A Quality Improvement Intervention to Reduce Postoperative Opiate Use in Neonates

Abstract

BACKGROUND AND OBJECTIVES: Opiate use in neonates can affect clinical outcomes after surgery and may alter future neurodevelopment. We implemented a multimodal opioid reduction strategy in our NICU for infants undergoing nonemergent gastrointestinal surgery. METHODS: After multiple stakeholder’s meetings, our opioid reduction intervention included giving neonates postoperative standing intravenous acetaminophen every 6 hours for 48 hours, a standardized postsurgical sign-out with the NICU team in which pain control was directly addressed, and a series of postsurgical pain education seminars with NICU providers. To assess the impact of our quality improvement project, we used process control charts to investigate trends in postoperative opioid use in our preintervention (January 2012 to April 2016) and postintervention (May 2016 to September 2019) cohorts. RESULTS: A total of 77 infants were included in the study (40 in the preintervention cohort and 37 in the postintervention cohort). Patient characteristics were equivalent. The intervention significantly reduced the trend in postoperative morphine equivalents (median: 7.96 mg/kg in preintervention cohort versus 0.095 mg/kg in postintervention cohort; P < .0001). The Neonatal Pain, Agitation, and Sedation Scale pain scores and safety profiles were equivalent in both groups. The intervention was also associated with a 24-hour reduction in postoperative ventilation time (P < .048) and a 7-day reduction in the use of total parenteral nutrition (P < .017). CONCLUSIONS: Standing intravenous acetaminophen coupled with provider education can successfully reduce opioid use in postsurgical neonates. Given the concern for opioid exposure in neonatal neurodevelopment as well as clinical benefits of reduced opioids, similar strategies for opioid reduction may prove useful at other institutions.

Impact of dexmedetomidine in conjunction with a weaning protocol on post‐surgical opioid use in a neonatal intensive care unit

“…Lastly, the protocol suggested scheduled acetaminophen to be used in the post‐operative period, which increased use of this adjunct analgesic significantly (13 vs. 93%, p < 0.001). A QI project to reduce post‐operative opioid exposure in neonates reported in 2020 used intravenous acetaminophen and saw significant reductions in opioid exposure 28 . Sykes et al 25 postulate that IV acetaminophen in the post‐operative period may have had the greatest opioid‐sparing effects (over dexmedetomidine).…”

“…A QI project to reduce post-operative opioid exposure in neonates reported in 2020 used intravenous acetaminophen and saw significant reductions in opioid exposure. 28 Sykes et al 25 postulate that IV acetaminophen in the post-operative period may have had the greatest opioid-sparing effects (over dexmedetomidine). Based on this, it may be that any benefits this project demonstrated with the use of the protocol actually represent benefits of scheduled acetaminophen use in the post-operative period.…”

Enhanced Recovery After Surgery for Pediatric Cleft Repair: A Systematic Review and Meta-Analysis

“…Multimodal analgesic regimens have already been adopted into numerous ERAS pathways for adult surgical recovery and are beginning to emerge in the pediatric literature. 29 Furthermore, recent literature has demonstrated support for the safety and efficacy of NSAIDs and gabapentin in managing acute pain in neonates. 30 A reasonable concern regarding implementation of enhanced recovery pathways is an elevated risk for complications or hospital readmission caused by interventions aimed at hastening recovery and decreasing time to patient discharge, which has been noted in some ERAS pathways for adult hepatic and gastric surgery patients.…”

“…Multimodal analgesic regimens have already been adopted into numerous ERAS pathways for adult surgical recovery and are beginning to emerge in the pediatric literature. 29 Furthermore, recent literature has demonstrated support for the safety and efficacy of NSAIDs and gabapentin in managing acute pain in neonates. 30…”

Rescue Paracetamol in Postoperative Pain Management in Extremely Low Birth Weight Neonates Following Abdominal Surgery: A Single Unit Retrospective Study

“…Recent studies show that the introduction of intravenous paracetamol as part of a postoperative pain management protocol along with the education of care providers leads to improved quality of care indicators even in premature infants. (e.g., reduction of analgesic and sedative consumption, shortening of mechanical ventilation, and parenteral nutrition) (36)(37)(38)(39). Although these studies did not mention the usage of a loading dose of paracetamol.…”