, and 5.5% of children undergoing outpatient operations received opioid prescriptions for a median of 4 days (IQR, 2.3-5.2 days).4
In this study, pediatric surgeons’ beliefs were consistent with literature demonstrating that opioid-free postoperative pain management is effective.2,5 However, surgical residents and PACU nurses believed that children would require opioids for up to 3 days. This variability was greatest for teenagers, who are at high risk for opioid abuse.1 Residents and nurses have substantial involvement with postoperative pain management. At our institution, surgical residents prescribe greater than 90% of postoperative opioids for children,4 and the orders are typically communicated by PACU nurses.
Postanesthesia care unit nurses most frequently discussed alternative pain management strategies and inquired about prior opioid use. In a previous study evaluating practices for adult patients, 35% of surgical residents reported assessing patient risk for opioid abuse and 61% discussed nonnarcotic pain control.6 The lower discussion rate by residents in the present study may represent a lack of familiarity with opioid risk and multimodal pain control in the pediatric population.
After this survey, our institution created standardized pain medication order sets emphasizing nonopioid pain management, and nurses and residents completed an online module on multimodal pain management. We are developing a standardized preoperative pain management discussion and have introduced videos on pain management for families to view in the PACU. Future work will include reevaluation of pediatric postoperative opioid prescription rates.
This study was limited by being conducted at a single institution and having self-reported outcomes. In addition, we did not include questions about intraoperative variables, such as regional blocks, which may have affected results. However, to our knowledge, this is the first study to evaluate beliefs and practices of stakeholders in pediatric postoperative pain management.
The findings of this survey study identified significant differences in beliefs and counseling practices among pediatric surgeons, PACU nurses, and surgical residents regarding opioid use for postoperative pain management in children. Efforts at opioid reduction that include educational interventions involving all stakeholders should be explored.
Accepted for Publication: April 3, 2021.
Published Online: June 23, 2021. doi:10.1001/jamasurg.2021.2076
Corresponding Author: Sarah C. Stokes, MD, Department of Surgery, University of California, Davis, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 (email@example.com).
Author Contributions: Dr Stokes had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Stokes, Theodorou, Brown.
Drafting of the manuscript: Stokes.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Stokes.
Obtained funding: Theodorou, Brown.
Supervision: Brown, Saadai.
Conflict of Interest Disclosures: None reported.
Funding/Support: The project described was supported by grant UL1 TR001860 from the National Center for Advancing Translational Sciences, which is funded by the National Institutes of Health (Drs Theodorou and Brown).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Meeting Presentation: This paper was accepted for presentation at the 92nd Annual Meeting of the Pacific Coast Surgical Association Meeting; February 18-20, 2021; Monterey, California. However, that meeting was canceled.