We're going to get started, we want to start right on time, it's 10.15. So good morning, I hope your conference is off to a good start. My name is Andy Benson, I'm a member of the ANA Professional Development Committee. So it's a pleasure to welcome you to day two of the 2024 Hybrid Annual Congress. Before we begin this session, I just have a few announcements. By now, I hope that everyone has downloaded the ANA Meetings app. It's very important. Here you can get a bunch of different information. You can access the conference schedule, you can see the full speaker bios, and you can download any session handouts. Most importantly though, you can claim and submit your CE credit. So from the sessions page, you need to click the evaluation icon at the bottom and then submit it for each individual session. It'll open up 15 minutes prior to the end of each session. For those joining us virtually, you can find the same information on the schedule page of the website within each separate live stream session. Attendance you have until Monday, September 9th to complete these. After that time, you will no longer be able to claim any CE credit. So my advice, do it today so you don't have to worry about it in September. You can also ask questions in the questions icon. I'll be monitoring those or you can come up to the mic at the end of the session and ask your question. Lastly, please mark your calendars for the 2025 Annual Congress in Nashville. If you'd like to speak and share your expertise, the abstracts will open up August 14th. So for more information about the submission guidelines, please visit aana.com. So now it is my pleasure to introduce Dr. Lisa Herbinger. Dr. Herbinger is an Associate Professor, Associate Chair, and Staff CRNA at Samford University and Children's of Alabama in Birmingham, Alabama. So please join me in welcoming Dr. Herbinger as she presents Opioid Sparing Strategies for Children Having ENT Procedures. Good morning. I had a lecture yesterday afternoon and I started it with just saying in a beautiful venue and city like this and the weather that's amazing, the fact that you're sitting here spending this time with me is pretty amazing. I will just confess that if I were you, I probably would not be. So I really appreciate you being here and sharing this time with me. And a shout out to those watching virtually. I know there are people all over the place tuned in with us today also. So we are going to talk about Opioid Sparing Strategies for Children Having ENT Procedures, which obviously is a little bit different twist from Opioid Sparing with other procedures that maybe we can do regional and some different things. And so hopefully, regardless of whether you do pediatrics all day, every day, or just do some pediatrics every now and then, maybe you're one of those, I hate pediatrics and run any time it comes my way. This is geared toward practitioners that do some pediatric cases a lot or a little with hopefully just some informative information for you, some things that I will tell you I have learned over some years now following this topic. So hopefully it's some nice things for all of us to learn from, from the researchers that are looking at these things out here. So I have to do this quick disclosure statement. You do, you are expected to be here the majority of the meeting if you want to claim CEs. I do not have any conflicts of interest to disclose, and I will not be discussing any off-label medications or equipment. So learner outcomes, what are we going to talk about just briefly? We do, I do want to share with you some things about adverse events because putting that in the perspective of pain management, of course, is a big deal with these children and these types of procedures. Advantages and disadvantages of the more commonly used non-opioid adjuncts. And then I do want to touch a little bit on some ethical concerns related to this topic. And I'll just kind of hold that for now and talk about that as we go along. But there are some interesting things that I would like to share with you about that. So I decided to go kind of totally outside the box with this slide and talk about what we're not going to do today or what I'm not trying to do for you today. There's a reason for that that I may share with you in a minute. But first of all, I'm not here to tell you that I practice opioid-free anesthesia. I'm trying to be more conscious about opioids. It's some things that hopefully as I go along will make you a little more conscious and some things to consider. But I'm not up here to tell you you should not be using opioids. And I am not trying to at all imply that appropriate use of opioids perioperatively creates addicts or causes some horrible social problem. Again, it's hopefully to present some information that will just be useful to you and some things to maybe just rethink your practice a little bit. And bottom line, as you see my little dog there, I am not here to opioid shame you. There actually are a few people out there that might try to do that. Because of some things that I'll share with you, I mean, there's some really important aspects of this that we need to take seriously. But I want to make sure you understand that is not my intent. And again, I did this lecture two years ago on overall opioid sparing, not specific to ENT. And very gracious evaluation comments and vast majority, pretty much everyone had some really nice things to say except for one person who gave me the scathing evaluation comments about telling him or her that they're a horrible person and creating addicts. And anyway, it was totally misconstructed. So I do just want to make sure everybody understands what the intent of this lecture is. So I'm not up here to make you feel guilty about using your opioids. Okay. So as I mentioned, there's kind of been a journey with this for me. This is a potpourri slide. We're not going to talk about all these different things. I just want you to see that right off the bat in that upper left corner, this started with me, even though I've been doing these anesthesia longer than I want to confess, I'm like at 30 years now. But in October of 2021, the Tennessee Association, anybody here from Tennessee? The Tennessee Association asked me to do a few lectures and one of them they requested was on opioid adjuncts. And I will tell you, as I started putting the lecture together and what I thought was going to be just kind of a summary of what a lot of us do in our practice is when I really learned some things that were real eye-opening for me. And I have to admit, I was a little bit embarrassed that with all my years and my day-to-day anesthesia practice, some things that I was not as informed of as I should have been. So then you can see now over the years, I've presented this several other times, I've done some posters. I want to quickly give a shout out to one of my former students, Andrew Borg. You'll see a poster down there on the bottom right. He just graduated and he did his DNP project on this topic. And so with his permission and as his faculty advisor, I'm using some of his stuff. So I kind of