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Haskes K, Donado C, Carbajal R, Berde CB, Kossowsky J. Rescue designs in analgesic trials from 0 to 2 years of age: scoping review. Pediatr Res 2024; 95:1237-1245. [PMID: 38114607 DOI: 10.1038/s41390-023-02897-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/15/2023] [Accepted: 10/23/2023] [Indexed: 12/21/2023]
Abstract
Pediatric analgesic trials are challenging, especially in newborns and infants. Following an FDA-academic consensus meeting, we analyzed pragmatic rescue designs in postoperative trials of local anesthetics, acetaminophen, opioids, and NSAIDs involving children ages 0-2 years and assessed surgical volumes to provide trial design recommendations. Searches of PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science were conducted. A scoping approach identified trends in analgesic trials with an emphasis on randomized controlled trials (RCTs) utilizing immediate rescue designs. Age-specific surgical volumes were estimated from French national databases. Of 3563 studies identified, 23 RCTs used study medication(s) of interest and immediate rescue paradigms in children ages 0-2 years. A total of 270 studies met at least one of these criteria. Add-on and head-to-head designs were common and often used sparing of non-opioid or opioid rescue medication as a primary outcome measure. According to French national data, inguinal and penile surgeries were most frequent in ages 1 month to 2 years; abdominal and thoracic surgeries comprise approximately 75% of newborn surgeries. Analgesic trials with rescue sparing paradigm are currently sparse among children ages 0-2 years. Future trials could consider age-specific surgical procedures and use of add-on or head-to-head designs. IMPACT: Clinical trials of analgesic medications have been challenging in pediatrics, especially in the group from newborns to 2 years of age. Following an FDA-academic workshop, we analyzed features of completed analgesic trials in this age group. Studies using immediate rescue in placebo control, add-on, and head-to-head trial designs are pragmatic approaches that can provide important information regarding clinical effectiveness, side effects, and safety. Using a French national dataset with a granular profile of inpatient, outpatient, and short-stay surgeries, we provide information to future investigators on relative frequencies of different operations in neonates and through the first 2 years of life.
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Affiliation(s)
- Kyra Haskes
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Carolina Donado
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Ricardo Carbajal
- Pediatric Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Armand Trousseau-Sorbonne Université, Paris, France
- Institut National de La Santé et de La Recherche Médicale, UMR1153, Paris, France
| | - Charles B Berde
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.
| | - Joe Kossowsky
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
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Pirlotte S, Beeckman K, Ooms I, Cools F. Non-pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates. Cochrane Database Syst Rev 2024; 1:CD013353. [PMID: 38235838 PMCID: PMC10795104 DOI: 10.1002/14651858.cd013353.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Pain, when treated inadequately, puts preterm infants at a greater risk of developing clinical and behavioural sequelae because of their immature pain system. Preterm infants in need of intensive care are repeatedly and persistently exposed to noxious stimuli, and this happens during a critical window of their brain development with peak rates of brain growth, exuberant synaptogenesis and the developmental regulation of specific receptor populations. Nearly two-thirds of infants born at less than 29 weeks' gestation require mechanical ventilation for some duration during the newborn period. These neonates are endotracheally intubated and require repeated endotracheal suctioning. Endotracheal suctioning is identified as one of the most frequent and most painful procedures in premature infants, causing moderate to severe pain. Even with improved nursing performance and standard procedures based on neonatal needs, endotracheal suctioning remains associated with mild pain. OBJECTIVES To evaluate the benefits and harms of non-pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Non-pharmacological interventions were compared to no intervention, standard care or another non-pharmacological intervention. SEARCH METHODS We conducted searches in June 2023 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, CINAHL and three trial registries. We searched the reference lists of related systematic reviews, and of studies selected for inclusion. