Neonatal Quality Improvement
Neonatal Quality Improvement 3
Larissa Romanow, MD (she/her/hers)
Nicklaus Children’s Hospital
Miami, Florida, United States
Sedation in the NICU setting creates a delicate task of balancing the neurotoxic and addictive properties of medications with the comfort and optimization of cardiorespiratory settings in a patient. Literature has well established the neurotoxicity and lower cognitive scores associated with cumulative dose effects with benzodiazepine and opioids. Dexmedetomidine, an alpha-2 agonist, has been proposed as a potential alternative to augment or replace benzodiazepines and opioids without the side effects of respiratory depression or GI dysmotility.
The multidisciplinary medical team (neonatologists, residents, pharmacists, nurses) will implement a standardized sedation protocol to increase dexmedetomidine use and augment sedatives to reduce cumulative opioid and benzodiazepine exposure.
Baseline data collection involved a retrospective chart review at a 44-bed tertiary and quaternary care NICU from January to June 2022 of all mechanically ventilated patients who were sedated with exclusion criteria of PCA < 34 weeks, patients undergoing HIE or ECMO, >3 days at OSH institutional PICU/NICU, palliative care for sedation, or expiration during sedation episode. Sedation episodes were defined as sedation periods (minimum 3 days separated between exposures) with patients undergoing continuous IV infusion of sedatives. Guidelines for initiation of sedatives based on expected length of sedation, titration based on SBS scoring, and weaning protocols were implemented along with documentation and discussion on rounds. Intervention data collection involved run charts for the period of July to August 2022.
Baseline data revealed all sedation episodes (n=18) had fentanyl use(100%) with augmentation with concurrent sedatives in only 25% of sedation episodes. Dexmedetomidine and midazolam use occurred in 17% of sedation episodes. Post-intervention data (n=11) revealed fentanyl was used in 94% of sedation episodes, but 63% of them included augmentation with at least one other sedative. Dexmedetomidine use increased to 63% of sedation episodes (increase of 46%). Midazolam use remained with similar percentage prior to intervention (18%).
Through implementation of a standardized sedation protocol and education within the medical team, dexmedetomidine use increased. Further, sedation episodes with augmentation of fentanyl with dexmedetomidine increased to help reduce overall cumulative effects and withdrawal symptoms of opioids.