Feeding tolerance and providing fentanyl or MS for pain control

[wendiburrd]

I am a NICU nurse. In our unit, there is a recurring issue. For example, an infant comes back form Hernia or eye surgery. We would like to provide pain relief, of course. But many of our Mds ask us "Well would you like to feed or give Fentanyl / MS? I would like to know if there is any research available that states the benefits of providing post op pain relief and initiating feeding simultaneously. Even if the pain relief is in low doses? Can anyone help me?

[dawngloves, BSN, RN]

So what your docs are saying is that a pt on MSo4 must be NPO???

[prmenrs, RN]

Tylenol works, too, you don't always have to give Morphine. You can actually give the Tylenol just as they are going to surgery, and again when they get back (or 4 hours after the 1st dose). We had an anesthesia doc (this guy had done a fellowship in Neonatology) who would put an epidural catheter in the hernia kids, and give them some Duramorph, then pull out the catheters.

[Gompers, BSN, RN]

Always an issue, it seems.

After things like hernia surgery, we'll give tylenol q6h ATC if the baby comes back from the OR already extubated and seems comfortable. Usually works just fine for most kids and we're able to start feeds as soon as bowel sounds return. After eye surgery, which we do in the evening, the kids are usually vented overnight, waking up from the pavulon and everything, so we just give them half doses of IV morphine and full IV fluids until the next morning. Once they're coming around with breathing and bowel sounds, we pull the tube and restart full feeds, giving tylenol PRN.

BUT we usually run into the whole morphine/feeding problem with non-surgical kids, especially micropreemies. Our policy now states that any baby on the vent must recieve morphine or fentanyl ATC, either scheduled boluses or continuous drips. Since we obviously aren't going to wait until they're extubated to start feeds, we are going to have to feed and provide morphine at the same time. Some docs, especially the surgeons, are wary of this, but the kids need some pain relief if they're vented long-term. We've had many preemies up to full feeds, IVs out, on the vent. We just give oral morphine and then eventually wean them off once they're extubated.

The hardest cases are the short-gut kids. They've been sick and in pain forever from NEC, then they have to go through surgery and all that pain...so of course they're pretty addicted to narcotics by the time they've recovered and are starting feedings. Surgery gets so mad that we're giving morphine and fentanyl to these babies, saying that the reason the kids aren't tolerating feeds is that they're on the pain meds, but we just can't help that! We wean them off the meds as quickly as they tolerate (we do have set quidelines for weaning, but the pace depends on the baby) and if it's going to cause feeding problems, what can we do???

[canoehead, BSN, RN]

If they are intubated you give oral meds and feeds?? Or did I misunderstand.

[Gompers, BSN, RN]

If they are intubated you give oral meds and feeds?? Or did I misunderstand.

Yes, we do. What does your unit do? Hold feeds until extubation or d/c the morphine on vented feeders?

[canoehead, BSN, RN]

I'm not a NICU nurse, but I understood that intubated pts were always NPO. They are in our ICU (adult), and in the PICU I used to work. Don't they aspirate?

[Gompers, BSN, RN]

I'm not a NICU nurse, but I understood that intubated pts were always NPO. They are in our ICU (adult), and in the PICU I used to work. Don't they aspirate?

The difference is that when a patient is intubated in the adult or peds ICU, they are usually very sick. If it's going to be long-term, then they're trached and often given a G-tube, right?

In NICU, many of the younger preemies are vented for months before they're strong enough to be extubated. For example, most 24 weekers aren't ready to come off the vent completely for at least a month. They just don't have the strength, maturity, or calories needed to do all their own breathing without puttering out. We can't hold off on feeds for all those weeks or months because they'd have liver damage from the TPN by the time that happened - their particular TPNs have max levels of protein to aid in growth and the healing of their already damaged lung tissue. Once they're past the "sick" newborn period, and are just stable babies who happen to be on the vent, we start NG feedings and slowly work up to full feeds. We try to get their PICCs out ASAP because preemies like to get septic.

We've had kids on vents for months before finally extubating (or going for a trach) and they're usually on full feedings growing very well. No increase in aspiration or anything - why would there be with NG feeds? The only times I've seen aspiration pneumonia is when an NG tube wasn't properly in place, but since we monitor that like hawks it's very rare. I've seen more aspiration with kids on room air or cannulas who pull at their NG tubes, or who have horrible reflux and bottle feed, or a trached baby who they are trying to force into taking oral feeds.

The oral morphine works wonders, and if the baby is older we'll also use oral ativan for sedation. If we need something quick, like if a bigger, post-term baby has no IV and needs intubation, we'll give intranasal versed.

ETA - Just realized the whole "oral" morphine might have been confusing - I mean oral solution as opposed to IV. We give it down the NG.