got a head start on this even with one of my students, which is great. And then after several people telling me, you really need to put this in writing, put some of this stuff together, get it out there somewhere. So I do have a publication that recently came out and it's just, I would love to claim that it's all my work. It's really just pulling in some best practice things and some information. So I feel like now I at least have a big, broad view of some things that we just need to be thinking about and considering. So what's the big deal about this? I mean, so we do tons of these. We do these TNAs all the time, you know, most of the time we don't have problems, right? So why is this a big deal? Well, first of all, if nothing else but numbers, approximately 290,000 children less than 15 will have a tonsillectomy with or without an adenoidectomy annually. I mean, obviously that's a lot of those, right? And although critical adverse events and significant bad outcomes fortunately are rare, unfortunately when they do happen they can be life-threatening and lethal. And there are some very unique risks with the really young patients having these procedures. These children, especially statistically less than three years of age, risk factors on pretty much everything go up. The most common indications, of course, for these procedures, especially in the older children are recurrent throat infections, usually strep, but then things like sleep disorder, breathing, and obstructive sleep apnea due to these big tonsils and adenoids is of course a big indication for all the age groups and really the most common indication for these really young children. And in fact, in my practice over all these years and doing a lot of ENT, I honestly can't remember doing a tonsillectomy on a child less than three years old that was not for obstructive sleep apnea or some type of obstructive breathing problem. So there you go again with an added risk factor there that's very common in these younger children. So the majority of these are performed as outpatient or ambulatory procedures, which is a great thing, unless again something goes wrong, which fortunately doesn't happen much. And only like less than 3% need inpatient care. So again, we do tons of these, usually very safely with no big issues. It's just these unusual or unfortunate cases where we do have problems that we really need to be extra careful about. And then again, as far as like why are we really talking about this? Well, we know statistically that with children who have sleep apnea, 70% will have that sleep apnea taken care of with a tonsillectomy. So it is a very important, very significant procedure. And again, the reason why we do so many of them. We're absolutely not going to go through every one of these bullet points here. It's just kind of a laundry list of things for you to be aware of when we talk about adverse events, which again come into play when you talk about opioids and pain management and obstruction and that kind of thing. You can see intraoperatively that list there. Hemorrhage is probably one of the big concerns. Postoperative respiratory obstruction along with hemorrhage are probably the two bigger concerns. And then I do just want to call your attention to that bolded comment at the bottom. From strictly a liability stance, legally with closed claim studies, we know that airway obstruction or compromise is the major cause of litigation for significant adverse events and major injuries. Okay. So why are we talking about pre-op assessment here? Well again, if you're going to do an individualized, you know, best practice anesthesia plan for each of these children, we have to look at each one of them individually and kind of walk through their history. Thank goodness we have electronic records now. That has totally revolutionized our practice where you can go back and look at previous anesthetics. Of course, associated comorbidities, genetic disorders, history of recent illness, especially URI in the previous month. So I'm listing that here, and it is part of, you know, what the researchers will tell you. However, the point of this bullet is not to say we probably shouldn't be doing these well, actually, let me rephrase that. The point of this bullet is we probably should be rethinking whether or not we do these cases if they've been sick within a month. However, for those of you who do a lot of pediatrics, you probably recognize or would think quickly, if we did that, some of these kids would never get their surgery done, right? They come in the morning of surgery coughing with a runny nose, and they're on meds for reactive airway disease. And if you waited until they had none of those symptoms for a month, you know, you'd be lucky if you got their surgery done by the time they were 20, right? So the reality of our practice is we can't always wait that time period to get to where we think it's the safest point. So again, we maybe have to do some things differently to offset some of those risks. Airway exam, of course. Wheezing, I want to kind of hone in on this just for a second, because an example I give to my students a lot, which is real life, I've had it happen several times, is when you ask a question like, you know, you say you see albuterol on their med list, and you ask a question like, so tell me about the wheezing, you know, how big of a problem is it, when is the last time you heard any wheezing, and you go in room 10, and mom says, oh, they haven't wheezed in a long time. And well, what does that mean? Oh, he hasn't wheezed in like a year, okay? You go to the next room with a very similar patient, very similar scenario, and you ask mom, well, so how, when's the last time you heard any wheezing? She's like, oh, it's been a long time. Well, tell me about that, how long has it been? Oh, like last week, right? So it's all in the perspective of what they see every day. So you really need to think about how they tell you things, because obviously a patient who's wheezed a year ago, and a patient who was wheezing last week, we have to look at very differently. And then obviously, if they show up the morning of surgery, again, ideally, we don't want to do an airway procedure that day, but think about, which we see very often, these families who, they take off time from work, they drive three hours to our hospital, they spend the night in a hotel, they show up the next morning and they've got, you know, grandma taking care of the other kids, and you hear some wheezing and you tell them, hey, we can't do this today. You know, that doesn't go over real well either. So do a breathing treatment, listen to them again, it may be the best choice to go ahead and get it done that day. So that bullet especially, I wanted to kind of hone in on, because we see so much controversy. Even practitioner to practitioner level with comfort can vary a lot. And then another one I just want to bring out, I don't know what your hospital policies are, they can vary, of course, greatly from one place to another. We see a lot of high acuity, ENT, very young children, lots of sleep apnea, lots of ex