Standardizing morphine use for ventilated preterm neonates with a nursing-driven comfort protocol

Reduction of post-operative opioid use in neonates following open congenital diaphragmatic hernia repairs: A quality improvement initiative

BACKGROUND

A limited number of post-operative opioid reduction strategies have been implemented in the neonatal population. Given the potential neurodevelopment effects of prolonged opioid use, we created a quality improvement initiative to reduce opioids in our NICU and evaluated the intervention in our CDH population.

METHODS

Our opioid reduction intervention was based on standing post-operative IV acetaminophen, standardizing post-surgical sign-out between the surgical, anesthesia and NICU teams and a series of education seminars with NICU providers on post-operative pain control management. A historical control was used to perform a retrospective cohort analysis of opioid prescribing patterns in addition to a utilizing process control charts to investigate time trends in prescribing patterns.

RESULTS

Forty-five children with CDH underwent an operation were included in our investigation- 18 in our pre-intervention cohort, 6 in a roll-out cohort and 21 in our post-intervention cohort. Each cohort was clinically similar. The intervention reduced total post-operative opioid use (morphine equivalents) from 82.2 (mg/kg) to 2.9 (mg/kg) in our post-intervention group (p < 0.0001). Our maximum Neonatal Pain and Agitation Sedation Score over the first 48 post-operative hours were equivalent (p = 0.827). Safety profiles were statistically equivalent. The opioid reduction intervention reduced post-operative intubation length from 156 to 44 h (p = 0.021).

CONCLUSION

A multi-tiered intervention can decrease opioid use in post-surgical neonates with complex surgical pathology including CDH. The intervention proposed in this investigation is safe and does not increase pain or sedation scores in neonates, while lessening post-operative intubation length.

EVIDENCE LEVEL

Level II.

Endogenous and exogenous opioid effects on oligodendrocyte biology and developmental brain myelination

The elevated presence of opioid receptors and their ligands throughout the developing brain points to the existence of maturational functions of the endogenous opioid system that still remain poorly understood. The alarmingly increasing rates of opioid use and abuse underscore the urgent need for clear identification of those functions and the cellular bases and molecular mechanisms underlying their physiological roles under normal and pathological conditions. This review is focused on current knowledge on the direct and indirect regulatory roles that opioids may have on oligodendrocyte development and their generation of myelin, a complex insulating membrane that not only facilitates rapid impulse conduction but also participates in mechanisms of brain plasticity and adaptation. Information is examined in relation to the importance of endogenous opioid function, as well as direct and indirect effects of opioid analogues, which like methadone and buprenorphine are used in medication-assisted therapies for opioid addiction during pregnancy and pharmacotherapy in neonatal abstinence syndrome. Potential opioid effects are also discussed regarding late myelination of the brain prefrontal cortex in adolescents and young adults. Such knowledge is fundamental for the design of safer pharmacological interventions for opioid abuse, minimizing deleterious effects in the developing nervous system.

A Quality Improvement Intervention to Reduce Postoperative Opiate Use in Neonates

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.

Trends in narcotics and sedative use during mechanical ventilation of preterm infants in Canadian neonatal intensive care units

OBJECTIVE

Mechanical ventilation (MV) in preterm infants (PTI) causes discomfort. Whether it causes pain is controversial. Meta analysis reviews of published work on PTI during MV have shown no clinically significant impact of opioids on pain scales, and hence not recommended for routine use in neonatal intensive care units (NICUs). Similarly regular use of sedative midazolam is also not recommended. Therefore we hypothesized a downward trend in narcotics and sedatives used in MV of PTI in NICUs. This study aimed to assess trends of sedatives and narcotics use during MV of PTI in Canadian NICUs during 2004-2009.

METHODS

PTI born at gestational age (GA) of <35 weeks requiring invasive MV for >24 hours were identified retrospectively from the Canadian Neonatal Network database for 2004-2009. PTI were excluded if moribund on admission, had major congenital anomalies, surgery (except laser eye surgery), necrotizing enterocolitis, chest tube or history of maternal narcotic abuse. PTI were classified according to whether they received any narcotics (morphine, fentanyl, methadone, sufentanyl, meperidine, alfentynl and codiene) or sedatives (chloral hydrate, midazolam, lorazepam, phenobarbital, pentobarbital, ketamine and propofol) for >24 consecutive hours during MV. Trends of narcotics and sedatives were assessed using the Cochrane-Armitage Trend test separately for PTI born at <29 and 29-34 weeks of GA.

RESULTS

Among 5 638 study subjects, 2 169 (38.5%) received narcotics and 897 (15.9%) received sedatives. The most common narcotics were morphine (62.2%) and fentanyl (63.8%) and sedatives were phenobarbital (44.9%) and chloral hydrate (44.2%). A significant decreasing trend (P<0.01) in the use of any sedatives during MV was observed in PTI <29 and 29-34 weeks of GA. However, the use of any narcotics during MV increased significantly (P=0.03) among PTI <29 weeks of GA, and no change in trend was detected for PTI born at 29-34 weeks of GA.

CONCLUSIONS

The use of sedatives during MV in PTI born at <35 weeks of GA was positively affected, however the narcotics use during MV remained constant for PTI born at 29-34 weeks, and increased in extremely low GA group (less than 29 weeks) suggesting evidence based practice change was not observed during the study period.

Reduced narcotic and sedative utilization in a NICU after implementation of pain management guidelines

OBJECTIVE

To assess the opioid and benzodiazepine usage in a level IV NICU after implementation of pain guidelines.

STUDY DESIGN

Guidelines were developed for infants undergoing surgical procedures and infants on mechanical ventilation. Data collected for period 1 (July to December 2013) and period 2 (March to August 2014).

RESULTS

Gestational age, birth weight and infants with hypoxic respiratory failure or requiring major procedures were comparable in two periods. Number of patients exposed to opioids decreased from 62.9% (129/205) in period 1 to 32.8% (82/250) in period 2, P=<0.001. Cumulative dose exposure decreased, opioids in morphine equivalent dose, mg kg^-1 (1.64 (0.38 to 6.94) vs 0.51 (0.04 to 2.33), P=0.002), sedatives in midazolam equivalent, mg kg^-1 (0.16 (0.03 to 7.39) vs 0.10 (0.00 to 4.00), P=0.03). Ten patients required treatment for iatrogenic opioid withdrawal versus only three in post guideline, P=0.02.

CONCLUSIONS

Evidence-based guidelines led to significant reduction in opioids and sedatives exposure, and in the number of infants requiring methadone for iatrogenic narcotic dependence.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.