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An Opioid Sparing Anesthesia Protocol for Pediatric Open Inguinal Hernia Repair: A Quality Improvement Project
Jennifer L Chiem1, Amber Franz1, Nicholas Bishop1
1Department of Anesthesiology and Pain Medicine. Seattle Children's Hospital. University of Washington, Seattle, Wash.
Insights
This quality improvement project optimized pain management for pediatric open inguinal hernia repair using an opioid-sparing anesthetic protocol. The new protocol successfully reduced morphine use without increasing pain scores.
Area of Science:
- Anesthesiology
- Pediatric Surgery
- Quality Improvement
Background:
- Multimodal pain management is crucial for pediatric open inguinal hernia repair (OIHR).
- Standardizing anesthetic protocols can enhance patient outcomes and optimize care delivery.
- Opioid-sparing strategies are increasingly important in pediatric anesthesia.
Purpose of the Study:
- To standardize an anesthetic protocol for pediatric OIHR using plan-do-study-act (PDSA) cycles.
- To optimize multimodal pain management and explore opioid-sparing techniques.
- To evaluate the impact of protocol changes on pain scores, opioid rescue, and length of stay.
Main Methods:
- Utilized PDSA cycles to modify the intraoperative anesthetic protocol for pediatric OIHR.
- Compared three groups: baseline, exclusively ilioinguinal-iliohypogastric (II) blocks with fentanyl, and II blocks with dexmedetomidine (opioid-sparing).
- Analyzed data using statistical process control (SPC) charts, measuring rescue morphine, pain scores, PACU length of stay, and preparation duration.
Main Results:
- Over 6 years, 641 pediatric OIHRs were performed. Special cause variation was observed for rescue morphine, preparation duration, and PACU length of stay.
- The opioid-sparing protocol showed improvement in the percentage of patients requiring rescue morphine and reduced anesthesia preparation time.
- No significant adverse effect on maximum postanesthesia care unit (PACU) pain scores was detected.
Conclusions:
- An opioid-sparing anesthetic protocol utilizing II blocks and dexmedetomidine was successfully implemented for pediatric OIHR.
- This protocol optimized pain management without negatively impacting postoperative pain scores or morphine rescue rates.
- The study demonstrates the effectiveness of QI initiatives in refining pediatric surgical anesthesia.
Abstract:
Using plan-do-study-act (PDSA) cycles, this quality improvement (QI) project aimed to standardize an anesthetic protocol to optimize multimodal pain management for pediatric open inguinal hernia repair (OIHR).
Methods:
PDSA cycle 1: in December 2017, we standardized the intraoperative OIHR anesthesia protocol by replacing transversus abdominis plane (TAP) or ilioinguinal-iliohypogastric (II) blocks and fentanyl with exclusively II blocks and fentanyl. PDSA cycle 2: in January 2019, we used an opioid sparing strategy, replacing II blocks and fentanyl with II blocks and dexmedetomidine. We used statistical process control (SPC) charts to analyze data from the medical record. Outcome measures included the percent of patients requiring rescue morphine in the postanesthesia care unit (PACU), maximum PACU pain score, PACU length of stay (LOS), and anesthesia preparation duration.
Results:
The team performed a total of 641 pediatric OIHRs between July 2015 and June 2021. The three groups included 203 patients in our baseline group, 127 patients in the PDSA cycle 1 group, and 311 patients in the PDSA cycle 2 group. Special cause variation (SCV) occurred for the percent of patients requiring rescue morphine, anesthesia preparation duration, and PACU LOS. The percent of patients requiring rescue morphine showed improvement. Anesthesia preparation duration improved compared to baseline. There was no SCV detected in the SPC chart for maximum PACU pain score.
Conclusion:
We implemented an opioid sparing anesthetic protocol for pediatric OIHR utilizing II blocks and dexmedetomidine without adversely affecting postoperative pain score or morphine rescue rate over 6 years.
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