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that included term and preterm neonates who were mechanically ventilated via endotracheal tube or via tracheostomy tube and required endotracheal suctioning performed by doctors, nurses, physiotherapists or other healthcare professionals. DATA COLLECTION AND ANALYSIS Our main outcome measures were validated composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We used standard methodological procedures expected by Cochrane. For continuous outcome measures, we used a fixed-effect model and reported mean differences (MDs) with 95% confidence intervals (CIs). For categorical outcomes, we reported the typical risk ratio (RR) and risk difference (RD) and 95% CIs. We assessed risk of bias using the Cochrane RoB 1 tool, and assessed the certainty of the evidence using GRADE. MAIN RESULTS We included eight RCTs (nine reports), which enroled 386 infants, in our review. Five of the eight studies were included in a meta-analysis. All studies enrolled preterm neonates. Facilitated tucking versus standard care (four studies) Facilitated tucking probably reduces Premature Infant Pain Profile (PIPP) score during endotracheal suctioning (MD -2.76, 95% CI 3.57 to 1.96; I² = 82%; 4 studies, 148 infants; moderate-certainty evidence). Facilitated tucking probably has little or no effect during endotracheal suctioning on: heart rate (MD -3.06 beats per minute (bpm), 95% CI -9.33 to 3.21; I² = 0%; 2 studies, 80 infants; low-certainty evidence); oxygen saturation (MD 0.87, 95% CI -1.33 to 3.08; I² = 0%; 2 studies, 80 infants; low-certainty evidence); or stress and defensive behaviours (SDB) (MD -1.20, 95% CI -3.47 to 1.07; 1 study, 20 infants; low-certainty evidence). Facilitated tucking may result in a slight increase in self-regulatory behaviours (SRB) during endotracheal suctioning (MD 0.90, 95% CI 0.20 to 1.60; 1 study, 20 infants; low-certainty evidence). No studies reported intraventricular haemorrhage (IVH). Familiar odour versus standard care (one study) Familiar odour during endotracheal suctioning probably has little or no effect on: PIPP score (MD -0.30, 95% CI -2.15 to 1.55; 1 study, 40 infants; low-certainty evidence); heart rate (MD -6.30 bpm, 95% CI -16.04 to 3.44; 1 study, 40 infants; low-certainty evidence); or oxygen saturation during endotracheal suctioning (MD -0.80, 95% CI -4.82 to 3.22; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. White noise (one study) White noise during endotracheal suctioning probably has little or no effect on PIPP (MD -0.65, 95% CI -2.51 to 1.21; 1 study, 40 infants; low-certainty evidence); heart rate (MD -1.85 bpm, 95% CI -11.46 to 7.76; 1 study, 40 infants; low-certainty evidence); or oxygen saturation (MD 2.25, 95% CI -2.03 to 6.53; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. AUTHORS' CONCLUSIONS Facilitated tucking / four-handed care / gentle human touch probably reduces PIPP score. The evidence of a single study suggests that facilitated tucking / four-handed care / gentle human touch slightly increases self-regulatory and approach behaviours during endotracheal suctioning. Based on a single study, familiar odour and white noise have little or no effect on any of the outcomes compared to no intervention. The use of expressed breast milk or oral sucrose suggests that there is no discernible advantage of one method over the other for reducing pain during endotracheal suctioning. None of the studies reported on any of the prespecified secondary outcomes of adverse events.
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Affiliation(s)
| | - Katrien Beeckman
- Midwifery Research, Education and Policymaking, Universiteit Antwerpen, Brussel, Belgium
| | - Isabel Ooms
- Physiotherapy and Neonatology, UZ Brussel, Jette, Belgium
| | - Filip Cools
- Neonatology, UZ Brussel, Jette, Belgium
- CEBAM, Belgian Centre for Evidence-Based Medicine, Leuven, Belgium
- Vrije Universiteit Brussel, Brussels, Belgium
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Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants. J Pediatr Surg 2022; 57:683-689. [PMID: 34154813 DOI: 10.1016/j.jpedsurg.2021.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes. METHODS This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times. RESULTS Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses. CONCLUSION Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.
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Abdelmageed RI, Youssef AM, El-Farrash RA, Mohamed HM, Abdelaziz AW. Measurement of Cumulative Preterm Neonatal and Maternal Stressors During Neonatal Intensive Care Unit Admission. J Pediatr Psychol 2021; 47:595-605. [PMID: 34865092 DOI: 10.1093/jpepsy/jsab124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES By nature, the neonatal intensive care unit (NICU) environment is stressful for both infants and mothers. This study aimed to explore and quantify the severity of early life stressors in premature infants admitted to the NICU and evaluate the effect of cumulative neonatal stressors on maternal mental health. METHODS This cross-sectional study included 100 preterm infants admitted to the NICU for at least 10 days. Daily experiences with painful/stressful procedures for 10 days were determined using the Neonatal Infant Stressor Scale. The included mothers were assessed for their psychological well-being 1 week after NICU admission using the Parental Stressor Scale: NICU and Edinburgh Postnatal Depression Scale. RESULTS During the first 10 days of NICU admission, preterm infants experienced an average of 350.76 ± 84.43 acute procedures and an average of 44.84 ± 11.12 cumulative hours of chronic events, with the highest scores recorded on first 3 days of admission. Although intravenous flushing for patency was the most frequent acute procedure, blood gas sampling was the most painful. Forty-five percent of the mothers showed significant depressive symptoms, with the maternal role alteration reported as the most stressful experience, especially for young and new mothers (p < .001). The cumulative stressors experienced by infants were significantly associated with elevated maternal perception of psychological maladjustment (p < .001). CONCLUSION This study confirmed that the NICU environment is stressful for both infants and mothers, with the total cumulative stressors experienced by preemies in the NICU having an negative impact on maternal mental health.
