Postdischarge Opioid Prescription after Cesarean: A Quality Improvement Initiative.

OBJECTIVE: This study aims to determine if adoption of a user-friendly algorithm for individualized opioid prescribing at discharge would decrease the number of opioids prescribed after cesarean delivery. STUDY DESIGN: As part of a quality initiative, we developed and implemented an algorithm for opioid prescribing at discharge for patients after cesarean delivery. The intervention group comprised patients delivering by cesarean in the 6 months following initiation of the intervention. The intervention group was divided into three groups based on inpatient opioid needs 24 to 48 hours after delivery. Oxycodone tablets were prescribed at discharge based on inpatient group. The control group comprised patients delivering at the same institution in the 6 months prior to initiation of the intervention. The primary outcome was number of oxycodone tablets prescribed at discharge. The secondary outcome was the proportion of patients with a pain-related encounter or additional oxycodone prescription up to 6 weeks after delivery. RESULTS: From July to December 2020, a total of 382 subjects met criteria for the intervention. The comparison group consisted of 391 subjects discharged from January to June 30, 2020, after cesarean. Baseline characteristics and inpatient opioid use 24 to 48 hours after delivery did not differ between the groups. Compared with the control group, subjects in the intervention group had fewer oxycodone tablets prescribed at discharge (11.1 vs. 15.8, p < 0.001). The number of pain-related encounters within 6 weeks of delivery did not differ between the intervention and comparison groups (10.5 vs. 10.3%, p = 0.82). There was no increase in the additional number of oxycodone prescriptions after discharge (4.7% in the intervention group vs. 4.3% in the control group, p = 0.81). CONCLUSION: Discharge opioid prescribing based on inpatient use after cesarean reduces the number of opioids prescribed without increasing the number of pain-related encounters after discharge. A simple algorithm may ensure compliance from prescribers. KEY POINTS: · Previous research has shown that most opioids prescribed after cesarean delivery are unused after discharge. We implemented an algorithm for opioid discharge prescribing after cesarean delivery based on inpatient opioid consumption.. · Implementing an individualized approach to opioid prescribing reduced the number of tablets prescribed at discharge after cesarean delivery. The decrease in discharge prescribing did not correspond to an increase in pain-related encounters or additional narcotic prescriptions in the 6 weeks following delivery.. · The overprescription of opioids at discharge after cesarean delivery is well-established, and previous authors have found success in prescribing opioids at discharge based on inpatient use. Our study proposes a simple, reproducible algorithm for opioid prescribing at discharge after cesarean..

Can omphalocele ratio predict postnatal outcomes?

BACKGROUND: The clinical course of patients with omphalocele is challenging to predict. There is no standard method to characterize omphalocele size. Previous studies suggest that the ratio of abdominal circumference to omphalocele defect in-utero is indicative of postnatal outcomes. We hypothesize that omphalocele ratio correlates with outcomes of primary closure versus staged closure. METHODS: A retrospective chart review of all neonates diagnosed with omphalocele from 2002 to 2013 with prenatal ultrasounds available (n=30) was conducted. Omphalocele ratio was defined as omphalocele diameter/abdominal circumference (OD/AC). Data collected included primary versus staged closure, time to full feeds, duration of mechanical ventilation, and length of stay (LOS). Long-term outcomes and quality of life were also reported. RESULTS: ROC curve analysis generated optimal OD/AC ratio of 0.26. Twenty of 30 patients had a ratio less than this cutoff. Sixty percent (12/20) in the low-ratio group achieved primary closure versus zero (0/10) in the high-ratio group (p=0.001). Time on mechanical ventilation was 15.8 days (low-ratio) versus 79 days (high-ratio) (p=0.05). LOS was 33.8 days (low-ratio) versus 85.6 days (high-ratio) (p=0.119). PedsQL™ mean score was 85.5 ± 11.0 (n=20) at long-term follow-up. Readmission rates yielded no difference. CONCLUSIONS: The omphalocele ratio is a promising predictor of postnatal outcomes.

Percutaneous in utero thoracoamniotic shunt creation for fetal thoracic abnormalities leading to nonimmune hydrops.

PURPOSE: To describe a transabdominal, transuterine Seldinger-based percutaneous approach to create a shunt for treatment of fetal thoracic abnormalities. MATERIALS AND METHODS: Five fetuses presented with nonimmune fetal hydrops secondary to fetal thoracic abnormalities causing severe mass effect. Under direct ultrasound guidance, an 18-gauge needle was used to access the malformation. Through a peel-away sheath, a customized pediatric transplant 4.5-F double J ureteral stent was advanced; the leading loop was placed in the fetal thorax, and the trailing end was left outside the fetal thorax within the amniotic cavity. RESULTS: Seven thoracoamniotic shunts were successfully placed in five fetuses; one shunt was immediately replaced because of displacement during the procedure, and another shunt was not functioning at follow-up requiring insertion of a second shunt. All fetuses had successful decompression of the thoracic malformation, allowing lung reexpansion and resolution of hydrops. Three of five mothers had meaningful (> 7 d) prolongation of their pregnancies. All pregnancies were maintained to > 30 weeks (range, 30 weeks 1 d-37 weeks 2 d). There were no maternal complications. CONCLUSIONS: A Seldinger-based percutaneous approach to draining fetal thoracic abnormalities is feasible and can allow for prolongation of pregnancy and antenatal lung development and ultimately result in fetal survival.