Pediatric urologist Chad Crigger discusses perioperative pain management after procedures. He talks about the latest research findings by the Brady Urological Institute’s pediatric division on the risks of adolescents and young adults developing an opioid use disorder after urologic procedures, and he details the team’s research findings regarding the role of long-acting liposomal bupivacaine in improving pain scores reducing narcotic pain requirements for pediatric patients after minor urologic procedures.
Hi, I'm Chad Kriger, a pediatric neurologist here at Johns Hopkins. I wanna take a moment of your time to discuss perative pain management in the pediatric setting. As we know, pediatric patients are not just tiny adults. And so a careful consideration of their physiologic response surgery is important. Obviously, opioids have been in the news over the last several years as we continue to learn about the long term impacts of historical prescribing practices, careful consideration has to be taken when prescribing opioids to either Children or even in households with Children as they are more susceptible to the side effects and at increased risk of accidental overdose to this effect. In March of 2018, the American Academy of Pediatrics issued a six month challenge for surgeons to decrease their opioid prescribing by 50%. Now, we're lucky here at the Brady to have colleagues who are passionate and care about this issue and also colleagues around the country including in Texas and to get a better idea of the scope of this, what we want to look at is the risk of developing a persistent opioid use disorder in young adolescents and young adults undergoing common neurologic procedures to do this. We use Trinet Diamond database. This is a large claims database of over 212 million people from 992 health care institutions encompassing 99% of us health care plans. And what we did is we use CPT codes and cross reference them with insurance claims. And by doing this, we were able to identify over 32,000 patients who are opioid naive and then underwent common neurologic procedures. And based on these, we are able to form two cohorts. The first one that received an opioid prescription post operatively and the second cohort, which did not receive an opioid prescription and really determined the true risk or relative risk of developing a new persistent opioid disuse order. When we look at the rates of patients receiving opioid scripts for common neurologic outpatient procedures. We found that inguinal orchiopexy had over 70% of these patients receiving an opioid script. Now it's pretty high whether that's done by us or our general pediatric surgery colleagues, 70% is high even considering circumcision, one of the most common outpatient procedures we do as pediatric urologists, those patients were receiving a opioid script. Over 60% of the time when we look at the actual procedures themselves, all these had an increased risk of the new persistent opioid use disorder, aside from Pyeloplasty and Hydrocelectomy, probably because our end was a little too small. But when we look at the actual relative risk of each procedure. Our inguinal orchiopexy had a risk 2.18 times greater. And then looking at hypos spades, that risk was 17 times greater. So these patients that received an opioid were more likely to have a persistent use after surgery. So after defining the problem and the need and also room to improve and answer the challenge, we looked at adjuncts for surgery that we might be able to employ. Now, obviously, we love our baseball here in Baltimore. And so we named this study, the Baby Orioles study. This study was a phase three internally funded single blinded trial that looked at the effect of liposomal bupivac versus 0.25% bupivac only to determine if the risk of opioid taken after surgery. What the rate was between the two groups. What we did specifically was provide uh the surgery, all patients went home the same day. They were recommended to take our first line treatment for pain, which is usually children's Tylenol or Ibuprofen. And a rescue script was provided for an opioid based on their weight. Patients were randomized to biv again, bine 0.25% alone has an action of about 6 to 10 hours. And if we add that liposomal bilayer to it as well, that can extend the local retention and the effect up to 72 hours, all these patients again were recommended to take Tylenol and Ibuprofen with a rescue dose of opiate provided, we then followed up at 48 hours and at 10 to 14 days after surgery to assess parental pain scores, actual assessed pain scores and opioid usage. When we look at our two groups, we had 100 and two patients overall, 51 in each group. Importantly, there were no differences in terms of patient demographics or post operative care characteristics. So this made that our two groups were very similar in nature. When we look at our opioid use between the two groups, overall, it was 61% whether it was in the liposomal xr group or 0.25% pivoting. So even though it was a negative study, it showed importantly what we're using already works to 0.2525% bupivac and that the intervention that we used was safe. Now, obviously, pediatric pain management is very important to us and there's still room to improve whether that's relying on our post operative anesthesia colleagues to make sure we're decreasing our morbidity of surgery or for us as surgeons to take open principles whenever possible and translate them into minimally invasive or robotic techniques when we can safely do so.