premies, all those things that can, you know, make risks go up. And we have a policy that went through our med exec committee years ago that says any child that comes in for a tonsillectomy who's not hit their third birthday has to stay overnight for monitoring. So if you don't have something like that, at least just seriously consider that post-op course and pain management in these really young children before you let them go home. And then add to that if there are any other comorbidities, if they live, you know, three, four, five hours away and you're going to let them go home that afternoon, how much of an issue is it going to be if they needed to come back, things like that. You've got to put all that into the mix. Okay. So all of that, again, is to say you have to think about all of those things that when you then go forward into your anesthesia management plan, right, to think about how much opioid can I give, how sparing do I need to be, what can they handle, all those different things we've got to put in the mix. So we have to talk some about obstructive sleep apnea for some of the same reasons I just mentioned, and again, because of how that plays into our pain management plan. So I honestly don't know if the stat holds true for adults. I would kind of assume that it would, but I know in children, based on statistics and what the researchers are telling us, obesity is the most significant factor related to sleep apnea. Now, obviously, we have little skinny kids that still have sleep apnea. You can have central versus obstructive, and you all know those differences, but for the most part, obesity is a huge factor. And then if they do have sleep apnea, their risk of pulmonary edema, pneumonia, obstruction, all those things that we know can be adverse events with any patient, just go up then if they have sleep apnea. So again, when you're thinking about do we need to admit them post-op and monitor, do we need to be stingy with our pain management opioids and that kind of thing? So the gold standard, of course, is a sleep study. You see all the fancy wording there, you know, the AHI ratio and polysomnography, all that, but it's basically a sleep study. And what was interesting to me that I had never really thought about, I'd see that notation on a chart, put it in the mix, but when you look at these numbers, to me, it really kind of stands out as to how big of an issue this is as far as we actually tolerate a good bit before we consider them, in my opinion, to be significantly risky. If you look at moderate, meaning they have 15 to 30 apnea events an hour, that is basically saying up to every other minute, they're having an apnea episode, and that's still just moderate risk. And severe, all of a sudden, to me, sounds way worse. So a lot of these kids have really, really huge issues with sleep apnea, like worse than maybe we're thinking. And then these next couple things I'll talk about, one here, one on the next slide, I don't see often. I wanted to include them here because what I do see fairly often are patients that come in, mom starts talking about sleep apnea, pediatrician has talked about it a little bit, but they've never had a true sleep study done. And so then you're kind of wondering, where do they fall in this scale, right? Is it mild? Is it severe? Like, how much do we need to worry about that? So there are some centers, like we have an actual sleep disorder center in our hospital, they've got these little rooms that look like children's hotel rooms or something. Bring them in for the night, monitor them, get their true AHI ratio. But there are some centers, say it's going to take six weeks to get that testing done. Well, maybe they just admit them, do this other test where you monitor their oximetry overnight, and then as you can see there, there's just some scales for how many times they desaturate and to what level they desaturate to help quantify some risk. So just something to be aware of, that McGill score. And then this, I had honestly never heard of until I read this recently when I was putting this together, but this to me kind of equates to stop bang without the bang part. It's very similar. You literally just ask the caregiver some of these questions that you see here, mainly about snoring and how much trouble they have breathing. And then you can quantify that a little bit with three or more answers to this that put them in a risk category as kind of moderate. But then if they have all five, they're like 10 times the risk. If you ask a caregiver these questions and they say yes to everything, you've got some significant risk involved there probably. OK. So I want to talk a little bit about this briefly also because another thing we see very often, which I kind of just talked about a little, are these patients that come in and you go to interview the caregivers and they say, yeah, we've been told he has sleep apnea, but no, we've never had a sleep study. So whether or not sleep apnea is documented, meaning proven by a sleep study or some type of monitoring, if they tell you that, then we need to assume they fall in that category of higher risk for sleep apnea. You know, if you say, well, mom's probably not real familiar what that actually is, and they've never had a sleep study, so it's probably not a problem. Those are the ones that'll catch you by surprise. And so what I want you to think about here is the information in these two bullets that talk about documented or undocumented sleep apnea and what that means then with our pain management, specifically opioids. So increased sensitivity at lower doses, which I'm pretty sure all of you have seen adults or children with sleep apnea, and we see that happen, right, as soon as we give them a dose of something. What I did not know until recently is there's truly an alteration in what happens if they're mere receptors, if they have repeated episodes of desaturation. So when you think about what I mentioned before, these children that, say, have apnea with some desaturation every other minute that are in that just moderate risk category, they are going to respond differently all the way down to receptor level. It's not just they'll get sleepy and maybe struggle more to breathe. They truly have an altered response to their immune receptor. So when you put this information together, a kind of take-home fact here is a standard dose of opioid can be a relative overdose in children with sleep apnea. Not just, hey, I got a little heavy-handed, maybe we just need to crank on their jaw for a minute. I mean, not just a little too much. It can truly be, as far as that individual patient, can be an overdose. Okay, so this leads into, or I want to talk next about just a little bit about ethics. I will go ahead and confess, this is the information that I talked in some detail about before that apparently ruffled some feathers. So again, I want to remind you, this is just to give you this information for something to think about. Because I do think it's important. I think these are bioethicists from, I think Stanford, I'm kind of blanking now for a minute, where they are