Advice about last night

[Kaligirl02, ADN, BSN, MSN, LVN, RN, APRN, NP]

Hi everyone. I am hoping to get some advice on a situation that occurred last night. My assignment is on a vent and getting Q6 albuterol and pulmazine treatments. I received a prn fentanyl order for agitation. The baby showed no signs of agitation except for an elevated HR. The surrounding nurses as well as the RT insisted on me giving the prn fentanyl. The infant was asleep, respiration sin the 40's and we were trying to wean the O's. I feel that the reason why the infants HR was elevated was due to the neb treatments not due to agitation. Some stated, " what could it hurt by giving the baby the fentanyl?" I just felt that if the infant is asleep, the infant isn't in pain, therefore the fentanyl was not needed. After succumbing to pressure of administering the fentanyl, baby's HR continued to be elevated and did not drop out of the 180's. The RT then stated that the administration of the albuterol could not be given if the HR was in the 190's, so once the HR hit 187 they administered it. The infant had been trending in the low 180's to 190's this past week. Do you guys think the administration on fentanyl for agitation was required for this infant? I'm not too sure if this makes sense, please ask questions if needed.

[BittyBabyGrower, MSN, RN]

Albuterol does raise the HR. I think I would have been in the fence. We sedate our vent kids, especially ones with BPD, etc.

I would have just said in report that I tried a hit of Fent to see if It made a difference and it didn't.

[Kaligirl02, ADN, BSN, MSN, LVN, RN, APRN, NP]

I did mention that in report, and the oncoming nurse felt the same way I did. I guess I just wanted some reassurance that my train of thought wasn't wrong. Don't get me wrong, I wanted it to work, but after seeing that it didn't... I feel like I let myself and the baby down. Thank you for your opinion.

[SteveNNP, MSN, NP]

Albuterol ABSOLUTELY causes tachycardia, especially when given frequently and in higher doses. This is why a lot of units used to (and some still do) give Xopenex instead.

Sounds to me like you properly assessed pain, and found that the infant didn't require anything at that time. We have found that neonates become rapidly opioid-tolerant and dependent after only a day or two of narcotics. Fentanyl especially, being 1000x more potent than morphine with a much quicker onset of action. Unless the baby is showing true signs of pain, and not just agitation, we avoid narcotics in all our patients except surgical ones. And even babies who have open heart surgery via sternotomy are often off narcotics within 96 hours if they can tolerate Tylenol and it's well controlled. IMHO we shouldn't be giving out narcotics just because...especially since we don't know what it does to the plastic neonatal brain.

[NJNICUCCRN]

I think your assessment of the baby was spot on! I had a similar situation many years ago and I too felt pressured to do something that I felt was not necessary. That never happened again :)

[KRVRN, BSN, RN]

Newborns, especially preemies can shut down and stop showing typical pain symptoms. Were there frequent desats and episodes of clamping down?

[Janetnzrn]

We use a neonatal pain scale to assess pain/agitation. But we battle to get enough pain meds into our babies, certainly no prn orders on my unit! I agree with your assessment, Albuterol definitely would cause tachycardia. But asleep could have been just shut down, was the baby relaxed? Soft hands and feet, no grimacing etc?