Franz Amber M, Martin Lynn D, Liston David E, Latham Gregory J, Richards Michael J, Low Daniel K
From the Department of Anesthesiology and Pain Medicine, Seattle Children's, University of Washington, Seattle, Washington.
Anesth Analg. 2021 Mar 1;132(3):788-797. doi: 10.1213/ANE.0000000000004774.
Opioids have been a central component of routine adult and pediatric anesthesia for decades. However, the long-term effects of perioperative opioids are concerning. Recent studies show a 4.8%-6.5% incidence of persistent opioid use after surgery in older children and adults. This means that >2 million of the 50 million patients undergoing elective surgeries in the United States each year are likely to develop persistent opioid use. With this in mind, anesthesiologists at Bellevue Clinic and Surgery Center assembled an interdisciplinary quality improvement team focused on 2 goals: (1) develop effective anesthesia protocols that minimize perioperative opioids and (2) add value to clinical services by maintaining or improving perioperative outcomes while reducing costs. This article describes our project and findings but does not attempt to make inferences or generalizations about populations outside our facility.
We performed a large-scale implementation of opioid-sparing protocols at our standalone pediatric clinic and ambulatory surgery facility, based in part on the prior success of our previously published tonsillectomy and adenoidectomy protocol. Multiple Plan-Do-Study-Act cycles were performed using data captured from the electronic medical record. The percentage of surgical patients receiving intraoperative opioids and postoperative morphine preintervention and postintervention were compared. The following measures were evaluated using statistical process control charts: maximum postoperative pain score, postoperative morphine rescue rate, total postanesthesia care unit minutes, total anesthesia minutes, and postoperative nausea and vomiting rescue rate. Intraoperative analgesic costs were calculated.
Between January 2017 and June 2019, 10,948 surgeries were performed at Bellevue, with 10,733 cases included in the analyses. Between December 2017 and June 2019, intraoperative opioid administration at our institution decreased from 84% to 8%, and postoperative morphine administration declined from 11% to 6% using 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 postanesthesia care unit minutes remained stable per control chart analyses. Costs improved.
By utilizing dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia for pediatric ambulatory surgeries at our facility, perioperative opioids were minimized without compromising patient outcomes or value.
几十年来，阿片类药物一直是成人和小儿常规麻醉的核心组成部分。然而，围手术期使用阿片类药物的长期影响令人担忧。最近的研究表明，大龄儿童和成人术后持续使用阿片类药物的发生率为4.8%-6.5%。这意味着在美国每年接受择期手术的5000万患者中，超过200万人可能会出现持续使用阿片类药物的情况。考虑到这一点，贝尔维尤诊所和手术中心的麻醉医生组建了一个跨学科质量改进团队，专注于两个目标：（1）制定有效的麻醉方案，尽量减少围手术期阿片类药物的使用；（2）通过在降低成本的同时维持或改善围手术期结局，为临床服务增加价值。本文描述了我们的项目和研究结果，但并未试图对我们机构以外的人群进行推断或归纳。
我们在我们独立的儿科诊所和门诊手术设施中大规模实施了阿片类药物节省方案，部分基于我们之前发表的扁桃体切除术和腺样体切除术方案取得的成功。使用从电子病历中获取的数据进行了多个计划-执行-研究-行动循环。比较了术前和术后接受术中阿片类药物和术后吗啡的手术患者百分比。使用统计过程控制图评估以下指标：术后最大疼痛评分、术后吗啡抢救率、麻醉后护理单元总分钟数、总麻醉分钟数以及术后恶心呕吐抢救率。计算术中镇痛成本。
2017年1月至2019年6月期间，贝尔维尤进行了10948例手术，其中10733例纳入分析。2017年12月至2019年6月期间，我们机构术中阿片类药物的使用从84%降至8%，术后吗啡的使用从11%降至6%，采用了右美托咪定（dexmedetomidine）、非甾体抗炎药和区域麻醉等镇痛方法。根据控制图分析，术后恶心呕吐抢救率下降，而术后最大疼痛评分、总麻醉分钟数和麻醉后护理单元总分钟数保持稳定。成本有所改善。
通过在我们的机构中对小儿门诊手术使用右美托咪定、非甾体抗炎药和区域麻醉，围手术期阿片类药物的使用被降至最低，同时不影响患者结局或价值。
