TOP 24 - Dexmedetomidine as First-Intention Sedation in Preterm Infants: A Quality Improvement Initiative

Publication Number: 3752.TOP 24

Meriam J. Avades, Phoenix Children's Hospital, Phoenix, AZ, United States; Isheeta Tewari, Phoenix Children's Hospital, Phoenix, AZ, United States; Meghan Turbenson, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States; Harris Khawaja, Phoenix Children's Hospital, Scottsdale, AZ, United States

Background: Opioid use in the neonatal intensive care unit (NICU) is common practice with agents such as fentanyl and morphine. These medications have a large side effect profile, risk of withdrawal, and long term complications, such as neuroapoptosis and neurodevelopmental abnormalities. Prevention of poor neurodevelopmental outcomes in preterm infants is a critical factor in the acute management of this patient population. In recent years, dexmedetomidine (DEX) has been used for preterm infants and several animal studies have shown potential neuroprotective properties with its use. Chrysostomou et al. conclude that DEX is well-tolerated and effective for sedating neonates as young as 28 weeks gestational age. They describe the pharmacokinetic profile of DEX as having a longer half-life and larger area under the concentration curve, concluding that lower doses may be required to achieve the same level of sedation and to avoid adverse effects. O'Mara et al. found that, when compared to Fentanyl, the DEX group was less likely to require adjunctive sedation and had more free days without sedation; there was no difference in hemodynamics and the time to full feeds was decreased in the DEX group.

Objective: Our global aim is to reduce the cumulative opioid dose per hospital day during a NICU admission, and thus, reduce the adverse effects of prolonged opioid exposure in preterm infants. The SMART aim is for the St. Joseph Medical Center (SJMC) NICU to have a 50% decrease in the cumulative opioid dose per hospital day used during the admission of a preterm infant born less than 28 weeks, 6 days gestational age by January 2026.

Design/Methods: This quality improvement project follows a stepwise process: Plan, Do, Study, Act (PDSA). A retrospective chart review of data for 53 preterm infants (22 weeks, 0 days through 28 weeks, 6 days) born between October 2021 and December 2024 at SJMC was performed. We designed a practice guideline implementing the use of DEX as first-intention sedation for all preterm infants between 22 weeks, 0 days and 28 weeks, 6 days admitted to the SJMC NICU with a goal to reduce the cumulative opioid dose during their admission.

Figure 1. Driver diagram for reducing opioid use in preterm infants
This diagram outlines the project's aim to reduce the cumulative opioid dose per hospital day by 50% in preterm infants born less than 28 weeks, 6 days by January 2026. It shows the relationships between the project aim, the key primary drivers (e.g., standardization of process, education, and communication), and the specific change ideas designed to influence them.