Optimization of Post-surgical Analgesia After Pediatric Adenotonsillectomy: An Opioid-sparing, Steroid-forward Approach

Introduction: Safety concerns and abuse potential have led to calls to deemphasize opioids after pediatric adenotonsillectomy. More data is needed regarding the safety and efficacy of these efforts.

Methods: A single-site multi-surgeon QI project involving 3 PDSA cycles. PDSA1 described baseline practice, including acetaminophen, ibuprofen, and either oxycodone or dexamethasone for patients aged 5 years and above. In PDSA2, upfront opioid prescriptions were eliminated for all patients under 12 years old. PDSA2 also included provider education and modification of the postoperative electronic order set. PDSA3 involved optimization of acetaminophen and ibuprofen dosing schedules. Prescribed medications were tracked. Balancing measures included subsequent prescriptions, caregiver phone calls, ED visits, admissions, and return to OR for post-surgical hemorrhage. Outcomes were compared with Fisher’s exact test or Pearson Chi-square test.

Results: A total of 1708 patients were included, with 232 in PDSA1, 835 in cycle 2, and 641 in cycle 3. Oxycodone prescription rates decreased between PDSA1 and 2 from 23.7% to 1.6%, and then to 0.2% (p < 0.001) during PDSA3. Rates of subsequent opioid prescriptions decreased from 2.2% to 1.1%, then to 0.3% (p=0.027). Caregiver phone calls went from 23.8% in PDSA1 to 24.4% in PDSA2, then decreased to 8.4% (p < 0.001) during PDSA3. Return to ED rates decreased from 10.8% to 4.5% (p=0.003) from PDSA1 to 3. Readmission rates decreased from 3.9% to 1.3% (p=0.007). Return to OR rates were unchanged (0.9%, 0.4%, 0.6%).

Conclusions: Routine prescription of opioid analgesics can be safely eliminated from post-tonsillectomy care with a standardized, steroid-forward analgesic algorithm, provider education, and modification of electronic order sets.