Ruptured appendicitis is a common childhood condition requiring surgery (Serres et al., 2017) and subsequent pain control. Multimodal pain management may include local anesthetic infiltration, patient-controlled analgesia (PCA) for the administration of intravenous (IV) opioids, and scheduled ketorolac until patients are able to tolerate oral opioids (Liu et al., 2013). Although necessary in patients unable to tolerate oral opioids, it stands to reason that PCA may be associated with increased opioid consumption, side effects (e.g., constipation, pruritus), monitoring, cost, and length of stay (Charoenkwan & Matovinovic, 2014 ; Pearl et al., 2002). Often, children are not transitioned from IV to oral opioids until they have shown the ability to tolerate oral fluids (e.g., clear liquids), which may cause prolonged use of IV opioids.
Little is known about when children are most likely to tolerate the transition from IV to oral opioids without vomiting. Nausea and/or vomiting (or even the fear of nausea/vomiting) may cause patients, parents, and even nurses to postpone the introduction of oral opioids, which may result in increased healthcare costs (Pearl et al., 2002). Currently, there is no protocol in place telling nurses when to administer the oral opioids once the order has been placed. This leads to the bedside nurse deciding when she or he feels the patient is ready for the opioid. Anecdotal interviews with nurses on our unit revealed significant inconsistencies in this practice. Whereas some nurses reported starting oral opioids after the patient had tolerated only sips of clear liquids (e.g., 15 ml), others reported waiting until the patient tolerated significantly larger amounts (up to 240 ml in a few cases) over several hours. These inconsistencies may impact patients' level of comfort, length of stay, and, ultimately, overall healthcare costs.
No studies were found related to our specific area of study. Often after surgery, children are not allowed to eat or drink for a time, awaiting “return of bowel function.” However, postoperative fasting (i.e., nothing-by-mouth diet) was not found to reduce the incidence of vomiting after general anesthesia in an outpatient setting when compared with a more liberal diet (Radke et al., 2009). Interestingly, the freedom to eat and drink at will postoperatively led to happier children who reported less pain than the fasting group. Although the patients in this study were only followed for 24 hours after procedure, the results may have some relevance to our inpatient population. In another pediatric study, oral intake 1 hour after anesthesia for minor surgery also did not increase the incidence of vomiting in preschool children, and interestingly, fluids that were at body temperature actually seemed to decrease the incidence of vomiting (Mercan, El-Kerdawy, Bhavsaar, & Bakhamees, 2011).
A retrospective study of 200 pediatric patients who underwent a laparoscopic appendectomy looked at multimodal pain management and pain scores during the first 24 hours after surgery (Manworren et al., 2016). Only 26 (13%) of the patients were considered to be of a complex appendectomy with peritonitis, perforation, or gangrene. In this study, the length of stay was anywhere from 24 up to 193 hours, with the longer length of stay in patients who reported more significant pain. Interestingly, there was no significant relationship between pain and perforation status. The most common adverse effect was postoperative nausea and vomiting, reported in 9% of the simple (e.g., nonruptured) appendectomies and 11% of the complex appendectomies. There was no significant difference in the occurrence of nausea and vomiting with administration of oral analgesia. However, this study only looked at the first 24 postoperative hours; therefore, some of the nausea and vomiting could have been attributed to the anesthesia administered during the operation.
No studies were found regarding the early administration of oral opioids in children. However, the early introduction of oral morphine to adult patients undergoing intra-abdominal surgery was found to be safe and efficacious (Pearl et al., 2002). Despite not using prophylactic antiemetics, the patients who began early oral opioids had no increase in nausea, vomiting, or abdominal distension compared with the parenteral pain medication group. In addition, both groups reported adequate pain relief, and a significant cost savings was found with the use of oral opioids as compared with the use of morphine PCA.
Together, the results of these studies suggest that children may be able to tolerate oral fluids soon after surgery and that they may be able to tolerate oral opioids sooner as well. However, no studies were found regarding the optimal time to initiate oral opioids after pediatric surgery and whether patients do better with oral opioids if they have first tolerated clear liquids. This gap in the literature and inconsistencies seen in our own practice prompted this study.