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Affiliation(s)
| | - Azza M Youssef
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Egypt
| | | | | | - Asmaa W Abdelaziz
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Egypt
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Rabie A, Ghoneim T. Ultrasound guided continuous caudal epidural analgesia in neonates undergoing thoracotomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1914961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Aliaa Rabie
- Lecturer of Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria, Egypt
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Xu J, Gou L, Zhang P, Li H, Qiu S. Platelet-rich plasma and regenerative dentistry. Aust Dent J 2020; 65:131-142. [PMID: 32145082 PMCID: PMC7384010 DOI: 10.1111/adj.12754] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2020] [Indexed: 11/30/2022]
Abstract
Regenerative dentistry is an emerging field of medicine involving stem cell technology, tissue engineering and dental science. It exploits biological mechanisms to regenerate damaged oral tissues and restore their functions. Platelet‐rich plasma (PRP) is a biological product that is defined as the portion of plasma fraction of autologous blood with a platelet concentration above that of the original whole blood. A super‐mixture of key cytokines and growth factors is present in platelet granules. Thus, the application of PRP has gained unprecedented attention in regenerative medicine. The rationale underlies the utilization of PRP is that it acts as a biomaterial to deliver critical growth factors and cytokines from platelet granules to the targeted area, thus promoting regeneration in a variety of tissues. Based on enhanced understanding of cell signalling and growth factor biology, researchers have begun to use PRP treatment as a novel method to regenerate damaged tissues, including liver, bone, cartilage, tendon and dental pulp. To enable better understanding of the regenerative effects of PRP in dentistry, this review describes different methods of preparation and application of this biological product, and provides detailed explanations of the controversies and future prospects related to the use of PRP in dental regenerative medicine.
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Affiliation(s)
- J Xu
- Shenzhen Longgang Institute of Stomatology, Shenzhen, Guangdong, China.,Department of Otolaryngology, Longgang E.N.T. Hospital & Shenzhen Key Laboratory of E.N.T., Institute of E.N.T, Shenzhen, Guangdong, China
| | - L Gou
- Center for Genetic Medicine, Xuzhou Maternity and Child Health Care Hospital, Xuzhou, Jiangsu, China
| | - P Zhang
- Shenzhen Longgang Institute of Stomatology, Shenzhen, Guangdong, China.,Department of Otolaryngology, Longgang E.N.T. Hospital & Shenzhen Key Laboratory of E.N.T., Institute of E.N.T, Shenzhen, Guangdong, China
| | - H Li
- Shenzhen Longgang Institute of Stomatology, Shenzhen, Guangdong, China.,Department of Otolaryngology, Longgang E.N.T. Hospital & Shenzhen Key Laboratory of E.N.T., Institute of E.N.T, Shenzhen, Guangdong, China
| | - S Qiu
- Department of Otolaryngology, Longgang E.N.T. Hospital & Shenzhen Key Laboratory of E.N.T., Institute of E.N.T, Shenzhen, Guangdong, China
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Squillaro A, Mahdi EM, Tran N, Lakshmanan A, Kim E, Kelley-Quon LI. Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach. Clin Ther 2019; 41:1701-1713. [PMID: 31431300 PMCID: PMC6790974 DOI: 10.1016/j.clinthera.2019.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain. FINDINGS After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking. IMPLICATIONS The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.
