A Quality Improvement Intervention to Reduce Postoperative Opiate Use in Neonates

• Published in: Pediatrics (Evanston) 2020-12, Vol.146 (6), p.1
• Main Authors: Grabski, David F, Vavolizza, Rick D, Lepore, Sarah, Levin, Daniel, Rasmussen, Sara K, Swanson, Jonathan R, McGahren, Eugene D, Gander, Jeffrey W
• Format: Article
• Language: English
• Subjects: Acetaminophen; Administration, Intravenous; Analgesics; Analgesics, Opioid - administration & dosage; Child Development - drug effects; Female; Humans; Infant, Newborn; Infants; Intravenous administration; Male; Morphine; Narcotics; Neonates; Neurodevelopment; Newborn babies; Opiate Alkaloids - administration & dosage; Opioids; Pain; Pain management; Pain Management - methods; Pain Measurement; Pain, Postoperative - diagnosis; Pain, Postoperative - drug therapy; Parenteral nutrition; Pediatrics; Postoperative Care - statistics & numerical data; Postoperative period; Process controls; Quality control; Quality Improvement; Quality Reports; Retrospective Studies; Surgery
• ISSN: 0031-4005; 1098-4275
• DOI: 10.1542/peds.2019-3861

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. 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. 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; < .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 ( < .048) and a 7-day reduction in the use of total parenteral nutrition ( < .017). 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.