658 - Use of intravenous acetaminophen to reduce postoperative pain in surgical neonates

Friday, April 28, 2023

5:15 PM – 7:15 PM ET

Poster Number: 658
Publication Number: 658.139

Krishanta Maharaj, University of Toronto, Toronto, ON, Canada; Atiyeh Alssadat. Miran, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; Gonzalo Solis-Garcia, THE HOSPITAL FOR SICK CHILDREN, TORONTO, ON, Canada; Marina Raimondi, Sickkids, Toronto, ON, Canada; Carol McNair, The Hospital for Sick Children, Toronto, ON, Canada; Wendy Chen, The Hospital for Sick Children, Toronto, ON, Canada; Erin Chung, The Hospital for Sick Children, Toronto, ON, Canada; Lisa Isaac, University of Toronto/Department of Anesthesiology and Pain Medicine, Toronto, ON, Canada; Lujayn Mahmoud, The Hospital for Sick Children, Toronto, ON, Canada; Sarah A. Brown, The Hospital for Sick Children, Toronto, ON, Canada; Kyong-Soon Lee, The Hospital for Sick Children, Toronto, ON, Canada

Presenting Author(s)

Krishanta Maharaj, BSc, MBBS, MRCPCH, DM Pediatrics (she/her/hers)

Neonatal-Perinatal Medicine Fellow
University of Toronto
Toronto, Ontario, Canada

Background:

Optimization of postoperative pain with perioperative opioid sparing analgesia can enhance recovery after surgery and improve outcomes.

Objective:

We aimed to reduce the proportion of surgical infants with unrelieved postoperative pain defined as two consecutive pain scores with PIPP-R > 6 or FLACC > 3, from 20% to 10% over 12 months and sustain it for 12 months.

Design/Methods:

We used the Plan-Do-Study-Act methodology, process mapping, and fishbone analysis. Our primary outcome measures were reduction in the proportion of patients with unrelieved pain within 72 hours postoperatively and reduction in the use of postoperative opioids. Our process measure was the proportion of surgical cases where pre/intraoperative intravenous acetaminophen was given. We implemented interventions, including multidisciplinary team engagement, development and dissemination of pre/intraoperative acetaminophen guidelines, discussion of acetaminophen use in the preoperative huddle and the development of standardized EMR templates that included acetaminophen in preoperative order set. Pharmacy and nursing staff were educated to ensure optimal dosing and drug availability at the preoperative huddle.

Results:

With approximately 10 to 20 surgical patients per month, we evaluated 104 and 130 charts in the pre (Dec 2021 to April 2022) and postintervention (May 2022 to Nov 2022) periods, respectively. Mean gestational age was 32.0 weeks (SD 5.7) and mean birth weight was 1900g (SD 1079g). The use of pre/intraoperative acetaminophen increased from 6.1% to 33.8% (p-value < 0.001) between study periods (see Figure 1). The percentage of cases with unrelieved pain are beginning to show a decreasing trend (see Figure 2). There was no significant change in postoperative opioid dose per patient (see Figure 3).

Conclusion(s):

We increased pre/intraoperative acetaminophen use through targeted quality improvement interventions. Barriers to implementation included difficulties in preparation of intraoperative acetaminophen which we addressed by allowing preoperative administration in the NICU. There were also no standardized dosing guidelines for pre/intraoperative acetaminophen for neonates and through literature searches with our pharmacy colleagues, we created dosing guidelines and updated the hospital’s e-formulary. As data collection continues, we hope to see a continued decline in postoperative pain as well as a decrease in the use of opioids among our surgical patients.