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Background: Opioids are the primary post-operative (post-op) analgesic in neonates. Side effects include hypotension, apnea and ileus. Previous studies show IV acetaminophen decreases opiate need in specific populations including cleft palate repair, cardiac surgery. The effect of IV acetaminophen as part of a post-op pain algorithm is not known in common neonatal surgical procedures.

Objective: To determine if (a) a post-op pain algorithm including IV acetaminophen and (b) IV acetaminophen exposure reduces cumulative opioid requirements in neonates undergoing common surgeries in the NICU.

Design/Methods: This is a retrospective cohort study comparing cumulative post-operative opiate exposure between infants with common surgeries in two cohorts: pre-pain algorithm (2013-2015, “PRE”), post-pain algorithm (2016-2018, “POST”), and also between infants who received post-op IV acetaminophen versus did not. Cumulative doses in IV Acetaminophen and opioids were calculated for each patient in the72 hours post-op. Pain scores, respiratory depression, hypotension, time to extubation, time to first stool, and time to enteral feeds were secondary outcomes. Wilcoxon Rank Sum tests were used for outcome comparisons amongst groups.

Results: 690 infants met inclusion criteria. 306 (44%) patients were PRE and 384 (56%) POST. In the entire cohort, 202 patients (29%) received IV acetaminophen post-operative and 488 (70.7%) did not. PRE and POST median 72 hours opiate exposures were 0.56 mg (IQR 0-1.4) and 0.18 mg (IQR 0-0.82) respectively, p <0.01. Acetaminophen vs. non-Acetaminophen recipients had median opiate exposure of 0.30 mg (IQR 0-1.10) and 0.33 mg (IQR 0-1.2) respectively, p = 0.6245). Post-operative hypotension was 46.6% in PRE and 26.4% in POST (p <0.01); 27.9% and 38.5% in acetaminophen versus non-acetaminophen respectively (p = 0.01). Acetaminophen recipients had significantly higher pain scores (p <0.01). Median hours intubated was less in POST (22.3 hr, IQR 8.1-38.9) vs. PRE (25.8, IQR: 17.7-44.1); p < 0.01. Time to first stool was similar amongst all groups.

Conclusion(s): Implementation of a post-op pain algorithm in the NICU significantly reduced cumulative opioid exposure. Hypotension and intubation time were reduced with acetaminophen exposure. With an increase in the percentage of elevated pain score in the group receiving IV acetaminophen, addressing additional system factors is needed for optimal postoperative pain treatment.

Presented at the 2021 PAS Virtual Conference


Pediatrics | Pharmacy and Pharmaceutical Sciences

Multimodal Pain Control in Common Neonatal Surgeries: Post-operative Pain Protocol Reduces Opiate Exposure and Side Effects