The primary purpose of this study was to identify current practice regarding initiation of oral opioids in pediatric patients recovering from a ruptured appendectomy. On the basis of these data, our team aimed to provide a best practice recommendation for this population regarding initiation of oral opioids. The investigators hypothesized that, once patients were able to tolerate 30 ml or more of clear liquids (as evidenced by no vomiting within 1 hour of ingestion), they would be able to tolerate oral opioids as well.
We are a 24-bed, postsurgical unit in a large free-standing pediatric hospital in the Midwest United States. We see over 250 cases of appendicitis each year.
The human research review board approved this retrospective study. Potential subjects were identified through a data request for patients having had surgery for ruptured appendicitis (i.e., an appendectomy) during the period from December 2012 to May 2013. Both female and male patients aged 2–18 years were considered. Patients who developed an abscess were excluded because the disease process may cause a more complex trajectory, which may include vomiting secondary to abscess formation. Children under 2 years old were excluded because appendicitis is so rare in that age group. From 167 potential patients, 43 were identified as having had a ruptured appendix and using IV opioids for postoperative pain management.
Data were extracted by the two investigators and double-checked for accuracy by a third co-investigator working independently who has since retired. Data included time from the end of surgery to tolerance of clear liquids, the volume and type of clear liquids ingested, bowel function, any documented emesis, whether or not an antiemetic was administered, any medications administered within 24 hours of starting clear liquids (i.e., acetaminophen, anti-inflammatory, IV opioids), time from the end of surgery to when the provider ordered oral opioids, time from prescription of oral opioids to administration of oral opioids, and time from tolerance of clear liquids to administration of oral opioids. Data were analyzed using the Statistical Package for the Social Sciences (SPSS 22; IBM SPSS Inc., Chicago, IL) or with Excel. Statistical significance was established at p ≤ .05. Descriptive statistics included means (SDs) and frequencies.
After data collection, 10% of charts were double-checked for accuracy. The accuracy of data collected was 97.675%, with an error noted in the age of one patient. The age field for all charts was again double-checked. The investigator then reviewed another 10% of charts and found 100% accuracy. Patient confidentiality was maintained throughout the study by assigning patient identification numbers that were kept separate from any patient identifiers. Data were stored on a password-protected encrypted IronKey flash drive.
Forty-three patients met the inclusion criteria. The average age was 9 (SD = 4.12) years, the average weight was 43 (SD = 21.53) kg, the average length of stay was 5 (SD = 1.95) days, and 23 were male. The average time to ingesting clear liquids after surgery was 29 hours. The average consumption was 354 (SD = 288.94) ml of clear liquids before administration of the first oral opioid. Five patients (14%) drank less than 30 ml, and one patient (2%) took the oral opioid before consuming any clear liquids.
Many patients received non-opioid medications before the administration of oral opioids. Non-opioid medications included rectal acetaminophen (5.6%), IV acetaminophen (11.1%), oral acetaminophen (27.8%), IV ketorolac (83.7%), and oral ibuprofen (2.3%). Oral opioids were administered to 84% of the patients after stopping the continuous IV opioid medications, and 16% did not receive oral opioids once the IV opioid medications were discontinued. The oral opioid ordered was either oxycodone/acetaminophen (tablet) or oxycodone (liquid), and the average dose ordered was 0.09 (SD = 0.02) mg/kg. Oral opioids were ordered an average of 41 hours after surgery (SD = 25.86 hours). The average time between the order being placed and the oral opioid being administered was 7.8 (SD = 9.37) hours, with 55% of the patients receiving the oral opioid within 3 hours of the order being placed. Only bowel sounds (i.e., no flatus or bowel movement) were documented for 51% of the patients before the administration of the oral opioid, and 20.9% of the patients received an IV antiemetic within 24 hours before ingesting the oral opioid. The average time between when providers ordered a clear liquid diet and when the patient ingested clear liquids was 28 (SD = 25.79) hours, with a range of 1 up to 119 hours. Regardless of demographics, how much clear liquid was ingested, how soon patients consumed the oral opioid, bowel function, or whether or not they received an antiemetic, no patient had a documented emesis after the administration of an oral opioid.