from. But that's actually a screenshot of the citation of this article. And what they did was just raised some ethical concerns that as pediatric practitioners, giving opioids we should just be aware of. And this is evidence-based. They have a huge set of references that they pulled these recommendations, so to speak, from. And so, first of all, we now know that perioperative exposure can be a pathway to misuse later. Especially in some adolescents, when we trigger those receptors, based on some biogenomics and things that we don't know when we're seeing these patients, there is a possibility that we're setting them off, maybe onto a pathway we would rather not put them on. Now again, that's not to say we should not be using opioids. It's to say, let's just think about what we're doing and think about are there some options and some things like that. Adjust, consider it. Our techniques can influence some things later. Aggressive treatment can be a little bit misleading for other practitioners and other caregivers and people later. The bullets there with some highlights. So we're pain management specialists, right? I mean, I know we do it perioperatively. We don't routinely see patients way out post-op unless you happen to be working in a pain management service, chronic pain somewhere. But for the most part, we're pain management specialists, especially perioperatively. We should be educating and doing research and leading by example and kind of being one of those practitioners on the forefront of this rather than waiting on other people to tell us how to do this, right? And then the next bullet, and I'm gonna show you what this is based on in the next couple of slides. We know that pediatric-related opioid harm is rising. I'll just hold for there on that for now because I'm gonna show you how we know that in just a minute. And then opioid stewardship, what I do want to bring out here that is also kind of a disclaimer to this lecture. Children are in one of our vulnerable population groups, right? If you and I have a procedure, we expect some discomfort afterwards, especially if it's a significant procedure, an incision. Tonsillectomies for sure in adults, I understand, can be brutal. But we intellectually can just deal with that. Nobody wants to see children in pain. We don't, especially their caregivers. So we'd have to take care of their pain. We just need to recognize some of these risks and put these thoughts into a mix where we can give them the best pain management plan that we can, which includes trying to help with this ongoing opioid crisis that we're in. So it's this balance between doing the best thing for our patient and just considering some of these issues that we know are going on related to the opioid crisis. So with that, let me share some of those with you. Just briefly, our timer, I'm trying to watch time. Our timer didn't start, but I think I'm okay. I'm looking at time here a bit. Okay, yeah, we started at 10.15, okay. So statistics related to children and opioids. So if you look at the bottom of the slide, you see Friedman. This is public health researchers, PhD public health researchers. These are not anesthesia people. These are public health researchers who looked at CDC data specifically on drug overdose deaths. So right now, we're not talking about a specific drug. We're just talking about any overdose that led to a death. And for this first part here, they were looking at this 14 to 18-year-old age group. So these adolescents in just that four-year group. So first of all, overall drug overdose deaths doubled from 2010 to 2021 from 2.4 to 5.4 per 100,000. Between 2019 and 2020, so in that one year, overdose mortality increased by 94%, and the next year, another 20%. Now we're gonna hone it down into the opioids, specifically fentanyl and the fentanyl analogs. 77% of those deaths in 2021 were attributed to the fentanyl group. And we know back around 2015 is when some prescription drugs were showing up laced with some analogs. There are several of them out there now. There's no way I would remember the list. Carfentanil comes to mind when I think about this. But we now know that that has led to an increase in opioid deaths also with people who didn't even realize they were getting an opioid. And so take-home point here, bold print, beginning in 2020, this is the one that really hit home with me, the relative increase in overdose deaths in this four-year adolescent age group has now surpassed that of the general population. So we now have this adolescent age group, their rate of overdose is now higher than the general population. I mean, I don't know about y'all, that's gotta sink in a little bit. I mean, that's just sad. That is just really sad. Okay, then just to continue on a little bit, because to me, these were the things that literally had me pivot some when I started putting some of these lectures and things together, because not only was I thinking about adverse effects and some negative things about opioids, now I'm looking at all these bad statistics that were just really kind of scary to me. So again, in the study from 99 to 21, now they're opening out and looking at birth to 20 years, so bigger group. So just for some comparison here, in 1999, 5% of 175 deaths were due to fentanyl. By 2021, 94% of over 1,600 deaths were related to fentanyl. From 2013 to 2021, mortality rate back to this four-year adolescent group increased 3,740%. And I'm a total geekwad. I'm also very skeptical when I see things that kind of shock me. I actually went back to the reference and some simple, with a calculator math, just making sure that wasn't a typo or a decimal in the wrong place kind of thing, and this number held up. So that much of a percent increase in that year stretch there. So now let's talk a little bit about the younger children. In the zero to four-year-old group, fentanyl-related mortality increased 590%. In 2021, 40 deaths happened less than a year old and 93 children one to four years old. So right there, I was like, wait a minute, this isn't diving here. We don't have babies and three and four-year-olds out getting street drugs. And I know we don't have this horrible opioid overdose problem with anesthesia and surgery and in the hospital. So I was truly, totally confused about what this was. So I dug a little deeper. This citation from Gaither, she is a Yale public health researcher who went into the same set of statistics and started looking at like root cause effect kind of things. And what it came down to were these really young children were overdosing in their home. So this is like mom and dad's opioids are sitting around or big brother, big sister or something. They get a hold of them, take them and overdose. So I think that's a little bit scary too. So we could talk an hour or more just about safe storage and disposal and some things that are going now with opioids, which is a whole other rabbit hole we could go down. But that's just something I think we need to keep in mind too is are we sending patients, not just children, but all patients home with too many opioids that then aren't used, sitting