Transcript presentation - Children`s Mercy Hospital

The Drug Exposed Neonate;
Now What?
Neonatal Abstinence Syndrome (NAS)
Betsy Knappen APRN, BSN,
Jodi Jackson MD
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Breast
Feeding
Policy
Ongoing
Community
Support
Protocol
NAS
Parent
Education
Nursing
Education
Competencies
to Monitor
Education
Pharmacological
Interventions
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Is NAS a Real Problem?
 Over the last decade, there has been increasing public
health, medical, and political attention paid to the
parallel rise in two trends
– Increase in the prevalence of prescription opioid abuse
– Increase in the incidence of neonatal abstinence syndrome
(NAS)
 Increase in the prevalence of NAS
– 1.20 per 1,000 U.S. hospital births in 2000
– 3.39 per 1,000 U.S. hospital births in 2009
3
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Finnegan Scale
Are you familiar with the scale?
50%
50%
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No
Ye
s
A. Yes
B. No
Finnegan Scale
What is your comfort level with
using the scale?
20%
fo
rt
a
bl
e
Co
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fo
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a
Co
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Ve
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20%
bl
e
20%
ra
l
t
20%
So
m
ew
ha
at
al
l
20%
Ne
ut
Not at all
Somewhat
Neutral
Comfortable
Very Comfortable
No
t
1.
2.
3.
4.
5.
Percentage of Mother-Baby Nurses Reporting
Discomfort with Elements of NAS Scoring Before and
After Education
100
90
80
70
60
50
40
30
20
10
0
20
10
0
0
0
0
0
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0
10
Before
After
Elements of the Finnegan
Scale
 Opioid receptors are concentrated in the
CNS and the gastrointestinal tract, the
predominant signs and symptoms of pure
opioid withdrawal reflect:
– CNS irritability
– Autonomic over-reactivity
– Gastrointestinal tract dysfunction
7
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Finnegan CNS



No CNS disturbance
Excessive high pitched cry
Continuous high pitched cry
0
2
3



Sleeps less than 1 hr after feeding
Sleeps less than 2 hr after feeding
Sleeps less than 3 hours after feeding
3
2
1


Hyperactive moro reflex
Markedly hyperactive moro reflex
2
3




Mild tremors disturbed
Moderate-severe tremors disturbed
Mild tremors undisturbed
Moderate-severe tremors undisturbed
1
2
3
4

Increased muscle tone
2

Excoriation
1


Myoclonic jerks
Generalized convulsions
3
5
8
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Finnegan
Metabolic/Vasomotor/Resp




No Disturbance
Sweating
Fever less than 101° F (99-100.8, 37.2-38.2 C)
Fever greater than 101° F (38.4C)
0
1
1
2
 Frequent yawning (3-4x/exam period)
1
 Mottling
1
 Nasal stuffiness
 Sneezing (3-4x/exam period)
1
1
 Nasal flaring
 RR > 60/min
 RR > 60/min with retractions
2
1
2
9
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Finnegan GI
 No GI disturbance
0
 Excessive sucking
1
 Poor feeding
2
 Regurgitation
2
 Projectile vomiting
3
 Loose stools
2
 Watery stools
3
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Adapted from L.P. Finnegan (1986)
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Which is the First Line
Treatment for NAS?
Sk
17%
dl
ad
Sw
in
Ho
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di
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ts
Lig
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Sk
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17%
in
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17%
Lo
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an
Fe
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17%
yl
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Ph
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ph
M
A. Morphine
B. Phenobarb
C. Fentanyl
D. Low Lights
E. Skin to Skin
Holding
F. Swaddling
17%
Comfort Measures
 Initial treatment
– Minimizing environmental stimulation
 Light
 Sound
– Decreasing Auto-stimulation






