<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>BACKGROUND: </strong>Unnecessarily long preprocedural fasting can cause suffering and distress for children and their families. Institutional fasting policies are designed to consistently achieve minimum fasting times, often without regard to the extent to which actual fasting times exceed these minimums. Children at our hospital frequently experienced clear liquid fasting times far in excess of required minimums.</p>

<p><strong>AIMS: </strong>The aim of this study was to&nbsp;utilize quality improvement methodology to reduce excess fasting times, with a goal of achieving experienced clear liquid fasting times ≤4&nbsp;hours for 60% of our patients.</p>

<p><strong>METHODS: </strong>This quality improvement project was conducted between July 2017 and August 2018. A multidisciplinary team performed a series of Plan-Do-Study-Act cycles focused on children undergoing elective procedures at a large children's hospital. Key drivers for clear liquid fasting times and relevant balancing measures were identified. Data were analyzed using control charts and statistical process control methods.</p>

<p><strong>RESULTS: </strong>Approximately 16&nbsp;000 children were involved in this project. Over the course of the project, the percentage of children with goal clear liquid fasting times improved from the baseline of 20%-63%, with a change in the mean fasting time from 9&nbsp;hours to 6&nbsp;hours. There were no significant effects on balancing measures (case delays/cancellations and clinically significant aspiration events).</p>

<p><strong>CONCLUSION: </strong>Using quality improvement methodology, we safely improved the duration of preoperative fasting experienced by our patients. Our results provide additional data supporting the safety of more permissive 1-hour clear liquid fasting minimums. We suggest other institutions pursue similar efforts to improve patient and family experience.</p>

<p><strong>BACKGROUND: </strong>Children routinely undergo inhalational induction of general anesthesia. Intravenous line placement typically occurs after induction of anesthesia and can be challenging, particularly in infants and young children.</p>

<p><strong>AIMS: </strong>We conducted a retrospective observational study to determine whether there was an association between clear liquid fasting time and the number of peripheral intravenous catheter insertion attempts in anesthetized children. The secondary aim was to identify factors associated with multiple attempts to insert intravenous lines.</p>

<p><strong>METHODS: </strong>After institutional research board approval, we retrieved a data set of all children between 0 months and 18 years who received general anesthesia at our hospital between January 1, 2016, and September 30, 2017. Data included age, gender, weight, race, ASA status, gestational age, number of peripheral intravenous catheter insertion attempts, any assistive device for insertion, and insertion site. Inclusion criteria were mask induction, ASA status 1 or 2, non-emergency, ambulatory surgical procedures and placement of a single intravenous line during the anesthetic.</p>

<p><strong>RESULTS: </strong>9,693 patients were included in the study. 8,869 patients required one insertion attempt and 824 underwent multiple insertion attempts. 50% of patients in the single insertion attempt group had clear liquid fasting time less than 6.9 hours compared to 51.8% of patients requiring multiple attempts. Logistic regression model adjusted for age, ASA status, gender and BMI did not find an association between duration of clear liquid fasting time and rate of multiple insertion attempts for intravenous catheters (OR 0.99, 95% CI 0.98-1.01, P = 0.47).</p>

<p><strong>CONCLUSIONS: </strong>Clear liquid fasting time was not associated with multiple insertion attempts for intravenous line insertion in children receiving general anesthesia. Factors such as patient age, ethnicity, time of day of induction of anesthesia and American Society of Anesthesiologists Physical Status classification show a greater association with the risk of multiple intravenous line insertion attempts.</p>