Opioid-free Anesthesia for Supracondylar Fractures. Doable, but better? Fad or the future?
Todd Glenski, MD, MSHA, FASA and Lynn D. Martin, M.D., M.B.A.
Opioid-free anesthesia (OFA) is gaining traction at certain centers and appears to be a growing trend. Today’s PAAD will review a significant QI project undertaken at Seattle Children’s utilizing OFA in an extremely common pediatric surgery.
Original Article:
Henson LO, Chiem J, Joseph E, Patrao F, Low DK. Transitioning to Opioid-free Anesthesia for Pediatric Supracondylar Fracture Repairs: A Patient Safety Report. Pediatr Qual Saf. 2025 Jan 7;10(1):e777. doi: 10.1097/pq9.0000000000000777. PMID: 39776951; PMCID: PMC11703429.
Following their published success with other surgical lines and OFA1-4, Seattle Children’s rolled out an OFA pathway for children undergoing supracondylar fracture repairs, for which they perform about 400 a year. It’s important to note that OFA for these cases was not mandated and was a “gradual shift in practice” after pathway release. They note this as a limitation in the manuscript, but it’s just the reality of QI implementation. Additionally, the surgeons were on board with this change in practice, which is always helpful when rolling out a pathway.
In total, 816 OFA patients were compared to 464 patients who received opioids (typically 0.1 mg/kg morphine or 1 mcg/kg fentanyl) during their anesthetic. The OFA pathway included pre-operative ibuprofen and options of intraoperative dexmedetomidine (0.5-1 mcg/kg), acetaminophen (12.5 -15 mg/kg) and ketamine (0.5 mg/kg). If any opioid was delivered in the intraoperative period, the patient was not classified as OFA. All patients received IV fluids and ondansetron.
The team analyzed three clinical effectiveness measures summarized here:
1. Max pain score in PACU: OFA 3.70 vs Non-OFA 3.39
2. Postop IV opioid rescue rate (did they get opioids in PACU – yes/no): OFA 38.73% vs Non-OFA 38.34%
3. PONV rescue rate (did they get antiemetics in PACU – yes/no): OFA 0.23% vs Non-OFA 1.53%
The Balancing Measure was PACU LOS which was: OFA 86.10 min vs Non-OFA 79.86 min.
In the manuscript, there are impressive control charts (created by AdaptX) that show these measures over time. Below shows the significant shift from Non-OFA to OFA from 2018 onwards:
Overall, the max pain score did not differ between groups, the PACU IV opioid rescue rate was similar, the PONV rate (already low) decreased 7-fold, and the PACU LOS (already high?) was extended by an average of 6 minutes.
It’s clear that an OFA is feasible for this patient population and appears to have minimal downside, but let’s not confuse this with an opioid free perioperative visit as 38% of these patients ultimately ended up receiving opioids in the PACU. In general, the PACU IV opioid rescue rate appears high for the non-OFA patients, raising the question of whether more appropriately timed intraoperative opioids (ex: fentanyl at the end of case) or more dexmedetomidine at the end of case or in the PACU would decrease the need for rescue doses. Granted, this is not the point of the study, but it could be investigated further.
The PONV rate decreased from an already low baseline, which is important to note. This reduction is attributed not only to the removal of opioids but also to the administration of dexmedetomidine. The PACU LOS, which already seems somewhat high in the baseline group, was further increased. However, PACU LOS in general appears to be a separate quality improvement project worth exploring, especially given the presence of new staff and an increase in OR suites at their institution.
In personal communication with the senior author, I (LDM) learned that there is still significant variation in the OFA protocol (i.e., timing and/or dose of dexmedetomidine, ketamine, and/or acetaminophen) among the anesthesiologists. The next PDSA cycle currently underway is to look at the OFA physicians and find who has the lowest pain scores and PACU opioid rate to further refine (i.e., narrow the variability) the OFA protocol and spread this better practice; thereby, further improving outcomes.
Overall, Seattle continues to show that OFA is a reasonable anesthetic for different types of surgery. The key question now is: are you willing to try this at your institution? Why or why not? Is there a downside to trying? Send your thoughts and comments to Myron who will post in a Friday reader response.
References:
1. Chiem JL, Franz AM, Hansen EE, et al. Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data. Paediatr Anaesth. 2024;34(11):1087-1094. doi:10.1111/pan.14979
2. Franz AM, Dahl JP, Huang H, et al. The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery-A quality improvement project. Paediatr Anaesth. 2019;29(7):682-689. doi:10.1111/pan.13662
3. Chiem JL, Donohue LD, Martin LD, Low DK. An Opioid-free Anesthesia Protocol for Pediatric Strabismus Surgery: A Quality Improvement Project. Pediatr Qual Saf. 2021;6(5):e462. doi:10.1097/pq9.0000000000000462 (PMID 34476314)
4. Chiem JL, Franz A, Bishop N, Liston D, Low DK. An Opioid Sparing Anesthesia Protocol for Pediatric Open Inguinal Hernia Repair: A Quality Improvement Project. Pediatr Qual Saf. 2022;7(2):e548. Published 2022 Mar 30. doi:10.1097/pq9.0000000000000548