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Affiliation(s)
- Anthony Squillaro
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Nhu Tran
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ashwini Lakshmanan
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Pirlotte S, Beeckman K, Ooms I, Van Rompaey B, Cools F. Non-pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates. Hippokratia 2019. [DOI: 10.1002/14651858.cd013353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Katrien Beeckman
- Universiteit Antwerpen; Midwifery Research, Education and Policymaking; Brussel Belgium
| | - Isabel Ooms
- UZ Brussel; Physiotherapy and Neonatology; Jette Belgium
| | - Bart Van Rompaey
- University of Antwerp; Department of Nursing and Midwifery; Antwerp Belgium
| | - Filip Cools
- CEBAM, Belgian Centre for Evidence-Based Medicine; Kapucijnenvoer 33, blok J, bus 7001 Leuven Vlaams-Brabant Belgium 3000
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Akcan E, Polat S. Comparative Effect of the Smells of Amniotic Fluid, Breast Milk, and Lavender on Newborns' Pain During Heel Lance. Breastfeed Med 2016; 11:309-314. [PMID: 27315487 DOI: 10.1089/bfm.2015.0174] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The aim of this randomized controlled experimental study was to evaluate the effect of the smells of amniotic fluid, breast milk, and lavender on the pain of newborns during heel lance. METHODS The sample of the study consisted of 102 newborn infants who complied with the sampling criteria between August and November, 2011. The newborns smelled the samples (lavender, breast milk, amniotic fluid, and distilled water) for 5 minutes before the heel lance until 5 minutes afterward. The Neonatal Infant Pain Scale (NIPS), heart rate, and oxygen saturation were evaluated 1 minute before, during, and 1 minute after the heel lance. Data were evaluated by descriptive statistics, chi-square, intraclass correlation analysis, Spearman's rho correlation, Bonferroni's advanced analysis, Shapiro-Wilk, Kruskal-Wallis, Mann-Whitney U, Friedman, and Dunnett's tests. RESULTS The newborns in the control group had severe pain and the newborns in the breast milk, amniotic fluid, and lavender groups had moderate pain during the heel lance (p < 0.05). While the NIPS score of the newborns in the lavender group was lower than the breast milk and amniotic fluid groups during the heel lance, it was lower in the breast milk and amniotic fluid groups than the lavender group afterward. The lowest falls in oxygen saturation and increased in heart rate were in the breast milk and lavender groups during heel the lance. CONCLUSION The smells of lavender and breast milk prevent the increased heart rates, NIPS, falling oxygen saturation, and reduced pain during the invasive procedures in newborns more than amniotic fluid or control group.
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Affiliation(s)
- Esma Akcan
- 1 Department of Pediatric Nursing, Faculty of Kumluca Health Sciences, Akdeniz University , Antalya, Turkey
| | - Sevinç Polat
- 2 Department of Pediatric Nursing, School of Health, Bozok University , Yozgat, Turkey
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Walia H, Tumin D, Wrona S, Martin D, Bhalla T, Tobias JD. Safety and efficacy of nurse-controlled analgesia in patients less than 1 year of age. J Pain Res 2016; 9:385-90. [PMID: 27358574 PMCID: PMC4912325 DOI: 10.2147/jpr.s106960] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background The management of acute pain presents unique challenges in the younger pediatric population. Although patient-controlled devices are frequently used in patients ≥6 years of age, alternative modes of analgesic delivery are needed in infants. Objective To examine the safety and efficacy of nurse-controlled analgesia (NCA) in neonates less than 1 year of age. Methods Data from patients <1 year of age receiving NCA as ordered by the Acute Pain Service at our institution were collected over a 5-year period and reviewed retrospectively. The primary outcomes were activation of the institution’s Rapid Response Team (RRT) or Code Blue, signifying severe adverse events. Pain score after NCA initiation was a secondary outcome. Results Among 338 girls and 431 boys, the most common opioid used for NCA was fentanyl, followed by morphine and hydromorphone. There were 39 (5%) cases involving RRT or Code Blue activation, of which only one (Code Blue) was activated due to a complication of NCA (apnea). Multivariable logistic regression demonstrated morphine NCA to be associated with greater odds of RRT activation (OR=3.29, 95% CI=1.35, 8.03, P=0.009) compared to fentanyl NCA. There were no statistically significant differences in pain scores after NCA initiation across NCA agents. Conclusion NCA is safe in neonates and infants, with comparable efficacy demonstrated for the three agents used. The elevated incidence of RRT activation in patients receiving morphine suggests caution in its use and consideration of alternative agents in this population.
