Quality Improvement Initiative Significantly Cuts Infant Exposure to Drugs After Tracheostomy

Duration of treatment with opioids and benzodiazepines in NICU slashed by more than half

The neonatal intensive care unit is the first stop for infants after a tracheostomy. At Nationwide Children’s, a pilot Quality Improvement initiative (QI) has cut the duration of exposure to opioids in these babies by more than 75 percent and to benzodiazepines by nearly 60 percent.

Standardized care practices, development and implementation of pain, sedation and paralysis management guidelines, timely addition of the sedative dexmedetomidine, improved communication across multiple disciplines, and education were key factors leading to the reduction, researchers say.

The effort follows a 2016 U.S. Food and Drug Administration safety notice that concludes prolonged exposure to opioids and some benzodiazepines could be harmful to the developing brain.

A report of the initiative is published in Pediatric Quality & Safety.

“These patients, as a group, seem to require the longest period of sedation,” says Teresa Puthoff, PharmD, an advanced patient care pharmacist in the NICU at Nationwide Children’s and a leader of the initiative.

Opioids remain a necessity because infants can’t always safely use opioid alternatives currently used by adults and, “it’s harmful to the baby’s brain if he or she has postsurgical pain that’s untreated,” Dr. Puthoff says.

After surgeons place a tracheostomy tube to help infants breathe, infants need pain management, sedation and paralysis so that they don’t excessively move their heads, neck or trunk and adversely affect the healing of the incision site, says Roopali Bapat, MD, FAAP, a neonatologist and another leader of the initiative.

“We don’t want to use these drugs for a prolonged period of time and we don’t want to cut them short,” says Dr. Bapat, who is the Quality Improvement Director of the Division of Neonatology. “That’s the driving force behind the project: to provide pain and sedation management for optimal duration and promote adequate healing.”

Before the initiative, infants were given opioids an average of 24 days, ranging from six to 148 days, and benzodiazepines an average of 21 days, ranging from one to 114 days.

The QI team of neonatologists, ear, nose and throat (ENT) surgeons, nurses, advanced practice nurses, respiratory therapists, pharmacist and a wound team representative, worked to standardize and personalize care. They mapped out their processes, dug into patient charts and medical literature and had repeated discussions with ENT and NICU clinical teams to identify where to make change.

Now, surgeons perform tracheostomies at certain times so the infants enter the NICU when staffing is highest. The tracheostomy tube is changed consistently five days after the operation.

The patient care team develops individual plans to escalate and de-escalate sedation and pain management daily. The pharmacist writes a detailed note explaining the plan, which is available to all shifts in the medical record.

When paralysis is discontinued, sometimes infants need additional sedation. Instead of increasing opioids, the team may increase the benzodiazepine or add dexmedetomidine if the tracheostomy site is nearly healed and ready for the first tracheostomy tube change.  Dexmedetomidine may have neuroprotective properties as it does not act on NMDA (N-methyl-D-aspartate) receptors or GABAA  (gamma amino butyric acid) receptors as opioids and benzodiazepines do.

After implementing these and more changes, the average length of opioid duration is 5.4 days, benzodiazepine 9 days and dexmedetomidine 4.6 days.

“Babies may require tracheostomy in the NICU for multiple reasons. Some of these could be related to the consequences of immature lungs from being born premature, lung anomalies or problems in the airway, or sometimes genetic or muscular disorders, Dr. Bapat says. “What we’ve been able to show is that despite the different etiologies, there is an opportunity to standardize care to a large extent and thereby minimize the duration of these medications.”

The investigators are now working on multi-disciplinary collaborative efforts to minimize exposure to opioids in the post- operative period for all patients in the neonatal ICU.

Citation: Puthoff TD, Shah H, Slaughter JL, Bapat R. Reduction of analgesia duration after tracheostomy during neonatal intensive care: a quality initiative. Pediatric Quality & Safety. 2018 Sep 28;3(5):e106.