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

Rana, Divya; Bellflower, Bobby; Sahni, Jasmine; Kaplan, Adam; Owens, N; Arrindell, Esmond L.; Talati, Ajay J.; Dhanireddy, Ramasubbareddy

doi:10.1038/jp.2017.88

Cited by 30 publications

(36 citation statements)

References 48 publications

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“…In the EUROPAIN study, paracetamol prescription (14%) was more common than that of sedatives/hypnotics (12%) but still lower when compared to opioid exposure (26%). Besides the guidelinedriven decrease in morphine use as mentioned earlier and the increased paracetamol prescription of Rana et al, there is another recent paper on a clinical guideline-driven impact of reduced exposure to morphine and increased use of paracetamol (21,24). Baarslag et al reported that the adherence to a protocol that subsequently implemented intravenous paracetamol as a firstline treatment of pain after a major non-cardiac surgery in neonates and infants resulted in low (add-on) morphine needs, similar to the extent as published in the initial placebo-controlled randomized trial on the effect of intravenous paracetamol on post-operative morphine exposure (24,25).…”

Section: Epidemiology Of Drug Prescription Practices Of Analgesics Inmentioning

confidence: 92%

“…In contrast, Simons et al (morphine maintenance infusion, 10 µg/kg/h) did not observe lower blood pressure in morphine-exposed preterm neonates nor in inotropic prescription practices, irrespective of the post-menstrual age, within their randomized, placebocontrolled study (12). Finally, morphine delayed the attainment of full enteral nutrition (secondary analysis) by 3 days [17 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) in the placebo arm compared to 20 (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) days in the morphine arm] in the NEOPAIN trial (13).…”

Section: Introductionmentioning

confidence: 94%

“…Finally, the implementation efforts resulting in the bedside implementation of structured guidance on opioid prescription are effective to lower the use and the variability between units (21). This reduction in morphine prescription can be quantified by the number of exposed neonates (33% instead of 63%, −47%) or the cumulative morphine (0.51 mg/kg instead of 1.64 mg/kg, −68%) dose in opioid-exposed neonates.…”

Section: Epidemiology Of Drug Prescription Practices Of Analgesics Inmentioning

confidence: 99%

“…This reduction in morphine prescription can be quantified by the number of exposed neonates (33% instead of 63%, −47%) or the cumulative morphine (0.51 mg/kg instead of 1.64 mg/kg, −68%) dose in opioid-exposed neonates. To further stress the clinical relevance of such implementation efforts, this exercise also resulted in an important and statistically significant decrease (from 10/205 to 3/250 cases) in neonates for whom methadone was prescribed to treat iatrogenic neonatal abstinence syndrome (21). Rana et al have not described their data on paracetamol prescriptions, but the paper supplement at least suggests that these pain treatment guidelines resulted in more paracetamol prescription, both when considering the cases exposed as well as the duration of exposure in these cases (21).…”

Section: Epidemiology Of Drug Prescription Practices Of Analgesics Inmentioning

confidence: 99%

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A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

Allegaert

2020

Front. Pediatr.

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Effective and safe pain relief in neonates matters. This is not only because of ethical constraints or human empathy, but even more because pain treatment is an important and crucial part of contemporary medical, paramedical, and nursing care to improve the outcome in neonatal intensive care graduates. Paracetamol (acetaminophen) is likely one of the pharmacological tools to attain this, with data on prescription practices suggesting that paracetamol is somehow the "rising star" in neonatal pain management. Besides very rare topical clinical scenarios like peripartal asphyxia and subsequent whole body hypothermia or the use of cardiorespiratory support devices, data on paracetamol pharmacokinetics and metabolism were reported throughout neonatal age or weight ranges, and we have summarized these data. In this review, we subsequently aimed to provide the reader with the currently available observations on the use of paracetamol as analgesic for different pain syndromes (major surgery, minor surgery or trauma, and procedural pain), with focus on the limitations of paracetamol when prescribed for neonatal procedural pain management. We hereby intentionally will not discuss other indications (patent ductus arteriosus and fever) for paracetamol administration in neonates. Based on the available evidence, paracetamol has opioid-sparing effects for major pain syndromes, is effective to treat minor to moderate pain syndromes, but fails for effective procedural pain management in neonates. This efficacy failure for procedural pain management should stimulate us to continue to search for more effective interventions, including non-pharmacological interventions and preventive strategies. Furthermore, there are also upcoming association type of epidemiological studies on the relation between exposure to analgesics-including paracetamol-and the negative short-or long-term outcome characteristics (neuro-behavioral, atopy, and fertility). Consequently and in addition to the search for effective alternatives to prevent or treat pain, studies on long-term outcome following paracetamol exposure are needed to inform all stakeholders on the full effect-side effect balance of the different strategies to treat pain.

