Background New pain and sedation guideline was launched on the neonatal unit in August 2021.¹ Several changes were recommended, such as morphine/fentanyl cycling every 2 weeks. New pharmacological agents were recommended e.g. dexmedetomidine and oxycodone.

Aims

1. To audit the implementation of new pain and sedation guideline

2. To assess how well recommendations in the guideline were adopted in practice.

AimsAudit Standards

1. 100% preterm neonates on continuous morphine are > 2 weeks at point of initiation.

2. 100% preterm neonates on continuous morphine are started on a dose of 5 micrograms/kg/hr.

3. 100% neonates on continuous morphine infusion > 2 weeks are switched to fentanyl.

4. 100% neonates who are started on a clonidine infusion have been on a continuous IV opioid infusion for > 4 weeks

5. 100% preterm neonates <34 weeks are not given a continuous midazolam infusion.

Method Eligible neonates for inclusion in the study were identified by running a Medchart report.

Inclusion criteria

• Admitted to neonatal unit between January–September 2022

• On a continuous morphine infusion

Data collected from Medchart, Badgernet and EPR by single investigator. Data was added to an Excel spreadsheet, and was anonymised and password protected. Audit was registered with Trust and no ethical approval was required.

Results 151 patients were identified for inclusion in the study.

Morphine was administered to 100% patients, fentanyl to 9% patients, clonidine to 10% patients, dexmedetomidine to 1% patients and midazolam to 3% patients.

Oxycodone/ketamine were not given to any patients during the study period.

Audit standard 1: age at initiation of morphine infusion

91 babies who received continuous IV morphine in the study were preterms (<37 weeks).

71/91 patients (78%) were aged < 2 weeks when morphine was started.

Audit standard 2: starting dose of morphine = 5 microgram/kg/hr

2/91 patients (2%) started on 5 microgram/kg/hr morphine. 56/91 patients (62%) started on 10 microgram/kg/hr morphine.

Audit standard 3: morphine/fentanyl cycling

14 babies were on continuous IV morphine for > 14 days.

10/14 (71%) were not switched to fentanyl after 2 weeks.

Audit standard 4: clonidine initiated after 4 weeks of opioid use

15 neonates on continuous IV clonidine were identified.

60% of neonates (9/15) were started on a clonidine infusion before 4 weeks of continuous opioid use

Audit standard 5: age at initiation of midazolam

4 neonates included in the study were on continuous IV midazolam infusion

100% patients had a corrected gestational age >34 weeks.

Unclear whether patients were on midazolam for sedation or other reasons (e.g. seizures)

However, we can confidently say that we are not giving midazolam to our most vulnerable population (< 34 weeks)

Conclusions Only one of the audit standards was met:

• midazolam use in babies < 34 weeks

Room for improvement in terms of:

• starting morphine infusions in first 2 weeks of life

• starting morphine at a lower dose (5 microgram/kg/hr)

• morphine/fentanyl cycling after 2 weeks

• delaying starting clonidine infusions until 4 weeks of opioid use

Limitations Small sample size - only 151 patients studied.

Reference

1. Trust NICU Guidelines: Pain and Sedation Guidance - available via Clinibee website https://app.clinibee.com/