E. Mahdi1, S. Ourshalimian1, C. J. Russell2, A. Abigail Zamora1, L. I. Kelley-Quon1,3 1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 2Children’s Hospital Los Angeles,Pediatric Hospital Medicine,Los Angeles, CA, USA 3University Of Southern California,Preventative Medicine,Los Angeles, CA, USA
Introduction: Analgesic management after appendectomy for perforated appendicitis varies widely. This study assessed whether postoperative opioid use is associated with prolonged postoperative length of stay (pLOS) and 30-day readmission compared to nonopioid analgesic (NOA) use.
Methods: A retrospective cohort study was performed using the Pediatric Health Information System® (PHIS) database, representing 47 children’s hospitals in the United States. Children ages 2–18 years old diagnosed with perforated appendicitis undergoing an appendectomy from 1/1/2005-10/01/2015 were identified. Patients were categorized as receiving no analgesics after surgery, NOA alone (acetaminophen, ibuprofen and/or ketorolac) or opioid analgesics (±other NOA) and then further stratified by what postoperative day (POD) analgesic medication was administered. Adjusting for hospital and patient demographics, multivariable linear mixed-effect modeling was performed to evaluate the impact of postoperative opioid use on pLOS and 30 day readmission. E-value (evidence value) analysis was conducted to quantify unmeasured confounding.
Results: Overall, 47,726 children with perforated appendicitis were identified and had mean pLOS of 5.1 (± 3.6) days. On POD 1, 77.6% (N=37,014) received opioids, 17.7% (N=8,448) only received NOA and 4.7% (N=2,264) received no analgesics. Adjusted models demonstrated that opioid use on POD 1 was independently associated with a 0.7 day (95% CI: 0.5-0.9) longer pLOS compared to children whose POD 1 analgesics were limited to NOA. For children who received opioids on POD 1 (N=37,014), 75.8% (N=28,061) continued to receive opioids during the remainder of their hospitalization. Continued use of opioids on POD 2 or later was independently associated with a 2.8 day (95% CI: 2.5-3.0) longer pLOS compared to children whose POD 2-5 regiment was limited to NOA. For children who only received NOA on POD 1, 12.8% (N=1,370) received no further analgesics on POD 2 or later, 53.8% (N=5,767) only received NOA, 30.3% (N=3,249) received opioids combined with NOA, and 3.0% (N=326) received opioids for their remaining hospitalization. Compared to children receiving NOA for their remaining hospitalization, starting opioids on POD 2 was independently associated with a pLOS of 2.9 days (95% CI: 2.6-3.2) longer if combined with NOA and 3.3 days (95% CI: 2.6-4.0) longer when opioids were used alone. Use of opioids did not significantly impact 30-day readmission. E-value analysis did not identify significant unmeasured confounding.
Conclusion: Postoperative opioid use is associated with prolonged pLOS in children undergoing appendectomy for perforated appendicitis. However, eliminating opioid use, even on POD 2, may result in decreased pLOS.
