Percentage of pediatric patients < 18 years old who undergo a procedure and receive atleast one non-opioid adjunct preoperatively or intraoperatively.

Multimodal pain management in children during the perioperative time frame can decrease postoperative pain, improve clinical outcomes, and patient satisfaction after surgery. Opioids remain an important analgesic strategy in acute pain management yet carry significant risk of perioperative complications including postoperative nausea and vomiting (PONV) and dose-dependent respiratory depression. The American Society of Anesthesiologists (ASA) and Society for Pediatric Anesthesia (SPA) have published guidelines and recommendations which endorse the routine use of multimodal analgesia when appropriate to reduce opioid exposure and  opioid-related side effects. Current evidence supports the use of opioid sparing analgesics in pediatric surgical populations that act through different mechanisms. This list includes (but is not limited to) acetaminophen, NSAIDs, dexamethasone, ketamine, clonidine, and dexmedetomidine.

Preop Start to Anesthesia End

Pediatric patients requiring anesthesia

• Age ≥ 18 years of age
• ASA 5 and 6 including Organ Procurement (CPT: 01990)
• Procedure Types
  • TEE/Cardioversions
  • Bronchoscopy without another procedure
  • Obstetric Procedures
  • Diagnostic Imaging Procedures
  • Open Cardiac and 'other' cardiac procedures (determined by Procedure Type: Cardiac Surgery value codes: 1, 4)
• Non-Operative Procedures
  • ECT 
  • Endoscopy and ERCP without another procedure
  • Intubation Only cases
  • Otoscopy (00124)
  • Central Line Placement (00532)
  • Lumbar Puncture (00635)
  • Other (01990, 01991, 01992, 01999)
  • Rooms tagged as ‘Other - offsite anesthesia’
  • Cases with procedure text ‘(Actual) ABR Testing’ (without any additional procedures listed)
• Patients who remained intubated postoperatively 
• Cases with a Spinal, Combined Spinal/Epidural or Unknown neuraxial technique (determined by Anesthesia Technique: Neuraxial value codes: 1, 3, 4)
• Cases with no analgesia given

At least one non-opioid adjunct (medication, local, regional block, caudal, or epidural) was administered to the patient during the preoperative or intraoperative period.

Dexamethasone given alone is not considered a non-opioid adjunct to prevent multiple false positives that may skew measure performance.

Opioid Sparing Medications must be administered between Preop Start and Anesthesia End via a valid route (see MPOG route concepts listed above). Systemic lidocaine administered via IV infusion is considered as an alternative to regional anesthesia techniques.

Local Anesthetic Considerations: Documentation must occur between Anesthesia Start and Anesthesia End 

• Captured through administration of medications with text including ‘-caine’ via medication routes NOT including
  • 2001  Intravenous 
  • 2034  Laryngotracheal
  • 2006  Inhalational
  • 2024  Endotracheal 
  • 2004  Intramuscular (Ketorolac only)
• Intraop notes mapped to ‘Misc - Local Infiltration of surgical site by surgical team’ (ID:50626) are also considered. 

Analgesia Given: Cases without any analgesia administered between Preop Start and Anesthesia End will be excluded. Analgesia is defined as Peripheral Block, Neuraxial Block, Local Injection, Opioid Medication, or Opioid Sparing Medication.

Algorithm for determining patients who remained intubated postoperatively:

1. Was the patient transported to PACU? If Yes, Include.  If No, then 
2. Was extubation time prior to Anesthesia End? If Yes, Include. If No or missing, then,
3. Was MPOG concept 50380 ‘Emergence - ETT in place, patient manually ventilated’ documented between procedure end and anesthesia end? If Yes, exclude. If no, then,
4. Were sedation medication infusions continued after Anesthesia End? If Yes, exclude. If no, then include

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Not Applicable

Any provider(s) signed into the case between Anesthesia Start and Anesthesia End 

1. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273.
2. Cravero JP, Agarwal R, Berde C, et al. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth. 2019;29(6):547-571.
3. 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.
4. Zhu A, Benzon HA, Anderson TA. Evidence for the Efficacy of Systemic Opioid-Sparing Analgesics in Pediatric Surgical Populations: A Systematic Review. Anesth Analg. 2017;125(5):1569-1587.