around, become a risk later. That's just kind of an education thing that coming down the road. Okay, so let's now talk specifically kind of why we're here. ENT procedures, some thoughts about opioid sparing or even opioid free. So this has been what I think from here on will be considered kind of a foundational research finding and study that has been published. This is from the group out of Seattle Children's. So anybody here from the Seattle area? Because I'm gonna talk several times and keep giving shout outs to this group. They've become, yeah? Oh, good, I couldn't see you back there. All right. Yeah, I've got these lights right here, I couldn't see. So first of all, the primary author of Franz, Amber Franz, she is an anesthesiologist. And then the second author, John Dahl, is an ENT surgeon. And then there's a list of some others you see there. But what I want you to see, these are actual quotes. You see I have them in quotation marks over there. So this group started and went on this campaign for several years, like a PI, quality improvement type project that went on for several years. And what they did was started with ENT, looking at ways to cut back some and consider some of these risks involved with opioids. And so one of the first things they did was the anesthesia group and the ENTs got together and had some discussions. And based on a lot of strong evidence that's out there now, the ENT surgeons agreed and supported that Catorlac in children for tonsillectomies does not increase the risk of post-tonsillectomy bleeding. Okay, now I don't know how many of y'all do a lot of tonsillectomies, but that's all, I've always heard that. I've always had a fear of that. Don't give them any non-steroidal, actually some will tell you, because it increases the risk of bleeding. Now hear me when I said in children, what I don't know for sure is that is, is it totally not true in adults, or if we just don't have enough study on that yet. For one thing, there's not near as many, as you know, adults have in tonsillectomy. So it probably just hasn't been studied extensively. But we now know that based on current evidence, Catorlac is safe. Now I can tell you in my facility, where we have about 12 ENT surgeons, it's a real mix with who wants to go with what. So I'm still careful about how I use it, and which surgeons are okay with it, because they're gonna blame me if I give it, and they have a post-bleed, and they didn't want me to give it, right? That's just real life. But they talked to their surgeons, they came up with a protocol for using Catorlac, and that's what we're gonna talk about some coming up. And again, this is just a screenshot of the front page of their article. I know you can't read that, I just wanted to show you that, and it's in my references, but they published this in 2019. Okay, so we're not gonna go every step through this, but I wanna point your attention to a couple things. So these three columns are not comparison groups for this study. What they did was they ran a protocol for several months with the first column, changed it in the middle column, changed it again in the third column, and then ran data and looked at outcomes. And so for right now on this slide, what I want you to kind of pay attention to is that bigger gray square that talks about induction. So you can see they used a standard protocol for SIVO, propofol, Zofran, dexamethasone, LR, and SIVO, okay? Right around the MAC, give or take some, of SIVO. Okay, so let's go on then to this slide, because this is where I summarized it and maybe made it a little easier to look at all the pieces. So in the first cohort where they did morphine and acetaminophen, they had about, that's actually a typo, I realized this morning, it was actually 333 patients, so a few more. So that first cohort was morphine and acetaminophen, and to back up a little bit, ASA 1, 2s, and 3s, two to 19 years old. So three ASA categories, big group of age participants. Then in that second column where they changed the protocol, what they did was dropped morphine, added dexamethamidine, dropped acetaminophen, because to be honest, they said it's just pricey. We're just gonna try to not give this pricey IV acetaminophen, and so they started doing PO, ibuprofen, like right before coming back to the OR. Then in the third group, they dropped the pre-op PO ibuprofen, kept the dexamethamidine, and added Catorlac at the end of the procedure. So after the tonsils are done, when they're dried up and everybody feels like bleeding is under control, then they gave the Catorlac. Some of the surgeons, about 2 3rds, injected some local anesthesia into the tonsil bed, but what they found when they then ran all the data and looked at outcomes, they decreased their opioid use from 100% to 20%. They sent them home with a protocol for alternating acetaminophen and ibuprofen, they did give them some oxycodone if they had some breakthrough pain, but what they basically showed and what they published as far as their conclusions, was that dexamethamidine and Catorlac provides effective analgesia without increasing recovery times, without changing outcomes, without raising pain scores. So in other words, they were able to do away with opioids and use the dexamethamidine and Catorlac. So this is just a sampling of some things that are out there. There's a lot going on. We're talking specifically about Catorlac here. We're gonna talk some about Catorlac, some about dexamethamidine, but about Catorlac, you can see those first three authors, they have presented evidence that Catorlac is safe in children for tonsils, not in adults, which is what I mentioned before. The next one down, that Rabani citation, they basically concluded that Catorlac was safe for tonsils in children. The next one down, actually, other side. Their findings, they concluded, we still need to not do that. And then, unfortunately, Cochrane, which I kind of think of as sort of the pinnacle of these meta-analyses and reviews, they said, eh, we're still on the fence with this. They just kind of said, this is inconclusive. It's also, if you notice, older. So this was back in 2013. So I think if they looked at some things that have come about since, the findings could be different. But I just wanted to show you, there's a lot more out there, a lot more, but these are just a few that were part of my citation list and I just wanted to show you. So let's talk now specifically about dexamethamidine. So I saw this picture that had absolutely nothing to do with my lecture, looking for something else, and it literally brought to mind a comment that I'd heard one of my colleagues at Children's say one day when she said, unless you've been living under a rock, you're using dexamethamidine for like everything now. And so I'm not telling you anything you probably don't already know, but I will speak just specifically about tonsils. So we know that dexamethamidine decreases opioid use or needs. It promotes smooth emergence. Talk about something we could talk about forever, for those of you, in fact, let me just stop real briefly. How many of y'all do what you think