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Section: Epidemiology Of Drug Prescription Practices Of Analgesics Inmentioning

confidence: 92%

Section: Introductionmentioning

confidence: 94%

Section: Epidemiology Of Drug Prescription Practices Of Analgesics Inmentioning

confidence: 99%

Section: Epidemiology Of Drug Prescription Practices Of Analgesics Inmentioning

confidence: 99%

See 2 more Smart Citations

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

Allegaert

2020

Front. Pediatr.

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“…Implementation exercises of guidelines on opioid use are effective to reduce the utilization of these drugs and its variability [ 26 ]. This reduction in exposure was reflected in the number of patients (from 63% to 33%) and the cumulative morphine dose (from 1.64 to 0.51 mg/kg, −68%).…”

Section: Neonatal Clinical Pharmacologymentioning

confidence: 99%

Rational Use of Medicines in Neonates: Current Observations, Areas for Research and Perspectives

Allegaert

2018

Healthcare

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A focused reflection on rational medicines use in neonates is valuable and relevant, because indicators to assess rational medicines use are difficult to apply to neonates. Polypharmacy and exposure to antibiotics are common, while dosing regimens or clinical guidelines are only rarely supported by robust evidence in neonates. This is at least in part due to the extensive variability in pharmacokinetics and subsequent effects of medicines in neonates. Medicines utilization research informs us on trends, on between unit variability and on the impact of guideline implementation. We illustrate these aspects using data on drugs for gastroesophageal reflux, analgesics or anti-epileptic drugs. Areas for additional research are drug-related exposure during breastfeeding (exposure prediction) and how to assess safety (tools to assess seriousness, causality, and severity tailored to neonates) since both efficacy and safety determine rational drug use. To further improve rational medicines use, we need more data and tools to assess efficacy and safety in neonates. Moreover, we should facilitate access to such data, and explore strategies for effective implementation. This is because prescription practices are not only rational decisions, but also have psychosocial aspects that may guide clinicians to irrational practices, in part influenced by the psychosocial characteristics of this population.

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Pain and Sedation Scales for Neonatal and Pediatric Patients in a Preverbal Stage of Development

et al. 2019

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IMPORTANCEBecause children in a preverbal stage of development are unable to voice their feelings, they completely depend on their caregiving team for the interpretation and management of their pain and discomfort. Thus, accurately validated scales to assess pain and sedation levels are crucial.OBJECTIVE To provide clinicians a complete overview on the validity and reliability of the existing pain and sedation scales for different target populations (preterm infants, term infants, and toddlers) and in different clinical contexts.EVIDENCE REVIEW BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycCRITIQUES, PsycINFO, PSYNDEXplus Literature and Audiovisual Media, and PSYNDEXplus Tests were the databases screened from their inception to August 2018. All studies examining the validity or reliability of a given pain or sedation scale for patients in a preverbal stage of development were included in this systematic review. Those scales that were tested for at least construct validity, internal consistency, and interrater reliability were subsequently scored using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist.FINDINGS In total, 89 validation articles comprising 65 scales were included. Fifty-seven scales (88%) were useful for assessing pain, 13 scales (20%) for assessing sedation, and 4 scales (6%) for assessing both conditions. Forty-two (65%) were behavioral scales, and 23 (35%) were multidimensional scales. Eleven scales (17%) were validated for infants on mechanical ventilation. Thirty-seven scales (57%) were validated for preterm infants, 24 scales (37%) for term and preterm infants, 7 scales (11%) for term-born children, 7 scales (11%) for preterm infants, term infants, and toddlers, and 17 scales (26%) for term infants and toddlers. Twenty-eight scales (43%) considered construct validity, internal consistency, and interrater reliability.CONCLUSIONS AND RELEVANCE Clinicians should consider using scales that are validated for at least construct validity, internal consistency, and interrater reliability, combining this information with the population of interest and the construct the scale is intended to measure.

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

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

Cited by 30 publications

References 48 publications

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

Rational Use of Medicines in Neonates: Current Observations, Areas for Research and Perspectives

Pain and Sedation Scales for Neonatal and Pediatric Patients in a Preverbal Stage of Development

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