NCA for Post-operative Analgesia and Opioid Reduction in the NICU

Purpose/Objectives: To decrease the post-operative opioid need from the current average of 5 mg/kg/day to 3.5 mg/kg/day (30%) IV MME (intravenous morphine milligram equivalents) by June 30, 2021 after implementation of a nurse controlled analgesia (NCA) service for the management of post-operative pain for eligible surgical procedures. This is a sub aim of a project aimed at reducing systemic opioid exposure in our NICU.

Design/Methods: A multidisciplinary team consisted of members from neonatology, surgery, anesthesiology, pain team, pharmacy, and nursing. Potential interventions were created from barriers identified for the implementation of NCA in the NICU. We developed a comprehensive process map and key driver diagram (Figure 1). Eligible procedures were scheduled > 24 hours in advance and included open thoracic, abdominal or genitourinary cases, and weight > 2 kgs at the time of surgery. Once a surgical plan was identified, Pain team was consulted to identify the mode of post-operative analgesia (NCA or Regional Analgesia (RA)). Placement of NCA orders prior to surgery allow the NCA syringe to be available in the immediate post-operative period. An NCA online education module was co-created by NICU nursing and Pain team prior to the project initiation date. The Pain Team managed post-operative NCA and were available 24/7. Daily Pain Team rounds provides an opportunity for pain evaluation and management in a collaborative manner.

Results: NCA was utilized for 20 surgeries during the intervention period from May 1, 2020 to April 30, 2021. Cumulative opioid requirement was reduced from a baseline of 5 mg/kg to 1.78 mg/kg IV MME with the use of NCA (Figure 2). Unresolved pain was defined as 2 consecutive pain assessment scores >4, separated by at least 30 minutes. During the first 24 hours post op, 50% (10) of NCA patients experienced no episodes of unresolved pain and 90% (18) of NCA patients experienced <2 episodes of unresolved pain. The parent satisfaction for infants who received NCA was over 90%.

Conclusion/Discussion: A comprehensive process map and KDD helped the teams have a shared mental model, and identified the failure modes and barriers for implementation and sustainment. Frequent administration of PRN medication as determined by the prescribed NCA lockout period was a new modality and required persistent re-enforcement to optimize the analgesia delivery mode of the NCA in a timely manner. Our next step is to expand the use of regional analgesia and NCA to infants who require surgery with < 24 hours scheduling notice.

Utilization of NCA has helped us provide optimal post-operative pain management while remaining cognizant of minimizing the neurotoxic effects of larger doses of systemic opioids. Our project demonstrates that analgesic techniques and modalities used in older patient populations can be efficiently used in neonates.