of as a significant amount of pediatric anesthesia? Okay, good, we got a lot of hands going up. How many of you here are students? Great, oh my gosh. So did a bunch of you tolerate me yesterday? Yeah, I'm seeing heads nodding, okay. I love talking with students, because you guys are going to spread the word about this stuff, you know? So start your practice off with some of these things and spread it. So I told them yesterday, the two things right now that I think we're going to all be seeing eventually, pretty soon, on pretty much every patient is dexamethamidine and point-of-care ultrasound for like, everything. So, but in this specific category, those of you that have done some of this, and you know what those tonsillectomy patients are doing when they wake up. If you take opioids even out of the picture, what dexamethamidine will do for you for emergence delirium will make you a winner, like, in a day, seriously. So, if you're not using some dexamethamidine for some of your cases, just for emergent delirium, you're kind of missing out. I challenge you to try it. Okay, so then back on topic here. Decreases opioids, promotes smooth emergent, decreases risk of respiratory complications, because again, it's not an opioid. There's no respiratory depression effects. And then there's a whole long list of citations there, and there are many, many more out there. So that's, there's nothing debatable about that, okay? Now, what you will see some different sources tell you is about dosing. There's information out there with anything from .25 per kilo up to four per kilo. But what we do know is when you get up at that two and higher range, you can have some delayed awakening and recovery, and possibly some extended PACU time. So, two per kilo tends to be that point where you probably won't have significant issues with that. .5 to one tends to be kind of the more common dose now, especially if you have surgeons that are pretty fast. At our place, we do a lot of half per kilo dexmedetomidine on these shorter cases, and then I don't have trouble extubating and hanging out too long in recovery room. So that's kind of where the dosing on that is, kind of some bigger ranges there. And then there's a big meta-analysis from the HE group down there that you can see. Doing this, doing dexmedetomidine for tonsillectomies, we've seen no difference in post-op pain scores with dex alone versus opioids. So again, I'm not telling you you're a bad person for using opioids. I'm just saying if we can get the same result with something other than an opioid, should we not at least just consider it? And of course, decreased risk of some respiratory complications because dexmedetomidine doesn't cause respiratory depression. So here's what we're doing that I just wanted to share with you at our place. So our anesthesia group saw what the Seattle Children's group was doing. They're so open and so, like, here is our stuff. Take it if you want to try it and use it. So we did. We took their protocol, and you can see there, especially in that middle section after IV placement, it is very similar to the Seattle protocol. We give a little bit more dexamethasone, a little bit lower dose of dexmedetomidine, but it's basically almost, except for those things, identical to the Seattle Children's protocol. Now, if you look at the top, we're just doing that right now for our tubes and adenoids or just adenoids. We've not progressed to tonsillectomy yet because I'll just be honest with you, it's the reason why I put the little colored baby steps over there. This process kind of needs baby steps, right? I mean, you've got to get buy-in, you've got to get people wanting to do it with you. If it's going to be successful, you can't just do it in the OR. You've got to have some pre-op help, you've got to have some post-op help. So everybody's got to be on board. So you can't, you're not going to walk in one day and say, okay, from now on, we're not using any opioids on any of our ENT cases. Yeah, y'all try that and see what happens. They actually did sort of try that here, and it did not go well. So learn from us, baby steps. And I'll also mention this situation for us is very similar to the Seattle Children's setup. So they have their big main children's facility where they do, you know, everything from healthy patients with short cases to the really high acuity big cases. And then they have their outpatient associated surgical center. So this is our outpatient ambulatory care ASA 1 and 2 center. We're also doing it now in the big house, that's what I call our main facility, for adenoids and tubes, not just tubes, for adenoids and tubes, or adenoids, we just haven't progressed to the tonsillectomy yet. And you can see there again, we are using Catorlac, we are using dexmedetomidine, so it's very similar to what the Seattle group is doing. Okay, I want to share this with you because I get asked this a lot. And again, it's kind of like the dexmedetomidine for emergent delirium. I think once you try this, you'll become, you'll kind of get hooked. But for those of you who have done pediatrics where these kids just come in for tubes, what's pretty much the standard of practice now, unless there are comorbidities or something going on where you think you might need IV access, we bring them in, get them monitored, put the mask on their face, ENT pops the tubes in, we're done, right? So you have no IV. Well what we quickly figured out was possibly more about behavioral things than actual pain, but for whatever the reason, these kids would wake up just kind of crazy. And we don't have an IV, there's no way to give them something like you can, a patient who's post-op with an IV running. So years ago, we started doing intranasal fentanyl, and some of you guys are probably doing that. We would do two per kilo, still do, a lot of the colleagues I work with, two per kilo of fentanyl, squirt it in the nose, either just before the surgeon starts, I like to do it when the surgeon moves from the first ear to the second ear, that way I know they're nice and deep in sleep, it's not going to trickle down in their airway. But what I'm now doing is two per kilo of dexmedetomidine nasal, and it is beautiful, and they don't have then the opioids on board. So again, it's that question of, were we doing a terrible thing with intranasal fentanyl? No. But if we can do intranasal dexmedetomidine and get the results, or maybe even better effect, I mean, why not? And I even played around, totally anecdotally, nothing scientific here, but I do a lot of ENT, and I would, for several different days, I would do two per, three per, four per, it is supported by research that you can see there at the bottom of the screen, and then I would just go back and talk to the PACU nurse later where I left the patient, and even up to that four per kilo dose, they were not staying too long in PACU, they were not having any kind of obstructive events because they're too sedated or sleepy, and the bottom bullet there, which should not be our major implication for sure, but your PACU nurses will be your biggest fans, because they've got