According to the 2006 statement from the American Society of Peri-Anesthesia Nurses, the occurrence of postoperative nausea and vomiting remains one of the most common complications after general anesthesia (Couture, Maye, O'brien, & Beldia Smith, 2006). Nausea and vomiting was rated as the top concern for patients postoperatively in one study (Habib & Gan, 2012) and as worse than postoperative pain in another (Lichtor, 2012). Many nurses and parents are hesitant to start oral opioids when children are experiencing nausea. This has created a barrier to the initiation of oral opioids in postoperative patients. Parental preferences have been found to strongly influence decisions to withhold opioids particularly in view of adverse effects from these medications (Voepel-Lewis, Zikmund-Fisher, Lavoie Smith, Zyzanski, & Tait, 2015). Even while patients are hospitalized and nurses are administering medications postoperatively, the parents continue to have significant influence in the decisions regarding their child's care, which may include withholding opioid medication.
In a review by Eby (2012) regarding postoperative feeding, a consistent theme revealed that the implementation of early feeding (defined by initiation within 24 hours) in the postoperative patient was well tolerated and may actually produce more positive outcomes in terms of postoperative ileus and length of hospital stay. These findings were supported by a Cochrane Collaboration Review (Charoenkwan & Matovinovic, 2014), which also found several benefits to early postoperative feeding including faster recovery of bowel function, less infectious complications, a shorter hospital stay, and higher satisfaction. Our study showed that the average time to initiate a clear liquid diet was over 24 hours and no patients experienced vomiting. This variation could be from multiple contributing factors including patients sleeping, family reluctance to allow administration, and nursing hesitation to initiate the diet. As studies have shown no difference in complication rates and a decreased length of stay with an earlier feeding regimen compared with routine care (Charoenkwan & Matovinovic, 2014 ; Le Guen, Fessler, & Fischler, 2014), it may stand to reason to initiate clear liquids earlier, which in turn could allow for earlier transition to oral opioids if needed. Jimbo and colleagues (2017) looked at initiating clear liquids 3 hours after surgery in patients with nonruptured appendicitis and found that patients were discharged within 48 hours and no complications were reported in the 7-day follow-up period.
A systematic review (Rawlinson et al., 2012) found that the use of non-steroidal anti-inflammatory drugs (NSAIDs) reduced the need for opioid usage and decreased the incidence of postoperative nausea and vomiting when compared with controls and the use of nonopioid analgesics has been recommended. In addition to offering opioids for pain management, the nurses in our study administered nonopioid medications to most patients, which may have contributed to lower opioid consumption, the low number of patients who required an antiemetic, and the absence of vomiting found in our study.
Our study adds to the current literature assessing multiple factors associated with postoperative nausea and vomiting in children undergoing appendectomy surgery for ruptured appendicitis. The limitations of this study are a smaller sample size and the reliance of retrospective documentation (especially considering that the study was conducted shortly after transitioning to electronic health record). This review was initiated after the electronic health record being available for only a 6-month period at the time of study approval. A future study that includes a larger sample size over a longer period would help provide more extensive results. Because of the retrospective nature of our study and having not examined pain scores postoperatively, it is impossible to determine the exact nature as to why opioids were either not given at all or were delayed by several hours after being ordered. Another factor that could be considered a limitation in this study is having two different services managing the plan of care, one focusing on the diet and the other focusing on the pain management. This could be a contributing factor to the different ranges in which the clear liquid diet and the oral opioids were ordered. In a future study, it would be beneficial to have one team manage both aspects of care.
In conclusion, there was no emesis recorded in our sample regardless of demographics, how much clear liquids were ingested, when oral opioids were consumed, bowel function, or what medications were given before oral opioids. This suggests that pediatric patients may be able to tolerate oral opioids after consuming as little as 30 ml of clear liquids after surgery. The results also suggest that patients may ultimately be able to transition from IV to oral opioids earlier, which could increase patient satisfaction and decrease hospital cost and hospital length of stay. We have shared our findings with nursing staff, the pain management team, and the general surgery team. We have recommended initiation of oral opioid administration after tolerating as little as 30 ml of clear liquids. Our organization is still in the process of developing a formal pathway for this, but many have accepted the change in practice already. Future research could include a prospective design with a larger sample, looking at when providers order oral analgesics, how nurses decide when to administer oral opioids, and whether or not the delay in opioid administration is related to the patients being comfortable or other deciding factors.
The authors thank Michelle Czarnecki, MSN, RN/BC, CPNP; Keri Hainsworth, PhD, and Sandra Jodarski, BSN, RN, CPN, for their contributions to this study.
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