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. 2025 Dec 9.
doi: 10.1097/j.pain.0000000000003875. Online ahead of print.

Pain management guidelines reduce opioids in post-operative and mechanically ventilated neonates

Jeffrey Do  1 , Stephen A Kutcher  2 , Elspeth McGregor  3 , Ewa Sucha  2 , Richard J Webster  2 , Cynthia Joly  4 , Amanda Blazevic  5 , Stephanie Veldhuijzen van Zanten  1 , Emanuela Ferretti  1   4
Affiliations

Pain management guidelines reduce opioids in post-operative and mechanically ventilated neonates

Jeffrey Do et al. Pain. .

Abstract

This study assessed the implementation of pain management guidelines to reduce cumulative opioid exposure by 20% in ventilated and postoperative neonates. We retrospectively analyzed the cumulative opioid exposure dose (expressed in morphine equivalents) in neonates admitted to our intensive care unit who underwent surgery and/or were invasively ventilated for greater than 24 hours, comparing data from 18 months pre-implementation and 16 months postimplementation of pain guidelines. A 3-month transition period was included for implementation. The analysis included demographics, Neonatal Pain, Agitation, and Sedation Scale (NPASS) scores, and safety metrics extracted from the hospitals' electronic health records. Our study cohort included 170 patients (N = 84 preguideline, N = 11 transition period, N = 75 postguideline). Gestational age and days of life at admission, sex, and birth weight were similar between study periods. Cumulative median opioid exposure (mg/kg) was reduced by 55% with guideline implementation: median ([interquartile range], preguideline 4.5 [1.3-11.4], postguideline 2.0 [0.6-0.55], P = 0.009; difference of medians [95% bootstrap confidence interval] 2.5 [0.17-4.88]). Length of stay (days) was similar (preguideline 11 [7-26], postguideline 9 [4.5-18.5], P = 0.3). The frequency of NPASS measurement increased significantly (preguideline 21%, postguideline 65%, P < 0.001). Median NPASS pain/agitation and sedation scores were unchanged during the study. There was no increase preguideline and postguideline in mortality (18%, 12%, P = 0.6), rates of intubation (85%, 75%, P = 0.12), median duration of peripheral intravenous access (4 [2-6], 4 [2-6] days, P = 0.4), or median duration of total-parenteral nutrition (7 [3-14] days, 7.5 [4-16] days, P = 0.8). Evidence-based guidelines reduced cumulative opioid exposure in mechanically ventilated and postoperative neonates by 55% without adverse effects on pain and increased documentation of pain assessments by 44%.

Keywords: Agitation and Sedation Scale (NPASS); Mechanical ventilation; Neonatal Pain; Neonates; Opioids; Pain management; Post-operative; Quality improvement.

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