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Opioid use after cardiac surgery in children with Down syndrome
Sara L Van Driest1, Anushi Shah, Matthew D Marshall
11Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN. 2Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN. 3Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN. 4The University of Texas School of Biomedical Informatics at Houston, Houston, TX. 5Center for Human Genetics Research, Vanderbilt University School of Medicine, Nashville, TN.
Insights
This study found no evidence of opioid resistance in children with Down syndrome after cardiac surgery. Opioid doses were similar between groups, though longer hospital stays in the Down syndrome cohort correlated with higher opioid exposure.
Area of Science:
- Cardiology
- Pediatric Surgery
- Pharmacology
Background:
- Cardiac surgery in children with Down syndrome requires careful pain management.
- Previous studies have suggested potential differences in opioid response in this population, but evidence is limited.
Purpose of the Study:
- To compare cumulative opioid doses in pediatric patients with and without Down syndrome following cardiac surgery.
- To identify factors influencing opioid requirements in these patients.
Main Methods:
- Retrospective observational comparative study of pediatric patients undergoing cardiac surgery.
- Data collected from electronic medical records, comparing patients with Down syndrome (n=44) to a matched cohort without Down syndrome (n=77).
- Weight-adjusted opioid doses were analyzed at 24 and 96 hours post-surgery using univariate and multivariate regression.
Main Results:
- No significant difference in median cumulative opioid doses was observed between patients with and without Down syndrome at 24 hours (+0.39 mg/kg) or 96 hours (+0.54 mg/kg).
- Factors significantly correlated with higher opioid doses included younger age, longer cardiac bypass time, benzodiazepine use, and neuromuscular blockade.
- Patients with Down syndrome experienced longer hospital stays, which correlated with higher opioid exposure and peak creatinine levels.
Conclusions:
- The study did not find evidence supporting opioid resistance in pediatric patients with Down syndrome after cardiac surgery.
- Opioid requirements were influenced by surgical factors and co-administered medications rather than the presence of Down syndrome.
- Longer hospitalizations in patients with Down syndrome may be linked to opioid exposure and renal function.
Objectives:
To determine the cumulative opioid doses administered to patients with Down syndrome after cardiac surgery and compare them with patients without Down syndrome.
Design:
Retrospective observational comparative study.
Setting:
PICU in a university-affiliated freestanding pediatric teaching hospital.
Patients:
Infants and children who presented to our institution for heart surgery after July 1, 2008, and met the following criteria: 1) no opioid medications for 48 hours prior to surgery, 2) sternotomy approach with primary closure, and 3) no additional operative procedures in the 5 days after surgery. All patients with Down syndrome were included, and patients without Down syndrome with similar age, type of cardiac lesion, and length of surgical procedure were selected in a ~2:1 ratio, blinded to opioid exposure.
Interventions:
None.
Measurements And Main Results:
Clinical and demographic data were extracted from electronic medical record data. Univariate analyses and multivariate linear regression modeling were performed to determine the influence of Down syndrome, patient characteristics, and clinical covariates on weight-adjusted opioid dose. The differences in median cumulative opioid doses between those with Down syndrome (n = 44) and those without Down syndrome (n = 77) were not significant in the first 24 hours (+0.39 mg/kg [95% CI, -0.45 to +1.39 mg/kg]) or 96 hours (+0.54 mg/kg [95% CI, -0.59 to +2.07 mg/kg]) after surgery. Age, cardiac bypass time, benzodiazepines, and neuromuscular blocking agents were significantly correlated with opioid dose, but Down syndrome, gender, pain score, creatinine, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid medications were not. Patients with Down syndrome had longer hospital stays; in multivariate analysis, higher opioid exposures in the first 96 hours after surgery and higher peak serum creatinine values correlated with longer hospitalization.
Conclusions:
This cohort did not provide evidence for opioid resistance in patients with Down syndrome. Younger age, longer cardiac bypass time, exposure to benzodiazepines, and neuromuscular blockade did correlate with increased opioid doses after cardiac surgery.
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