Swaddling
Positioning
responding to infant’s cues
frequent feedings
non-nutritive suck
clustering of cares
(Hudak & Tan, 2012; Jansson & Velez, 2012)
12
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When to use Pharmacologic
Treatment
 The Rule of 24:
– When 2-3 consecutive scores = 24
 3 Consecutive scores of 8-11
 2 Consecutive scores 12 or higher
13
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Opioid/Unknown/Poly
Morphine
Initial Dose
Morphine
Dose
Escalation
When pharmacologic treatment begins, patient will be started on scheduled dosing, no
prns will be used
- Start morphine if Score of 24 Rule is met.
- Start course based on highest score in the last 24 hours.
Score
Frequency/Route: Every 3 hours PO
8-10
0.05 mg/kg/dose
11-13
0.08 mg/kg/dose
14-16
0.11 mg/kg/dose
>16
0.17 mg/kg/dose
If Score of 24 Rule is met after initiation, increase dose by 20%. Dose may continue to be
increased by 20% every 12 hours (3-4 doses) if Score of 24 Rule is met.
15
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Pharmacologic Treatment
 Allow infant to stabilize 24 hours on a dose
that controls symptoms prior to initiation of
weaning.
 If symptoms are not controlled on a total
daily dose > 1 mg/kg/day, consider adding
a second line medication (clonidine).
16
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Second Line Medication
•If patient requires more than 1 mg/kg/day of
morphine, add second line medication
•After starting second line medication, allow infant to
stabilize for 24 hours. If Score of 24 Rule is met,
continue to gradually increase morphine dose as
outlined in titration schedule.
Clonidine
Initial Dose
Route
1 mcg/kg/dose every
6 hours
PO
Maintenance
Dosing
Max dose 1
mcg/kg/dose
every 3 hours
Comments
Clonidine suspension = 100
mcg/mL = 0.1 mg/mL
Typical dose range: 0.5 to 1
mcg/kg/dose every 3 to 6 hours
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Weaning Pharmacologic
Treatment
 “Stable NAS score” is defined as all NAS
scores < 8 in the preceding 24 hours
 Allow 24-48 hours between medication
weans
 After discontinuing tx continue NAS scoring
 Discharge infant when scores < 8 for at least
48 hours
18
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Morphine Only
When NAS scores are stable, IF doses are:
< 0.1 mg/kg/dose then wean dose by 20%**
≥ 0.1 mg/kg/dose then wean dose by 10%**
-Allow 24 hours between morphine weans; Consult pharmacist after 2 dose changes
When morphine dose reaches 0.02 mg/kg/dose every 3 hours, change frequency to
every 6 hours
This part of the wean has been most difficult, it is still being
revised
Morphine and
Clonidine
Discontinue morphine when infant has tolerated a dose of 0.02 mg/kg/dose every 6
hours for 24-48 hours.
When NAS scores are stable, IF doses are:
< 0.1 mg/kg/dose then wean dose by 20%
≥ 0.1 mg/kg/dose then wean dose by 10%
-Allow 24-48 hours between morphine weans; Consult pharmacist after 2 dose changes
When morphine has reached ~ 0.05 mg/kg/dose, hold morphine wean and decrease
clonidine by 25% daily until discontinued
Resume decreasing morphine dose per pharmacist weaning schedule and discontinue
morphine when infant has tolerated
0.02 mg/kg/dose for 24-48 hours.
19
** Percent is calculated from the original
morphine
dose
atReserved.
the
start
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Improving Care of the Infant at Risk for
Neonatal Abstinence Syndrome through a
Standardized Family Centered Protocol and
Nursing Education
Betsy Knappen APRN, BSN,
Kim Mason RN, BSN, Andrea Vance RN, BSN,
Jodi Jackson MD
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METHOD
 Oct 1, 2013: NAS Protocol Trialed
– Mandatory NICU admit for high risk infant stopped
– Infants admitted to Mother-Baby unit
– NAS scoring per NICU RN
 Dec 1, 2013: Mother-Baby education completed
– Infants scored and cared by Mother-Baby RN
– Transferred to NICU when Tx needed
 Jan, 2014: Joined the iNICQ Collaborative
– PDSA QI process utilized for ongoing projects
– Begun standardized education program for NICU nurses
– NAS Scoring competency/reliability for NICU/Mother-Baby
21
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MEASURES
 Outcome Measure:
– Infants at risk for NAS avoiding NICU admit and Tx
 Initial: month blocks pre/post protocol for NICU admission/ Tx
 Ongoing: Quarterly review admission/ Tx ; run chart
 Process Measures:
– Nurses attending education, impact on
competency/comfort
 Initial: comfort with NAS; Likert scale self report before/after
 Ongoing: measure of reliably with competency evaluation
 Validation of all scores > 8 by second observer
22
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Percent
Infants Requiring Pharmacological Treatment
60
50
40
30
20
10
0
Before Protocol
After Protocol
Location of Care During Hospitalization
80
Percent
60
NICU
Mother-Baby Unit
40
20
0
Before Protocol
After Protocol
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NAS scoring indicated after
delivery









Morphine
Codeine
Hydrocodone (Lortab, Vicodin)
Oxycodone (Percocet, Oxycontin)
Methadone
Suboxone
Heroin
Tramadol
Benzodiazepines: Ativan, Xanax, Valium, Clonaxepam
(Klonopin)
 Polysubstance use- combination of medications (ie: mood
stabilizer with an antidepressant or antipsychotic)
25
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NAS scoring not indicated after delivery
(warrants close observation)
 CNS depressant:
– Alcohol, Marijuana, K2
 Hallucinogens:
– Cocaine, LSD, Methamphetamines, PCP, Phenylisopropylamines
(Esctasy)
 SSRI:
– Celexa, Lexapro, Prozac, Paxil, Zoloft, Luvox
 SSRI/Norepiphrine Reuptake Inhibitor:
– Cymbalta
 Mood Stabilizer:
– Lithium, Lamictal ?
 Antipsychotics:
– Seroquel, Abilify, Latuda, Risperdal, Invega, Zyprexa, Geodon,
Saphris, Fanapt, Haldol
 Anxiety:
– Vistaril, Buspar
26
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Standardized
Approach
to Educating Families at
Risk for Neonatal
Abstinence Syndrome
Kim Mason RN, BSN; Betsy Knappen,
APRN, BSN; Dawn Caspers, BS
Pharm, Jodi Jackson, MD
Measures
 Outcome Measure
– Number of families at-risk for NAS who were provided
education and material prior to admission
 Secondary outcome:
– Number of families at-risk for NAS who are provided
education and material after admission, but prior to
giving birth, or after delivery (but within 24 hours)
 Process Measures
– Completion of consult checklist
 Balancing Measures
– Number of “urgent” unscheduled consultations
required
28
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Lessons Learned
 A key barrier in disseminating information to
families prior to delivery is identification of at-risk
families.
– Need for improved identification of at-risk patients
– Communication with primary care doctors regarding
institutional program
– Improved collaboration with community programs
– Need to develop a mechanism to measure and
quantify
– Parent-reported satisfaction with the process
30
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Breast Feeding Policy
 Circumstance to encourage, discourage and equivocal
 The encouragement and support of BF depends on:
–
–
–
–
–
–
–
Maternal drug use
Maternal alcohol use
Substance abuse treatment history
Any medical and psychiatric issues
Any medication needs
Infants health status, in utero or post-partum
The presence or absence and adequacy of maternal family
and community support, post-partum follow up, treatment
for substance abuse as needed
31
(Academy of Breastfeeding Medicine (ABM) Clinical Protocol #21)
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Our Next Initiative
•
CMH SCC
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Thank You for Your
Attention
Questions?
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