Franz Amber M, Dahl John P, Huang Henry, Verma Shilpa T, Martin Lynn D, Martin Lizabeth D, Low Daniel King-Wai
Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington.
Department of Otolaryngology Head and Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington.
Paediatr Anaesth. 2019 Jul;29(7):682-689. doi: 10.1111/pan.13662. Epub 2019 Jun 19.
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.
小儿扁桃体切除术和腺样体扁桃体切除术后的疼痛管理具有挑战性，传统上需要围手术期使用阿片类药物。然而，近期全国范围内的阿片类药物短缺促使贝尔维尤手术中心的麻醉医生寻找一种替代的围手术期镇痛方案，该方案既能减少阿片类药物的使用，又能有效缓解疼痛。我们组建了一个跨学科质量改进团队，采用计划-执行-研究-行动循环来试验一系列镇痛方案。最初，我们用术中右美托咪定和术前布洛芬取代了术中吗啡和对乙酰氨基酚（M/A方案）。然而，当结果不理想时，我们迅速过渡到术中使用酮咯酸和右美托咪定（D/K方案）。使用统计过程控制图方法对以下指标进行评估，并根据休哈特的变异理论进行解读：麻醉后护理单元的最大疼痛评分、术后吗啡补救率、麻醉后护理单元住院时间、总麻醉时间、术后恶心呕吐补救率以及术后30天内的再次手术率。M/A方案组有333例患者，D/I方案组有211例患者，D/K方案组有196例患者。采用D/I方案时，最大疼痛评分和麻醉后护理单元住院时间略有增加，但与M/A方案相比，吗啡补救率或总麻醉时间没有差异。采用D/K方案时，与M/A方案相比，术后疼痛控制和麻醉后护理单元住院时间相似。D/I和D/K方案的恶心呕吐补救率均有所降低。各组之间的再次手术率相似。总之，我们确定了一种用于小儿扁桃体切除术和腺样体扁桃体切除术中的麻醉方案，该方案使用右美托咪定和酮咯酸，可有效镇痛，且不增加恢复时间或再次手术率。
