Background: Regional anesthetic techniques are safe and effective in reducing pain and the need for opioid analgesia but may be underutilized in neonatal intensive care unit (NICU) patients. We developed an opioid stewardship pathway aimed at reducing the use of opioid analgesia in neonates by increasing caudal block utilization from a baseline of 50%-90% within 18 months. Methods: We used control charts to track intra-operative opioid utilization in morphine milligram equivalents per kilogram (MME/kg) and immediate post-operative extubation rates. Unrelieved pain (defined as two consecutive Neonatal Pain, Agitation & Sedation Scale (NPASS) scores >/ = 4), postoperative opioid use, and reintubation within 24 h were tracked as balancing measures. We ran sample statistical analysis comparing the outcome and balancing measures in surgeries with and without caudal block. Results: There were 125 surgeries in the pre-intervention and 48 in the post-intervention group. Caudal block utilization increased to 63%, while intra-operative opioid utilization decreased (0.230 vs 0.416 MME/kg), and extubation rates increased (75% vs 70%). There were no increases in unrelieved pain or post-operative opioid utilization. Caudal block was associated with decreased intra-operative opioid use (0.000 vs 0.366 MME/kg, p < 0.001) and increased extubation rates (83% vs. 59%, p < 0.001) with no increase in unrelieved pain (23% vs. 22%, p = 0.75) or post-operative opioid use (0.151 vs 0.000 MME/kg, p = 0.35). No patients required reintubation within 24 h. Conclusion: The modest increase in caudal block utilization is associated with a reduction in intraoperative opioid use and increased postoperative extubation rates without compromising pain control. Level of Evidence: Level III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The obesity epidemic has led to an increased number of adolescents requiring metabolic and bariatric surgery (MBS), but there is paucity of data on the impact of implementing all aspects of Enhanced Recovery After Surgery (ERAS) protocols to improve outcomes in this population. We implemented a comprehensive ERAS pathway for adolescents undergoing laparoscopic sleeve gastrectomy (LSG). Key elements included pre-operative fasting with carbohydrate loading in the morning of surgery, comprehensive anti-emetic and analgesic regimens including intra-operative lidocaine infusion (initiated before formal ERAS launch), regional anesthesia, and early goal-directed ambulation. We tracked opioid utilization, rescue anti-emetic use, time to oral intake, and hospital length of stay (HLOS) as outcome measures, and post-operative pain and returns to the system as balancing measures. Eighty-six patients (52 patients pre-ERAS and 34 patients post-ERAS) underwent LSG with no differences in demographics. The post-ERAS group had earlier time to oral intake (3.0 vs. 5.5 h, p = 0.003), used less rescue anti-emetics, (8.0 vs. 16.0 mg, p < 0.001), and had shorter HLOS (33 vs. 54 h, p < 0.001) but no difference in opioid use (0.370 vs. 0.435 MME/kg, p = 0.17), post-operative pain scores or return to the system. Our novel use of bariatric-specific ERAS protocol with intra-operative lidocaine infusion accelerates the time to goal-directed oral intake and decreases HLOS without increasing the rate of returns to the system. This study highlights the feasibility and effectiveness of adapting adult ERAS protocols to the pediatric MBS population. Level III.

Abstract Purpose This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia. Methods Children undergoing laparoscopic appendectomy within a multi-hospital children’s healthcare system were retrospectively reviewed from 2017 through 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 hours postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type. Results 2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6% vs. NB 54.6%, p = 0.005; complicated: QLB 28.5% vs. NB 39.9%, p = 0.01) and postoperatively (complicated: QLB 33.7% vs. NB 52.9%, p < 0.001) for those who received a QLB. This resulted in reduced opioid consumption as measured by morphine milligram equivalents per kilogram postoperatively. Conclusion QLBs can be safely administered in children and provide improvements in opioid consumption postoperatively. QLBs should remain a strongly favored regional anesthetic technique because of their wide applicability for abdominal surgeries in order to minimize rescue opioid analgesic use. Level of Evidence: Level III

This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia. Children undergoing laparoscopic appendectomy within a multi-hospital children’s healthcare system were retrospectively reviewed from 2017 to 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 h postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type. 2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6

Background: Many studies evaluating opioid stewardship interventions' effects on postoperative pain rely on emergency department (ED) visits or readmissions, but patient-reported pain scores represent a more complete picture of the postoperative experience. This study compares patient-reported pain scores after ambulatory pediatric and urologic procedures and the effect of an opioid stewardship intervention that nearly eliminated the use of outpatient narcotics.Methods: This is a retrospective comparative study including 3173 pediatric patients who underwent ambulatory procedures from 2015 to 2019, during which there was an intervention to reduce narcotic prescriptions. Postoperative day one phone calls assessed pain levels using a four-point scale (no pain, mild pain, moderate pain controlled with medication, or severe pain uncontrolled with medication). We quantified the proportion of patients prescribed opioids pre-versus post-intervention and compared pain scores for patients receiving opioid versus non-opioid regimens.Results: Opioid prescription rates demonstrated a 6.5-fold reduction after opioid stewardship efforts. The majority of patients (2838) received non-opioids, with only 335 patients receiving opioids. Opioid patients reported moderate/severe pain slightly more than non-opioid patients (14.1% vs. 10.4%, p 1/4 0.04). On by-procedure analyses, there were no subgroups in which non-opioid patients reported significantly higher pain scores.Conclusions: Non-opioid postoperative pain regimens appear to be effective, with only 10.4% of patients reporting moderate/severe pain after ambulatory procedures. Future studies assessing patient-reported outcomes are necessary to optimize pain control for all patients and to determine whether there is ever an indication for opioid prescription after ambulatory general pediatric or urologic surgery. Type of study: Retrospective comparative study. Level of evidence: Level III.& COPY; 2023 Elsevier Inc. All rights reserved.