University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, 48109, USA.
Urology-Childrens Wisconsin, 8920 W. Connell Ct. Milwaukee, WI 53226, USA.
J Pediatr Urol. 2021 Apr;17(2):259.e1-259.e6. doi: 10.1016/j.jpurol.2021.01.008. Epub 2021 Jan 9.
Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain.
As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures.
We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure).
Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p < 0.01). There was significant variation in opioid prescribing patterns by provider (p < 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries.
Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.
手术后急性疼痛是儿童开处阿片类药物的最常见指征之一。阿片类药物在使用后往往不能安全储存或处理，使儿童和其他在家中的人面临意外摄入或故意滥用的风险。我们目前缺乏常见门诊小儿泌尿科手术后术后疼痛管理的循证指南。因此，每位外科医生都必须根据自己对术后疼痛的假设来决定是否开处以及开处多少阿片类药物。
作为在两个学术中心建立阿片类药物处方指南的努力的一部分，本研究的目的是评估小儿泌尿科医生阿片类药物处方因素的当前变异性，并确定在常见门诊小儿泌尿科手术后接受高剂量阿片类药物处方的风险最大的患者。
我们回顾性评估了 2016 年至 2017 年期间在两家主要儿童医院进行的常见门诊小儿泌尿科手术（包皮环切术、睾丸固定术和疝气/鞘膜积液）后的术后阿片类药物处方模式。具体来说，我们评估了所有 18 岁以下儿童（18 岁或以下）的阿片类药物处方数量。使用 Kruskal-Wallis 检验和 Wilcoxon 秩和检验进行双变量分析。多变量逻辑回归用于确定预测高剂量阿片类药物（大于该手术规定的中位数剂量）处方的患者、外科医生和手术因素。
在两年期间，进行了 811 例包皮环切术和 883 例腹股沟手术（腹股沟睾丸固定术和疝气/鞘膜积液）。94%接受包皮环切术的患者和 97%接受腹股沟手术的患者接受了阿片类镇痛药治疗。接受包皮环切术的患者处方的剂量中位数为 20 剂；接受腹股沟手术的患者中，23.75%的患者接受了 15 剂或更多的阿片类药物。0-2 岁的患者，占所有患者的最大年龄组（41%），比所有其他年龄组接受的阿片类药物剂量明显更多，其次是年龄大于 10 岁的患者（p<0.01）。提供者的阿片类药物处方模式存在显著差异（p<0.01）（图 1）。多变量逻辑回归显示，年龄较小、药丸形式和较早的年份与所有手术中开出的阿片类药物剂量增加有关。
在没有门诊小儿泌尿科手术后阿片类药物处方政策的两个机构中，我们观察到提供者处方模式存在相当大的差异，几乎所有患者都接受了阿片类药物治疗，0-2 岁的患者接受了最多的剂量。这凸显了需要为门诊小儿泌尿科手术后的术后疼痛管理制定循证指南。
