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Variation Among Neonatal Intensive Care Units in Narcotic Administration
Doron J. Kahn;
Douglas K. Richardson, MD, MBA;
James E. Gray, MD, MS;
Francis Bednarek, MD;
Lewis P. Rubin, MD;
Bhavesh Shah, MD;
Ivan D. Frantz III, MD;
DeWayne M. Pursley, MD
Arch Pediatr Adolesc Med. 1998;152:844-851.
Objectives To compare rates of narcotic administration for medically treated neonates in different neonatal intensive care units (NICUs) and to compare treated and untreated neonates to assess whether narcotics provided advantages or disadvantages for short-term outcomes, such as cardiovascular stability (ie, blood pressure and heart rate), hyperbilirubinemia, duration of respiratory support, growth, and the incidence of intraventricular hemorrhage.
Study Design The medical charts of neonates weighing less than 1500 g, admitted to 6 NICUs (A-F), were abstracted. Neonates who had a chest tube or who had undergone surgery were excluded from the study, leaving the records of 1171 neonates. We modeled outcomes by linear or logistic regression, controlling for birth weight (<750, 750-999, and 1000-1499 g) and illness severity (low, 0-9; medium, 10-19; high,  20) using the Score for Neonatal Acute Physiology (SNAP), and adjusted for NICU.
Results Narcotic use varied by birth weight (<750 g, 21%; 750-999 g, 13%; and 1000-1499 g, 8%), illness severity (low, 9%; medium, 19%; and high, 37%), day (1, 11%; 3, 6%; and 14, 2%), and NICU. We restricted analyses to the 1018 neonates who received mechanical ventilation on day 1. Logistic regression, adjusting for birth weight and SNAP, confirmed a 28.6-fold variation in narcotic administration (odds ratios, 4.1-28.6 vs NICU A). Several short-term outcomes also were associated with narcotic use, including more than 33 g of fluid retention on day 3 and a higher direct bilirubin level (6.8 µmol/L higher [0.4 mg/dL higher], P=.03). There were no differences in weight gain at 14 and 28 days or mechanical ventilatory support on days 14 and 28. Narcotic use was not associated with differences in worst blood pressure or heart rate or with increased length of hospital stay.
Conclusions Our study found a 28.6-fold variation among NICUs in narcotic administration in very low-birth-weight neonates. We were unable to detect any major advantages or disadvantages of narcotic use. We did not assess iatrogenic abstinence syndrome or long-term outcomes. These results indicate the need for randomized trials to rationalize these widely differing practices.
From the Joint Program in Neonatology, Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children's Hospital, and Harvard Medical School, Boston, Mass (Mr Kahn and Drs Richardson, Gray, and Pursley); the Department of Maternal and Child Health, Harvard School of Public Health, Boston (Dr Richardson); Memorial Health Care and University of Massachusetts, Worcester (Dr Bednarek); the Department of Pediatrics, Brown University and Women and Infant's Hospital, Providence, RI (Dr Rubin); the Division of Neonatology, Baystate Medical Center, Springfield, Mass (Dr Shah); and the Division of Newborn Medicine, Floating Hospital for Children at Tufts New England Medical Center, Boston (Dr Frantz). Mr Kahn is a medical student at Albert Einstein College of Medicine, New York, NY.
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