Over the years, one of the things that I (RA) thought was a universal truth was that the NICU is very protective (overprotective?) of their babies and often treats outsiders as threats who are going to hurt their precious patients. Introducing new techniques to them was often met with suspicion and skepticism, and success depended on having a neonatology champion (further musings on this topic in a previous PAAD https://ronlitman.substack.com/p/epidurals-we-dont-need-no-stinkin epidurals ). We were delighted to review the work done at Nationwide Children’s Hospital a few months ago (1) on increasing the use of epidural analgesia in appropriate patients going to the NICU but weren’t sure if it would be practical in other institutions. So, we are delighted to find that improving postoperative pain management can be achieved at a wide variety of hospitals, with people and facilities dedicated to improving care. Today’s review is another quality improvement study done through the auspices of the Children’s Hospital Neonatal Consortium, and each participating institution was allowed to create their own action plans.
Original Article
Bapat R, Duran M, Piazza A, Pallotto EK, Joe P, Chuo J, Mingrone T, Hawes J, Powell M, Falciglia GH, Grover TR, Rintoul N, MacPherson MJ, Rose A, Brozanski B. A Multicenter Collaborative to Improve Postoperative Pain Management in the NICU. Pediatrics. 2023 Aug 1;152(2):e2022059860. doi: 10.1542/peds.2022-059860. PMID: 37409386.
Pain is bad, and babies exposed to repeated painful stimuli not only suffer at the time of the pain, but can have additional short- and long-term consequences, such as hemodynamic instability. neurodevelopmental changes and abnormal stress responses. Patients in the neonatal intensive care unit unfortunately, are often exposed to a lot of painful stimuli. Parents of NICU babies are an important part of their baby’s lives and support. Neonatal pain also impacts parental well-being, and parental perception of their infant's pain and effectiveness of treatment is predictive of parental stress, independent of overall satisfaction with overall care and anxiety." (2) Whether long term exposure to opioids may also be detrimental to developing brains is a subject for debate. The NEOPAIN studies showed some neurobehavioral changes including possible short term memory loss in 5 and 6 year olds who received morphine for sedation, versus those who received placebo. (3,4) However, this is not settled science, and there are many other studies that show either no change between opioid treated groups and controls, or improvement in behavioral outcomes. (5-7) It is important to note that the NEOPAIN population was comprised of ventilated preterm neonates who received relatively long-term morphine infusions for sedation/motion control while intubated and many of the other published studies evaluated longer term morphine infusion in “medical” preterm NICU patients. There is a dearth of studies of opioid used for analgesia (8) in a postoperative population of full term neonates.
Today’s PAAD by Bapat et al. (8) aims to improve immediate postoperative pain in neonates returning form the OR. The Children’s Hospital Neonatal Consortium Erase Postoperative Pain is a multicenter QI collaborative made up of 26 institutions, committed to improving pain management in the NICU. The consortium includes both large, well known academic institutions as well as smaller ones. The consortium used well validated QI methodology that they have previously used for other collaborative QI projects, called the Model for Improvement. Their goal was to reduce the incidence of moderate to severe pain after surgery from 19% to 15 % or less and to improve family satisfaction with pain management to greater than or equal to 90%. A Clinical Practice Recommendations (CPR) document was developed after an extensive literature review that participating Institutions could use to develop their interventions. Each individual institution was encouraged to choose approaches from the CPR document that they thought would be effective at their location, and what pain scale was going to be used for assessment. Each site identified their team leaders and worked collaboratively to develop driver diagrams, and center-specific aims, in addition to the interventions, and measurement strategies. These interventions were tested in multiple local center specific Plan-Do-Study-Act (PDSA) cycles. The Consortium used Healthcare Improvement (IHI) Breakthrough Series framework to enhance learning, education and collaboration, which included multiple educational opportunities and monthly virtual meetings.
Data was ultimately collected from 23 institutions on over 11,000 post-surgical time frames. The primary goals of reducing pain to 15 % or less were met during the study period and in fact continued to decrease over the “sustain” period to 12.6%. The overall parental satisfactions rates increased from 93% prior to the project to over 96%. In addition, documentation of pain improved, and sedation levels (monitored in 23% of operations) decreased. The Consortium and authors did not specify what types of assessment tools, opioid, nonopioid, regional techniques, or non-pharmacologic management should be used and left that up to the discretion of the individual sites. Although the consortium did not specify opioid or non-opioid drug dosage or track opioid administration during the course of the study cycles, sedation scores were employed to mitigate the adverse effects of excessive opioid use.
I (RA) find this article encouraging, although my institutions is not part of the consortium (I have no idea why), this increased focus on pain management in the neonate is critically important. It is reassuring to see progress and not just hit them up with more morphine approach.
We would love to hear from any of you who are more knowledgeable about, or participated in this project. I don’t think any of the authors are anesthesiologists (which is a shame), but did recognize at least one awesome anesthesiologist amongst the acknowledgements! Send your comments to Myron (myasterster@gmail.com) and he will post in a Friday Reader Response.
References
1. Puthoff TD, Veneziano G, Kulaylat AN, Seabrook RB, Diefenbach KA, Ryshen G, Hastie S, Lane A, Renner L, Bapat R. Development of a Structured Regional Analgesia Program for Postoperative Pain Management. Pediatrics 2021;147.
2. Franck LS, Callery P. Re-thinking family-centred care across the continuum of children's healthcare. Child Care Health Dev 2004;30:265-77.
3. Rao R, Sampers JS, Kronsberg SS, Brown JV, Desai NS, Anand KJ. Neurobehavior of preterm infants at 36 weeks postconception as a function of morphine analgesia. Am J Perinatol 2007;24:511-7.
4. Anand KJ, Hall RW, Desai N, Shephard B, Bergqvist LL, Young TE, Boyle EM, Carbajal R, Bhutani VK, Moore MB, Kronsberg SS, Barton BA. Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial. Lancet 2004;363:1673-82.
5. Anand KJS. Neonatal opioids and preschool outcomes. Pediatr Res 2021;89:407-8.
6. Anand KJ. Revisiting a dilemma: repetitive pain vs. opioid exposures? Acta Paediatr 2016;105:736-7.
7. de Graaf J, van Lingen RA, Valkenburg AJ, Weisglas-Kuperus N, Jebbink LG, Wijnberg-Williams B, Anand KJS, Tibboel D, van Dijk M. Does neonatal morphine use affect neuropsychological outcomes at 8 to 9 years of age? Pain 2013;154:449-58.
8. Bapat R, Duran M, Piazza A, Pallotto EK, Joe P, Chuo J, Mingrone T, Hawes J, Powell M, Falciglia GH, Grover TR, Rintoul N, MacPherson MJ, Rose A, Brozanski B. A Multicenter Collaborative to Improve Postoperative Pain Management in the NICU. Pediatrics 2023;152.