Annual Meeting Research

Opioid Prescribing Practices for At-Risk Pediatric Populations Undergoing Ambulatory Surgery

By Melissa M. Masaracchia, MD
Assistant Professor and Director of Resident Education
Section of Pediatric Anesthesiology
Children's Hospital Colorado
Department of Anesthesiology
University of Colorado School of Medicine
Aurora, Colorado

Pediatric patients with sleep disordered breathing (SDB) and obesity are at risk for opioid-induced respiratory depression. Although monitoring in the inpatient setting allows for early recognition of opioid-related adverse events, there is far less monitoring for these issues after ambulatory surgery since patients are discharged home. Because there are no established guidelines for proper opioid dosing in these pediatric subsets, we sought to determine if at-risk children were more likely to receive doses of opioids outside the recommended range at our institution.

To do so, we captured all patients between January 2019 and June 2020 who had an outpatient procedure generating an opioid prescription. From this sample, we identified patients who had an ICD-10 code that was suggestive of sleep disordered breathing or obesity. Between these groups, we analyzed patient demographics (age, sex, BMI, actual and ideal body weight), in addition to size descriptors used for calculations (actual or ideal body weight or lean body mass), and prescription characteristics.

We found that out of 4,674 patients identified, approximately 173 had a diagnosis code of sleep disordered breathing, obstructive sleep apnea, or tonsillar and/or adenoid hypertrophy, and 128 were obese or were found to have a body mass index-for-age greater than the 95th percentile.

Overall, patients with no comorbidities were more often prescribed standard or high doses of oxycodone (approximately 58.7%), while both obese patients and those with SDB were more likely to be prescribed lower doses, regardless of the size descriptor used for calculations.

For obese patients, 64% of prescriptions were based on ideal body weight. When ideal body weight was used, providers were more likely to prescribe higher doses of oxycodone (83.3%). But when actual body weight was used, low-dose oxycodone was more likely to be prescribed. Interestingly, no prescriptions used lean body mass for calculations, which is the preferred size descriptor for obese patients. For patients with SDB, 79.8% prescriptions were based on actual weight; and of those, the majority were written for low-dose oxycodone.

The variability in prescribing practices suggests that clinicians are not clear about how to appropriately dose opioids for these two populations, and because of this, children who fit these descriptions are more likely to receive opioid doses outside the recommended range. Future analyses will focus on identifying gaps in knowledge about opioid prescribing and figuring out what factors contribute to this.