©2013 children's mercy. all rights reserved. 09/13 the drug exposed neonate; now what?...

©2013 Children's Mercy. All Rights Reserved. 09/13©2013 Children's Mercy. All Rights Reserved. 09/13

The Drug Exposed Neonate; Now What?

Neonatal Abstinence Syndrome (NAS)

Betsy Knappen APRN, BSN, Jodi Jackson MD

©2013 Children's Mercy. All Rights Reserved. 09/13

NAS

ProtocolNursing

Education

Competencies to Monitor Education

Parent Education

Pharmacological Interventions

Ongoing Community

Support

Breast Feeding Policy


3


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


Finnegan ScaleAre you familiar with the scale?

A. Yes

B. No

Yes No

50%50%


Finnegan ScaleWhat is your comfort level with

using the scale?1. Not at all

2. Somewhat

3. Neutral

4. Comfortable

5. Very Comfortable

20% 20% 20%20%20%


Use o

f too

l

Assign

ing o

f Sco

res

Discer

ning

Elevat

ion

Timing

of S

corin

g

Use o

f Com

fort

Mea

sure

s

Differ

entia

tion

of E

lemen

ts

Qua

ntify

With

draw

al

Inte

rven

tion

Needs

Family

Sup

port

& Edu

catio

n 0

102030405060708090

100

0 0 0 0

20

0 010 10

BeforeAfter

Percentage of Mother-Baby Nurses Reporting Discomfort with Elements of NAS Scoring Before and

After Education


7


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


8


Finnegan CNS No CNS disturbance 0 Excessive high pitched cry 2 Continuous high pitched cry 3

Sleeps less than 1 hr after feeding 3 Sleeps less than 2 hr after feeding 2 Sleeps less than 3 hours after feeding 1

Hyperactive moro reflex 2 Markedly hyperactive moro reflex 3

Mild tremors disturbed 1 Moderate-severe tremors disturbed 2 Mild tremors undisturbed 3 Moderate-severe tremors undisturbed 4

Increased muscle tone 2

Excoriation 1

Myoclonic jerks 3 Generalized convulsions 5


9


Finnegan Metabolic/Vasomotor/Resp

No Disturbance 0 Sweating 1 Fever less than 101° F (99-100.8, 37.2-38.2 C) 1 Fever greater than 101° F (38.4C) 2

Frequent yawning (3-4x/exam period) 1

Mottling 1

Nasal stuffiness 1 Sneezing (3-4x/exam period) 1

Nasal flaring 2 RR > 60/min 1 RR > 60/min with retractions 2


10


Finnegan GI

No GI disturbance 0

Excessive sucking 1

Poor feeding 2

Regurgitation 2

Projectile vomiting 3

Loose stools 2

Watery stools 3

Adapted from L.P. Finnegan (1986)


Which is the First Line Treatment for NAS?

A. Morphine

B. Phenobarb

C. Fentanyl

D. Low Lights

E. Skin to Skin Holding

F. SwaddlingM

orphine

Phenobarb

Fentanyl

Low Li

ghts

Skin to

Skin Holding

Swaddlin

g

17% 17% 17%17%17%17%


12


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)


13


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


15

Opioid/Unknown/Poly

Morphine 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.

Initial Dose 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

Morphine Dose Escalation

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.


16


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


• 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.

Second Line Medication

Initial Dose Route Maintenance Dosing

Comments

Clonidine 1 mcg/kg/dose every 6 hours

PO Max dose 1 mcg/kg/dose every 3 hours

Clonidine suspension = 100 mcg/mL = 0.1 mg/mL Typical dose range: 0.5 to 1 mcg/kg/dose every 3 to 6 hours


18


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


19


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 Discontinue morphine when infant has tolerated a dose of 0.02 mg/kg/dose every 6 hours for 24-48 hours.

Morphine and Clonidine

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.

** Percent is calculated from the original morphine dose at the start of weaning

This part of the wean has been most difficult, it is still being revised

©2013 Children's Mercy. All Rights Reserved. 09/13©2013 Children's Mercy. All Rights Reserved. 09/13

Betsy Knappen APRN, BSN, Kim Mason RN, BSN, Andrea Vance RN, BSN,

Jodi Jackson MD

Improving Care of the Infant at Risk for Neonatal Abstinence Syndrome

through a Standardized Family Centered Protocol and Nursing

Education


21


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


22


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

©2013 Children's Mercy. All Rights Reserved. 09/13Before Protocol After Protocol 0

1020304050607080

NICUMother-Baby Unit

Per

cen

t

Location of Care During Hospitalization

Before Protocol After Protocol0

10

20

30

40

50

60

Per

cen

tInfants Requiring Pharmacological Treatment


24


25


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)


26


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

Kim Mason RN, BSN; Betsy Knappen, APRN, BSN; Dawn Caspers, BS

Pharm, Jodi Jackson, MD

Standardized Approach to Educating Families at

Risk for Neonatal Abstinence Syndrome


28


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


30


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


31


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

(Academy of Breastfeeding Medicine (ABM) Clinical Protocol #21)


• CMH SCC

Our Next Initiative


33


Thank You for Your Attention

Questions?

©2013 children's mercy. all rights reserved. 09/13 the drug exposed neonate; now what?...

Documents

education2013 childrens

rights res

finnegan scaleare

finnegan scalewhat

finnegan cnsno cns disturbance

finnegan gino gi disturbance

finnegan scaleopioid

mild tremors undisturbed