these kids now that there's really no way to handle them since they don't have an IV, but they're calm, and their airway's good, and they get back to mom and daddy pretty quick, and so I'm using nothing but intranasal dexmedetomidine now for just our two patients, okay? And again, there is literature out there supporting anything up to four per kilo nasal, and this is, I'm just kind of being honest here because it's not scientific, but the other reason I like to use two per is it's the same dose I did for years with fentanyl, and I don't have to stop and remember what to give, so two per fentanyl or two per dexmedetomidine will work really well for you. This is just a resource slide, we're not going to go through this, I actually took this from the Cote Pediatric Anesthesia textbook, which is kind of my bible for peds, just a lot of different things about some of these adjuncts with routes of administration, safe doses, some of the bigger implications, so again, just a resource for you there. You notice ketamine's on there, we're not talking about ketamine in this lecture, we are not doing ketamine for ENT, I'm not saying it shouldn't be done, I would have to see some things about how much you can give and not have some delays and something down the road, but we are obviously doing these other things that we've talked about. So again, I want to do a shout out to Seattle Children's because they are by far the front runners and just very progressive with not just opioid sparing, but with opioid free anesthesia. And again, what they did in this time period, you can see there from 2016 to 2022, they introduced kind of incrementally these opioid free protocols, and as you can see if you look at that third line down, the third chunk of stuff there, for ENT, urology, orthoderm, ophthalmology, GI dental, I mean they, and I'll show you a slide in a minute where you can just kind of get even a feel for that, so they rolled out these protocols over this time period, and for LAP-APIs alone, which obviously that's not ENT, but for LAP-APIs alone, which all the pediatric centers, as you probably know, do tons of those, they saved over 500 hospital days per year. So that's not only great for the patient, but don't think your administrators won't jump all over that one when you start looking at things like reimbursement and insurance and that kind of thing. So saving a lot of hospital days with this opioid free protocol, with the really important thing here, no difference in pain scores and no increased use of rescue opioids. Okay? So I will say this to hopefully not offend anyone. We can all say, I'm not sure I want to do this, or I want to try this, or I'm going to slowly put this into practice, see what happens. What we can't say is it can't be done. We cannot, it can be done. And so if you look there, excuse me, in April 2020, which is four years ago now, they were operating the outpatient surgery center. So I'm not talking about the big house here. Their outpatient surgery center that does their ASA 1 and 2 ambulatory care patients became the first opioid free center in the country. Literally in four years now, no opioids. Okay? That's pretty impressive to me anyway. So here's again a screenshot from a 2021 study from the same group. This is the same group that did the one I showed you earlier on tonsillectomies. Two years later, they published all their protocols, and literally you can look at the columns here, and you can see what they were doing before they went opioid free, what they're doing now since they've gone opioid free, and they've just put it out there for anybody to take, tweak, try it, whatever. But it's some really good information there. And I will just say regional anesthesia is a big part of this. Now obviously there's nothing regional we can do with ENT, which is why this lecture is kind of in a nichey spot. We don't have the luxury of any kind of regional anesthesia we can do for ENT procedures. But obviously a lot of these other cases you can. And now that two important things have happened that have really helped advance this in pediatrics, we now know that with newer ultrasound technology, we can do really safe neuroaxials and field or regional blocks in children that we were a little more concerned about earlier when just finding landmarks and some of those kind of issues were significant. The other thing that I just want you to be aware of, which again is not about ENT, because this is about regional, but just to kind of put in your mix with this conversation, the big players like NASORA and the ASRAP group that does all this stuff on regional anesthesia for children and adults have now said, they wrote a position statement, that children can have neuroaxial procedures and regional blocks with the exception of an interscaling block after the induction of general anesthesia. Because all of us in this room would probably cringe at the thought of trying to do a spinal or an epidural on a fighting five-year-old, right? So for years we thought, it's really not the safest thing to do because these children can't tell us what they're feeling. We can't get the responses we need. We can't check levels, all those things. That's kind of gone away. So those two things have, and actually the topic I spoke on yesterday with anesthesia effects on the developing brain, that too. So really those three things have really advanced regional. So that's a big player in these Seattle opioid-free protocols here. Where are we here? 11 of 7. Okay. This is a good topic. Oh, let me go back real quick, so I don't mess this up. So I literally just found this a few days ago and went into the speaker ready room when I got here and had them reload my slides because I wanted to just show it to you. I know you probably can't read this, but if you look over there under the big writing, that's a screenshot of a press release that came out from Seattle Children's in May 21. They hit their 10,000th opioid-free procedure. So that's still three years ago when they hit 10,000. All right. So again, you can say a lot of things, but you can't say it can't be done. All right. So tying up here. Sorry, I'm losing my throat. Opioid-sparing strategies for ENT promote all these things we've talked about. We don't need to go through that laundry list again. Big, big bullet here. Every child has to be looked at individually, right? There are absolutely times when opioids may be the best choice. There are absolutely times when opioid-free or for sure opioid-sparing may be the best choice. But we also got to know how to use all these adjuncts, how to come up with a good plan, pre-op, intra-op, post-op, that will promote the best outcomes for our patients. All right. So a lot of references here. You have those on your app with the slides. I have full text on all of these. If anyone's interested and wants to look at anything and has trouble finding it, you can email me here at Sanford. That is me. My name changed after I got married, but I didn't change it on my email. So if you email me here, I'll be glad to send you anything. Or if you have some questions later and want to