Increasing Caudal Block Utilization to Promote Opioid Stewardship in the NICU Population: A Quality Improvement Project

Background: Regional anesthetic techniques are safe and effective in reducing pain and the need for opioid analgesia but may be underutilized in neonatal intensive care unit (NICU) patients. We developed an opioid stewardship pathway aimed at reducing the use of opioid analgesia in neonates by increasing caudal block utilization from a baseline of 50%–90% within 18 months. Methods: We used control charts to track intra-operative opioid utilization in morphine milligram equivalents per kilogram (MME/kg) and immediate post-operative extubation rates. Unrelieved pain (defined as two consecutive Neonatal Pain, Agitation & Sedation Scale (NPASS) scores >/ = 4), post-operative opioid use, and reintubation within 24 h were tracked as balancing measures. We ran sample statistical analysis comparing the outcome and balancing measures in surgeries with and without caudal block. Results: There were 125 surgeries in the pre-intervention and 48 in the post-intervention group. Caudal block utilization increased to 63%, while intra-operative opioid utilization decreased (0.230 vs 0.416 MME/kg), and extubation rates increased (75% vs 70%). There were no increases in unrelieved pain or post-operative opioid utilization. Caudal block was associated with decreased intra-operative opioid use (0.000 vs 0.366 MME/kg, p < 0.001) and increased extubation rates (83% vs. 59%, p < 0.001) with no increase in unrelieved pain (23% vs. 22%, p = 0.75) or post-operative opioid use (0.151 vs 0.000 MME/kg, p = 0.35). No patients required reintubation within 24 h. Conclusion: The modest increase in caudal block utilization is associated with a reduction in intraoperative opioid use and increased postoperative extubation rates without compromising pain control. Level of Evidence: Level III.