Over 4,000 neonates undergo surgery in the United States every year. One of the key aspects of post-surgical care for the babies in the NICU following surgery includes adequate pain control. However, over-use of opioids for pain control and sedation can have numerous downstream side-effects on the babies including prolonged hospitalizations, opioid dependency, and neurobehavioral sequelae in early childhood.
In order to assure adequate pain control, but minimize opioid use in our post-surgical NICU, the NICU and Pediatric Surgery teams, led by Dr. Jeff Gander, Associate Professor of Pediatric Surgery, implemented a quality improvement project to reduce post-operative opioids in surgical patients beginning in 2015. The project’s intervention included supplementing post-operative pain control with intravenous acetaminophen in addition to minimizing opioid infusions. Although this was a change in unit culture, NICU team members held multiple post-operative pain management education seminars where the team discussed the value of reducing opioids and the role acetaminophen can play. Finally, the intervention also included standardizing the post-surgical handoff between the anesthesia, surgical, and NICU teams to include a discussion of pain management strategies.
When Dr. David Grabski, University of Virginia Surgery Resident, evaluated the results of the quality improvement initiative with Dr. Gander and Dr. Jonathan Swanson, Associate Professor of Pediatrics and NICU Medical Director, they found that the project reduced post-operative opioid use in babies undergoing abdominal surgery by 98%. They also saw no changes in the pain scores recorded for the babies or in the safety profile of babies following surgery, which was initially a major concern for the bedside nurses. In addition, the team found that the babies were extubated a full 24 hours faster than before then intervention, and there was a 7-day reduction in the use of intravenous nutrition, meaning that babies were able to feed much sooner.
Overall, the quality improvement initiative was so successful, the NICU has started implementing a very similar protocol in other aspects of post-surgical care for other patients in the NICU. The Pediatric Surgery team is also evaluating its use in children less than 1 year of age that are undergoing elective surgery in both the Pediatric Intensive Care Unit and Acute Care floors. Early results from these other patient populations look just as promising. In patients with congenital diaphragmatic hernia, initial research has shown a reduction in morphine equivalents from 82 to 2.9 mg/kg after this intervention. Post-operative intubation length in this population has also decreased from 156 to 44 hours.
Dr. Gander stated, “We decided to study how we can reduce opioids since I really feel they are detrimental to patient care. Pain control is important but opiates have so many side effects that the risks outweigh the benefits. I am excited about the effect our project had and that it was done in a collaborative way. So many people from so many different specialties contributed to it.”
For more information, please see:
Grabski DF, Vavolizza RD, Lepore S, Levin D, Rasmussen SK, Swanson JR, McGahren ED, Gander JW. A quality improvement intervention to reduce postoperative opiate use in neonates. Pediatrics 2020; 146(6):e20193861.
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