Increasing the Use of Intraoperative IV Acetaminophen Among Pediatric Dental, Adenoidectomy and Circumcision Surgical Patients

Narcotics given for pain relief have many undesired side effects.  Currently anesthesia practice at a large outpatient pediatric surgical facility regarding IV acetaminophen administration varies depending on type of surgery and practitioner.  Although there has been an increase in use of intraoperative IV acetaminophen with pediatric tonsillectomy patients, not all surgical patients are receiving the benefits of this narcotic-sparing medication.  Larabee’s model for evidence based practice change was used in the process to develop an evidence-based practice project. 

To address this problem the following PICOT question was formed.  Among pediatric patients receiving IV acetaminophen, does it decrease the requirement of narcotics in the postoperative phase? 

A search of the literature included the following databases: Medline, CINHL, Google scholar, PubMed, Nursing Reference Center and Scopus.  Search Terms included: Acetaminophen, Perfalgan, paracetamol, pediatric, intraoperative, post-operative, analgesia, pain, opioids. 

 The evidence search yielded 5, randomized controlled trials (RCT’s) that were critically appraised as good quality.  The grade for the body of evidence is high.  Among the 5 studies, 3 randomized controlled trials directly support a recommendation.  2 additional RCT’s included a combination of pediatric and adult participants.  All 5 of the studies demonstrated a decrease in intraoperative narcotic use.   

 Considering this evidence, it is strongly recommended that pediatric patients undergoing surgery receive intraoperative IV acetaminophen to decrease the amount of narcotics required in the postoperative phase.

 In collaboration with anesthesia services a quality improvement project was developed to implement and evaluate this practice change.  The aim of this project was to increase the percentage of children who receive intra-operative IV acetaminophen from a baseline of 75% to 95%.  Small test of change were implemented and included education for anesthesia.

The change of practice was collaboration between nurses, anesthesia, surgeons, information services and pharmacy staff.  In order to provide the narcotic-sparing medication to patients, the process involved developing a standardized order set to ensure proper ordering, releasing and delivery of the acetaminophen and availability of medication.  The change of practice also involved education to anesthesia and perioperative nurses, as well as surgeons, addressing the benefits, risks, harms and contraindication.  Collaboration also included barriers to ordering, administration and access to medication in a timely manner.

Data collection after education and sharing of literature findings, revealed an increase from baseline data of 75% to 96%.  The patient population included adenoidectomy, dental and circumcision patients who were eligible to receive intraoperative IV acetaminophen.  It is anticipated that the recommendation and knowledge will be spread to this patient population at the main hospital perioperative department.