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Standardized post-operative care practices for pediatric inguinal surgery lead to decreased opioid pain medication prescriptions.
Shannon T. Cannon, MD¹, Paul A. Merguerian, MD, MS², Jennifer J. Ahn, MD², Courtney K. Rowe, MD², Kathleen Kieran, MD, MSc, MME², Jonathan S. Ellison, MD².
¹University of Washington, Seattle, WA, USA, ²Seattle Children's Hospital, Seattle, WA, USA.

Background:
There is widespread evidence of over-prescribing opioid pain medication in children, which increases long-term risk for opioid overuse and dependency. However, the optimal amount of opioids for patients recovering from inguinal surgery has not been identified and wide practice variations exist. Using an evidence-based approach, we standardized post-operative opioid medication prescribing practices and discharge instructions for 9 surgeons performing pediatric inguinal surgery at a single institution. We hypothesized that this would decrease opioid prescriptions without an increase in unanticipated hospital visits or phone calls.
Methods:
We performed a retrospective review of all patients who underwent orchiopexy or hydrocelectomy between April 2015 and February 2018. An evidence-based standardization protocol was implemented in full as of July 2017. Standardization consisted of pre-populated order sets in the electronic medical record and instructions to regarding post-operative wound care, bathing instructions, and activity restrictions. Standard post-operative pain control consisted of standing acetaminophen and ibuprofen for 2 days and as needed thereafter as well as a recommended maximum dose of 0.1 mg/kg of oxycodone for 2 days. Providers could prescribe less oxycodone if deemed appropriate. We collected demographic data including surgery performed, laterality of procedure, patient age and BMI; data on pain control interventions including perioperative regional anesthesia, dosage and amount of oral narcotic pain medicine prescribed; and data on pain control effectiveness, including number of unanticipated post-operative phone calls received from the patients and emergency room visits. Data were collected using REDCap and statistical analyses were performed using independent t-test and chi-square tests.
Results:
A total of 275 children were included; 172 pre-standardization and 102 post-standardization. There was no significant difference between the demographic data of the two cohorts. The mean age was 4.66 years. Surgeries were evenly distributed between orchiopexy and hydrocelectomy, and a minority were bilateral. Regional anesthesia remained unchanged following standardization (p=0.211), evenly distributed between ilioinguinal and caudal anesthesia. After standardization, the number of unanticipated post-operative phone calls (p=0.843) or Emergency Department visits (p=1.00) did not increase. However, the mean number of opioid doses prescribed decreased from 20.5 to 12.5 (p<0.001).
Conclusions:
Using a standardized approach for post-operative care following pediatric inguinal surgery, we reduced opioid prescriptions by 43% without increases in unanticipated health care encounters. These findings suggest that fewer doses of opioid pain medication can be prescribed in the perioperative period, and there may be additional capacity for reduction in opioid prescriptions. While this
study is limited in its ability to determine the optimal amount of opioid pain mediation to prescribe, it demonstrates a method of limiting over-prescription. Future prospective studies to identify and validate the minimum opioid prescription and associated patient-reported outcomes are warranted.

	Before Standardization	After Standardization	p-value
Surgery Performed (%)
Orchiectomy	64.2	56.9	0.276
Hydrocelectomy	35.8	43.1	0.276
Bilateral	15.0	8.8	0.254
Regional Anesthesia Performed (%)	94	99	0.211
Opioid Doses Prescribed (n)	20.5	12.5	<0.001
30-day Unanticipated Post-operative Phone Calls (%)	16.0	13.7	0.843
30-day Emergency Department Visits (%)	0.6	0.9	1.00

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