CICU Nurse Practitioner Children's National Hospital Washington, District of Columbia, United States
Abstract:
Introduction: Both untreated pain and opioid exposure impact neurodevelopment in critically ill infants. Mitigating both the effects of opioids and pain remains challenging in the management of infants undergoing cardiac surgery. Our primary aim was to describe and compare opioid dosing in neonates and infants undergoing cardiac surgery.
Methods: We conducted a secondary analysis of a single center retrospective cohort of all Cardiac Intensive Care Unit (CICU) surgical patients < 1 year of age to quantify opioid exposure within the first 5 days following cardiac surgery. Patient characteristics, demographics, surgical data, as well as pain and sedation scores and medications within 5 days following cardiac surgery were collected via chart review and analyzed.
Results: Of 170 patients less than 1 year of age, 75 were neonates < 30 days of age at the time of surgery. The groups were similar with respect to gender, race, ethnicity and the presence of genetic abnormalities. Biventricular CHD without arch obstruction was more common in infants than in neonates. Neonates had significantly longer duration of mechanical ventilation, ICU and hospital length of stay. Within the first five postoperative days, mean total opioid exposure in morphine equivalents (ME) was significantly higher in neonates (10.39 ± 8.85mgME/kg) than in infants (5.06 ± 10.01mgME/kg) (p < 0.001). Mean initial opioid infusion doses (0.93 mgME/kg/hr vs 0.74 mgME/kg/hr) and mean maximum opioid infusion dosing (1.32mgME/kg/hr vs 1.13 mgME/kg/hr) were higher in neonates compared to infants. Similarly, mean total Dexmedetomidine exposure was higher in the neonatal population (45.39 ± 39.09mcg/kg) than in infants (29.01 ± 33.50mcg/kg). Neonates were also more commonly discharged on Methadone than infants (31.3% of neonates and 10.8% of infants).
Discussion: Compared to infants 1-12 months of age, neonates with CHD had more complex disease and postoperative risks to neurodevelopment, including opioid exposure. Our results highlight the importance of a careful assessment and targeted response to pain and discomfort, perhaps including non-pharmacologic measures and parental engagement when possible. Multicenter trials and sharing of best practices may help improve neurodevelopmental care and reduce opioid exposure in this vulnerable population.
