PROBLEM: Pain management in neonatal intensive care is not ideal. Premature infants undergo repeated painful procedures during critical periods, causing acute and ongoing pain. Pharmacological approaches are based upon adult practices, and despite controversy in the literature, opioids are commonly used for pain in vulnerable infants. Side-effect profiles and preferences contribute to varied ordering and administration among providers.
PURPOSE: To identify prevalence of opioid administration in preterm infants (postmenstrual age < 36 weeks' gestation) in one level III NICU, during an 8-week period. The specific aims of the study were to
1. describe demographics of infants receiving opioids for management of pain;
2. quantify dose, route, frequency, and indications of opioid order and administration; and
3. determine a systematic approach to recording total opioid dosing in mg/kg/d.
PARTICIPANTS: A convenience sample of all premature infants receiving opioids during a 6-week period in one NICU as studied by chart review. The data resulted in 159 episodes of daily orders for opioids including oral, intravenous bolus and continuous infusion.
DESIGN: The design was descriptive, a prevalence study of opioid ordering and administration over a finite period (6 weeks completed).
METHODS: Institutional review board approval was obtained for a prospective chart review. After screening all new orders via electronic medication (Pyxis) reports, charts were accessed (history and physical, medication administration record, nurses flow sheets, daily progress notes), data were abstracted to paper, and then entered into Excel and SPSS for descriptive analysis.
MAIN OUTCOME MEASURES: Information on demographics (weight and gestational age at birth and at the time of study), primary diagnoses, and pain scores (averaged) was collected. Order details (provider type [doctor of medicine, neonatal nurse practitioner, fellow, resident], dose, agent, route, frequency, and indications) were obtained. Administration data-time, dose, and RN (coded)-were recorded for bolus and continuous infusions.
PRINCIPAL RESULTS: The results obtained were as follows: Median birth weight (kg), 0.695 (0.342-3.679); median weight at the time of study (kg), 1.107 (0.444-3.679); median gestational age (week), 24.5 (24-34); and median PMA at the time of study (week), 29.1 (24.2-34.4). Administration routes included oral (32%) and intravenous (68%), primarily morphine (79%) with some fentanyl (21%). Bolus dosing varied in frequency from 2 to 24 hours (ordered prn and scheduled). Total daily opioid dosing/kg was calculated and plotted graphically. No relation between average pain score, provider and dosing, or timing of bolus opioid was found.
CONCLUSIONS: The study provides preliminary data integral to the design of future studies. The emergence of knowledge about opioid effect on the developing brain will optimize future pain management in premature infants.