Hospital Policy Slashes IV Acetaminophen Use for Tonsillectomy

A Colorado hospital managed to greatly decrease the use of intravenous (IV) acetaminophen (Tylenol) in pediatric tonsillectomy and adenoidectomy surgeries by implementing a standing order for the oral version to be administered, a new study found.

The patients fared better, and the strategy also saved money, Melissa Brooks Peterson, MD, of Children's Hospital Colorado/University of Colorado Anschutz Medical Campus in Aurora, told MedPage Today.

She presented the findings at the American Society of Anesthesiologists annual meeting, held virtually and in-person in San Diego.

Changing from an "opt-in" to an "opt-out" model of oral administration made the difference, she and her colleagues reported.

As Brooks Peterson noted, patients who undergo these common childhood surgeries often suffer from severe postoperative pain. "It lasts for 1-2 weeks after the surgery and is severe enough that pediatric patients struggle to continue to eat and remain hydrated, especially in the first 4-5 days after surgery," she said.

Acetaminophen is the standard painkiller for these procedures. But it was administered in a haphazard way at Children's Hospital Colorado, which performs hundreds of tonsillectomies a year, Brooks Peterson said. "Every patient was getting acetaminophen, but in many different ways and during different times in their care. This inconsistency in administration meant that some of our patients were not getting this medication before surgery, which is better for pain control, and instead were getting it after surgery."

For the new study, she and her colleagues tracked acetaminophen doses over a 4-year period from 2017 to 2020. At the beginning of 2019, the hospital instituted a new policy emphasizing standing orders for the drug (12.5 mg/kg PO, max 650 mg) for all patients undergoing tonsillectomy and/or adenoidectomy if there were no contraindications.

The number of IV acetaminophen doses dispensed fell from as many as 42 doses per month before the new policy to fewer than 5 afterward, a dip of 23.8 monthly doses on average (P<0.001), the researchers reported. They also noted preliminary statistics suggesting that nurses were more satisfied with patient outcomes after the change.

According to the study, savings on medication alone were more than $35,000 a year.

"Giving oral acetaminophen in a standard, reliable way to children before tonsillectomy surgery is a more efficient, cost-effective way to manage severe pain," Brooks Peterson said. "It can and should be a routine part of the multimodal, opioid-sparing plan for pain control for pediatric patients undergoing this surgery."

Asked for his perspective, Rick Novak, MD, of the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University in California, who was not involved with the study, said he also believes that IV acetaminophen is overused. "Making oral Tylenol a standing order is an advance," he told MedPage Today. "If Tylenol is given orally prior to the surgery, it works just as well, or better, than IV Tylenol."

In fact, he said, "IV Tylenol isn't that useful of a drug. It's weaker than narcotics, it's expensive, and it can be replaced by oral or rectal Tylenol. At the surgery center where I'm medical director, we never OK'd it to be on our formulary for all these reasons."

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