talk, I promise I'll try not to squeak at you. Let me know. So I see Andy coming up. He may have some questions from the audience or something or from the app. Are we on time? Okay, we're doing pretty good. We had a few questions online. One was, did you see any protocols in the literature that utilized LTAs with lidocaine for your pediatric tonsils? I don't remember seeing that on protocols. But in our center, the ENT surgeons will do that sometimes just before they go to put the mouth gag in and do their work, especially for some of the broncs. So that may be included in that bullet that talked about local anesthesia. Many of the anesthesia providers at our place are not doing it, but some of our ENT surgeons are using LTAs. I don't know if that's part of what they're considering in the protocols. It's a good question, though. It's definitely a form of local anesthesia. Great. There's one more, or a couple more. How often are you encountering bradycardia with the intranasal dosing of dexamethatomidine? Me, personally, have never seen it. I've never seen it, even with the big dose. I did several patients. I did a good many patients all the way up to that four-per-cure dose. Now, bradycardia, if you give a decent dose too fast or if you don't split your dose a little bit, I've definitely seen that. Not in a problematic way. It was easily resolved. I didn't have to treat it. But with intranasal, I've never seen it happen. All right. Do you give the intranasal Presidex in pre-op or after stage 2? And if in pre-op, how many minutes before you roll back? So we're doing a little bit of intranasal pre-op for, you know, pre-op anxiety, but you do have to give that some time, 20, 30 minutes at least, which is one of the reasons not, some people even say 40 minutes. As far as what we're doing for our BMT patients, our ear tube patients, we do that after their sleep. That's what I like to do between the ears because I know if they can tolerate the surgeon pricking the ear, they should be past that stage 2 point, and that's why I feel safe then dropping that into their nose while they're coming around to do the other ear. The questions are rolling in. Intranasal dosing, are you pulling from a vial or simply squirting intranasally? I'm squirting with no dilution straight from the vial. Now, I dilute my IV doses in the young children so I can feel safer about what I'm giving, but because of volume, I don't dilute if I'm doing intranasal. I literally, in fact, what I do, we have a natalist system. I don't know if you guys have used that, the little blunt tip natals. I'll draw up what I want to give from the vial, take that natal off, and put that blunt little plastic natal on it. That way I don't have to worry about poking them in the nose with the tip of the natal. So I will put my little natalist system soft natal on the end and squirt it in their nose with no dilution. Does that answer that? You think that answered that? Okay. No? What are your thoughts on rectal acetaminophen? We do a lot of that, too. In fact, you'll see that in a lot of protocols. We will do that sometimes right after we've gone to sleep. We tend to do it more on not like the BMT kind of patients and super short ones, but the ones where go to sleep, get their IV, get their tube or their LMA or whatever, drop their diaper, put in the suppository, move on. And we do a lot of rectal acetaminophen. And that resource slide that I showed you, the gray and white bars that came from the textbook, there's dosing on there and it talks about rectal acetaminophen. That's a great adjunct for a lot of things. All right. Do any of the opioid sparing protocols include Celebrex as an alternative to Catorlec? I've not seen that for children. Again, these protocols that I was looking at that came from Seattle Children's was in pediatric patients. If it's on there, I miss that. I don't remember seeing Celebrex on the protocols. All right. Are there other uses for dexamethotamidine like for shivering or emergence delirium? Emergence delirium, for sure. And that's what I literally right now, like I'm trying to remember. I'm practicing one day a week now, so obviously I'm not doing as many cases because I'm teaching full time one day a week. For probably at least a year or more, every single patient I have gets dexamethotamidine because I've seen such amazing results with emergence delirium. Again, that's me personally. There is evidence out there to support that. It definitely works for emergence delirium. As far as shivering, there's a lot of research out there on that. We don't see that problem in young children as much as you do in adults. But there's definitely some research out there going on. Like I said, we're using dexamethotamidine for like everything, right? And shivering is one of the indications that you can find some research and some studies out there on that. All right. And here's the last question. Even if we do opioid-free anesthesia, when patients go home and get a narcotic prescription from their surgeon, as the latest study showing most overdose death happens at home, how are we addressing this issue with our surgical colleagues? Well, that's where, again, this is an interdisciplinary, if you're really going to do it the way you would hope it could be done and successful, you've got to have everybody involved. So, again, like Seattle Children's, they sat down with their ENT surgeons. They talked about it. They did give them some scripts for oxycodone for breakthrough. It's just an education thing that you just have to take a step at a time and try to get as many people involved as you can. And, again, especially if you have an older child that has a tonsillectomy, they may need something for breakthrough. You can't let them go home and be miserable, right? So it's the steps. It's just considering some alternatives. And sometimes they may need some opioids for breakthrough once they get home. All right. Here's one more. Is there any literature describing different TNA techniques in pain post-operatively, like intercapsular versus traditional TNA? Probably. I would say I'm not familiar with those. I'm sorry, I can't speak to that. I think, you know, there are surgeons doing laser tonsils that they think is less painful post-op. We have surgeons that do shaving techniques and debridements versus full tonsillectomies. There are, for sure, different techniques out there. I would not try to get into that because I would give you wrong information. I think that would go down kind of more of a surgical path. And there's definitely different techniques that have different post-op pain responses. That would be helpful, too. You could get all the surgeons maybe to do laser tonsils. That might be helpful. Of course, that raises a new set of concerns, right, that don't have to do with opioids. Do we need to quit? Okay. All right, well, I'll be up here for a few minutes. I know you guys didn't have a chance to ask questions. If you wanted to, I'll hang out here for a few minutes if anybody has questions. And, again, thank you for being here.

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