<p><strong>BACKGROUND: </strong>Children who undergo common outpatient surgeries are routinely prescribed opioids, although available evidence suggests opioids should be used with discretion for procedures associated with mild to moderate pain. The study assessed trends in postoperative opioid prescribing over time to determine if prescribing declined.</p>

<p><strong>METHODS: </strong>We used a private insurance database to study opioid-naïve patients under the age of 18 who underwent 1 of 8 surgical procedures from 2014 to 2019. The primary outcome was the likelihood of filling a prescription for opioids within 7 days of surgery, and the secondary outcome was the total amount of opioid dispensed. We used Joinpoint regression analysis to identify temporal shifts in trends.</p>

<p><strong>RESULTS: </strong>The study cohort included 124 249 opioid-naïve children. The percentage of children who filled an opioid prescription decreased from 78.2% (95% confidence interval [CI] 76.3-80.1) to 48.0% (95% CI 45.8-50.1) among adolescents, from 53.9% (95% CI 51.6-56.2) to 25.5% (95% CI 23.5-27.5) among school-aged children and 30.4% (95% CI 28.6-32.2) to 11.5% (95% CI 10.1-12.9) among preschool-aged children. The average morphine milligram equivalent dispensed declined from 228.9 (95% CI 220.1-237.7) to 110.8 (95% CI 105.6-115.9) among adolescents, 121.3 (95% CI 116.7-125.9) to 65.9 (95% CI 61.1-70.7) among school-aged children and 75.3 (95% CI 70.2-80.3) to 33.2 (95% CI 30.1-36.3) among preschool-aged children. Using Joinpoint regression, we identified rapid opioid deadoption beginning in late 2017, first in adolescents, then followed by school- and preschool-aged children.</p>

<p><strong>CONCLUSION: </strong>Opioid prescribing after surgery decreased gradually from 2014 to 2017, with a more pronounced decrease seen beginning in late 2017.</p>

<p><strong>Importance: </strong>While the 2016 US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain was not intended to address postoperative pain management, observers have noted the potential for the guideline to have affected postoperative opioid prescribing.</p>

<p><strong>Objective: </strong>To assess changes in postoperative opioid dispensing after vs before the CDC guideline release in March 2016.</p>

<p><strong>Design, Setting, and Participants: </strong>This cross-sectional study included 361 556 opioid-naive patients who received 1 of 8 common surgical procedures between March 16, 2014, and March 15, 2018. Data were retrieved from a private insurance database, and a retrospective interrupted time series analysis was conducted. Data analysis was conducted from March 2014 to April 2018.</p>

<p><strong>Exposure: </strong>Outcomes were measured before and after release of the 2016 CDC guideline.</p>

<p><strong>Main Outcomes and Measures: </strong>The primary outcome was the total amount of opioid dispensed in the first prescription filled within 7 days following surgery in morphine milligram equivalents (MMEs); secondary outcomes included the total amount of opioids prescribed and the incidence of any opioid refilled within 30 days after surgery. To characterize absolute opioid dispensing levels, the amount dispensed in initial prescriptions was compared with available procedure-specific recommendations.</p>

<p><strong>Results: </strong>The sample included 361 556 opioid-naive patients undergoing 8 general and orthopedic surgical procedures; 164 009 (45.4%) were male patients, and the median (interquartile range) age of the sample was 58 (45 to 69) years. The total amount of opioids dispensed in the first prescription after surgery decreased in the 2 years following the CDC guideline release, compared with an increasing trend in the 2 years prior (prerelease trend: 1.43 MME/month; 95% CI, 0.62 to 2.24 MME/month; P = .001; postrelease trend: -2.18 MME/month; 95% CI, -3.01 to -1.35 MME/month; P &lt; .001; trend change: -3.61 MME/month; 95% CI, -4.87 to -2.35 MME/month; P &lt; .001). Changes in initial dispensing amount trends were greatest for patients undergoing hip or knee replacement (-8.64 MME/month; 95% CI, -11.68 to -5.60 MME/month; P &lt; .001). Minimal changes were observed in rates of refills over time (net change: 0.14% per month; 95% CI, 0.06% to 0.23% per month; P = .001). Absolute amounts prescribed remained high throughout the period, with nearly half of patients (47.7%; 95% CI, 47.4%-47.9%) treated in the postguideline period receiving at least twice the initial opioid dose anticipated to treat postoperative pain based on available procedure-specific recommendations.</p>

<p><strong>Conclusions and Relevance: </strong>In this study, opioid dispensing after surgery decreased substantially after the 2016 CDC guideline release, compared with an increasing trend during the 2 years prior. Absolute amounts prescribed for surgery remained high during the study period, supporting the need for further efforts to improve postoperative pain management.</p>

<p><strong>CONTEXT: </strong>Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period is limited.</p>

<p><strong>OBJECTIVES: </strong>Evaluate perioperative management of DNR orders at a tertiary care children's hospital.</p>

<p><strong>METHODS: </strong>We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from 2/1/2016 - 8/1/2017. Using standardized case report forms, we abstracted the following from physician notes: (A) patient/family wishes with respect to the DNR, (B) whether pre-operative DNRs were continued, modified, or suspended during the perioperative period, and (C) whether life threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision making in the perioperative period.</p>

<p><strong>RESULTS: </strong>Twenty-three patients aged six days to 17 years had a DNR in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures, and suspended for fifteen (51%). Three children (13%) suffered life threatening events. We identified four time points where systematic reconsideration should be documented in the medical record, recommended personnel, and important discussion points at each time point.</p>

<p><strong>CONCLUSION: </strong>Opportunities exist to improve how DNR orders are managed during the perioperative period.</p>