P1.051: A National Assessment of Dexmedetomidine after Neonatal Thoracic and Abdominal Operations

Background: There is an increasing emphasis on opioid-sparing analgesia after operations in neonates. Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist that provides analgesia and sedation without respiratory depression and is promising as an opioid-sparing agent. Based upon experience in adults and children, dexmedetomidine has been variably adopted by neonatologists caring for surgical patients. We sought to evaluate the adoption and efficacy of dexmedetomidine in US children’s hospitals for infants who have undergone thoracic and abdominal operations.

Methods: The Pediatric Health Information System (PHIS) database was used to identify infants who underwent open or minimally invasive repair of esophageal atresia (EA) or duodenal atresia (DA) at 49 US children’s hospitals between 2016 and 2023. The nature and timing of administration of postoperative sedative/analgesic medications, including opioids, acetaminophen, benzodiazepines, and dexmedetomidine was recorded. The PHIS-defined disease severity index and presence of any cardiac disease was noted for each patient. Outcomes, including time to goal feedings, need for prolonged mechanical ventilation, length of stay, and days of opioid administration were evaluated. The duration of any treatment for analgesic/sedative withdrawal with methadone and/or clonidine was assessed.

Results: A total of 2,265 neonates met the inclusion criteria. 25% (n=564) received dexmedetomidine in the postoperative period (mean, 6.4 days) and it was administered in the first 10 postoperative days in 19% (24% of EA and 11% of DA) for a median of 2 days. Individual hospitals used dexmedetomidine in 0-62% of their EA and DA patients (Figure). Overall, patients managed with dexmedetomidine in the initial postoperative period had longer length of stay, shorter time to full feedings, and were more likely to require more than four days of mechanical ventilation. (Table) In addition, they received more days of morphine, fentanyl, and methadone and were more likely to be treated with clonidine. On multivariable analysis, only dexmedetomidine use and illness severity score independently predicted longer length of stay, more morphine days, and administration of clonidine. Prolonged mechanical ventilation was only independently predicted by disease severity.

Conclusion: In a large cohort of infants with EA and DA managed at US children’s hospitals there was substantial variability in the use of dexmedetomidine. While disease severity was a strong driver of outcomes, dexmedetomidine was independently associated with increased opioid use and longer lengths of stay. In addition, patients managed with dexmedetomidine were significantly more likely to have received clonidine, presumably for management of withdrawal. Despite laudable intentions that underlie the use of dexmedetomidine in neonates, our findings suggest that it increases morphine use and may extend hospital stay, due perhaps to management of withdrawal. Based on these issues and wide inter-hospital disparity in its use, a randomized trial of dexmedetomidine in surgical neonates is indicated.