Photo Credit: Mohammed Haneefa Nizamudeen

The following is a summary of “Increasing Caudal Block Utilization to Promote Opioid Stewardship in the NICU Population: A Quality Improvement Project,” published in the September 2024 issue of Pediatrics by Fall et al.

Regional anesthetic techniques, such as caudal blocks, have been recognized for their safety and efficacy in managing pain and reducing opioid requirements. Yet, their use remains suboptimal in neonatal intensive care units (NICUs). To address this, researchers implemented an opioid stewardship pathway to increase the utilization of caudal blocks from 50% to 90% over 18 months. The study group monitored intra-operative opioid consumption, measured in morphine milligram equivalents per kilogram (MME/kg), and tracked immediate post-operative extubation rates using control charts. Investigators also assessed balancing measures, including unrelieved pain—defined as two consecutive Neonatal Pain, Agitation & Sedation Scale (NPASS) scores ≥4—postoperative opioid use, and reintubation within 24 hours. Statistical analyses were performed to compare outcomes and balancing measures between surgeries with and without caudal block administration. 

The study comprised 125 surgeries pre-intervention and 48 post-intervention. Post-intervention, caudal block utilization rose to 63%, leading to a significant reduction in intra-operative opioid use (0.230 vs. 0.416 MME/kg) and increased extubation rates (75% vs. 70%). Notably, there was no corresponding rise in unrelieved pain or post-operative opioid use. Statistical analysis revealed that caudal block administration was significantly associated with reduced intra-operative opioid consumption (0.000 vs. 0.366 MME/kg, p<0.001) and improved extubation rates (83% vs. 59%, p<0.001), with no significant increase in unrelieved pain (23% vs. 22%, p=0.75) or post-operative opioid requirements (0.151 vs. 0.000 MME/kg, p=0.35). Additionally, no patients required reintubation within 24 hours. These findings indicate that the modest increase in caudal block utilization is linked to a reduction in intra-operative opioid use and higher post-operative extubation rates while maintaining effective pain control.

Source: sciencedirect.com/science/article/abs/pii/S002234682400825X