Prevalence and Outcomes of Opioid Use Disorder in Pediatric Surgical Patients: A Retrospective Cohort Study.
Full text (subscription required): https://journals.lww.com/anesthesia-analgesia/Fulltext/2023/02000/Prevalence_and_Outcomes_of_Opioid_Use_Disorder_in.16.aspx
This was a retrospective matched cohort study examining the prevalence of opioid use disorder (OUD) in 10 to 18-year-olds and the association with post-operative outcomes over a 15-year period from 2004-2019. The study extracted data from the ‘pediatric health information system’ which is an administrative hospital database used in over 50 not-for-profit, US tertiary-care paediatric hospitals. Patients were identified as having opioid use disorder using a previously identified algorithm based on ICD-9 and ICD-10 coding.
The primary outcome was inpatient mortality with secondary outcomes including a range of post-operative outcomes including surgical complications, infections, ICU admission and prolonged length of stay. The study found that OUD had continued to increase year on year over the 15-year period despite increased awareness of opioid misuse in the US. The study also found that while mortality was not increased, multiple other outcomes were worse in the OUD cohort. These include ICU admission (RR 2.66 95%CI 2.07-3.40), surgical complications (RR 1.57 95%CI 1.24-2.00), post-operative infection (RR 2.02 95%CI 1.62-2.51), ventilation (RR 3.45 95%CI 2.71-4.40) and increased LOS with RR 2.53 95%CI 1.89-3.38).
The authors identify the limitations of this type of retrospective study but accurately acknowledge that there are limited alternative approaches for this kind of clinical question. This is particularly true when examining a condition which is quite rare. Again, the numbers of patients they could examine was impressive with over a half a million patients included in this study. They also acknowledge that this approach likely underrepresents the true prevalence of OUD and that it doesn’t differentiate between misuse, dependence and addiction but the authors have understandably needed to be pragmatic in their approach.
These peri-operative risks are likely comparable for all patients with chronic opioid use and are not insignificant.
There have been similar findings in adult studies. The take home message is that we should be identifying these patients pre-operatively to cease or at least reduce their opioids before surgery not only to improve pain management but to mitigate their surgical risk. We should also ensure that we are factoring this elevated risk into decisions about peri-operative management and disseminating this information to our surgical and intensive care colleagues.
Reviewed by Dr David Sainsbury