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Affiliation(s)
- Hina Walia
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sharon Wrona
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - David Martin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Nuseir KQ, Alzoubi KH, Alabwaini J, Khabour OF, Kassab MI. Sucrose-induced analgesia during early life modulates adulthood learning and memory formation. Physiol Behav 2015; 145:84-90. [PMID: 25846434 DOI: 10.1016/j.physbeh.2015.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/02/2015] [Accepted: 04/02/2015] [Indexed: 12/25/2022]
Abstract
This study is aimed at examining the long-term effects of chronic pain during early life (postnatal day 0 to 8weeks), and intervention using sucrose, on cognitive functions during adulthood in rats. Pain was induced in rat pups via needle pricks of the paws. Sucrose solution or paracetamol was administered for analgesia before the paw prick. Control groups include tactile stimulation to account for handling and touching the paws, and sucrose alone was used. All treatments were started on day one of birth and continued for 8weeks. At the end of the treatments, behavioral studies were conducted to test the spatial learning and memory using radial arm water maze (RAWM), as well as pain threshold via foot-withdrawal response to a hot plate apparatus. Additionally, the hippocampus was dissected, and blood was collected. Levels of neurotrophins (BDNF, IGF-1 and NT-3) and endorphins were assessed using ELISA. The results show that chronic noxious stimulation resulted in comparable foot-withdrawal latency between noxious and tactile groups. On the other hand, pretreatment with sucrose or paracetamol increased pain threshold significantly both in naive rats and noxiously stimulated rats (P<0.05). Chronic pain during early life impaired short-term memory, and sucrose treatment prevented such impairment (P<0.05). Sucrose significantly increased serum levels of endorphin and enkephalin. Chronic pain decreased levels of BDNF in the hippocampus and this decrease was prevented by sucrose and paracetamol treatments. Hippocampal levels of NT-3 and IGF-1 were not affected by any treatment. In conclusion, chronic pain induction during early life induced short memory impairment, and pretreatment with sucrose prevented this impairment via mechanisms that seem to involve BDNF. As evident in the results, sucrose, whether alone or in the presence of pre-noxious stimulation, increases pain threshold in such circumstances; most likely via a mechanism that involves an increase in endogenous opioids.
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Affiliation(s)
- Khawla Q Nuseir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan.
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Jehad Alabwaini
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Omar F Khabour
- Department of Biology, Faculty of Science, Tibah University, Al Madinah, Saudi Arabia; Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Manal I Kassab
- Department of Maternal and Child Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
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Czarnecki ML, Hainsworth K, Simpson PM, Arca MJ, Uhing MR, Varadarajan J, Weisman SJ. Is there an alternative to continuous opioid infusion for neonatal pain control? A preliminary report of parent/nurse-controlled analgesia in the neonatal intensive care unit. Paediatr Anaesth 2014; 24:377-85. [PMID: 24417623 PMCID: PMC4331187 DOI: 10.1111/pan.12332] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Continuous opioid infusion (COI) remains the mainstay of analgesic therapy in the neonatal intensive care unit (NICU). Parent/nurse-controlled analgesia (PNCA) has been accepted as safe and effective for pediatric patients, but few reports include use in neonates. This study sought to compare outcomes of PNCA and COI in postsurgical neonates and young infants. METHODS Twenty infants treated with morphine PNCA were retrospectively compared with 13 infants treated with fentanyl COI in a Midwestern pediatric hospital in the United States. Outcome measures included opioid consumption, pain scores, frequency of adverse events, and subsequent methadone use. RESULTS The PNCA group (median 6.4 μg · kg(-1) · h(-1) morphine equivalents, range 0.0-31.4) received significantly less opioid (P < 0.001) than the COI group (median 40.0 μg · kg(-1) · h(-1) morphine equivalents; range 20.0-153.3), across postoperative days 0-3. Average daily pain scores (based on 0-10 scale) were low for both groups, but median scores differed nonetheless (0.8 PNCA vs 0.3 COI, P < 0.05). There was no significant difference in the frequency of adverse events or methadone use. CONCLUSION Results suggest PNCA may be a feasible and effective alternative to COI for pain management in postsurgical infants in the NICU. Results also suggest PNCA may provide more individualized care for this vulnerable population and in doing so, may potentially reduce opioid consumption; however, more studies are needed.
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Affiliation(s)
- Michelle L. Czarnecki
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA
| | - Keri Hainsworth
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA
| | - Pippa M. Simpson
- Department of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Marjorie J. Arca
- Department of Surgery, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Michael R. Uhing
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA,Department of neonatology, Medical College of Wisconsin, Milwaukee, USA
| | - Jaya Varadarajan
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA
| | - Steven J. Weisman
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
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Maitra S, Baidya DK, Khanna P, Ray BR, Panda SS, Bajpai M. Acute perioperative pain in neonates: An evidence-based review of neurophysiology and management. ACTA ACUST UNITED AC 2014; 52:30-7. [DOI: 10.1016/j.aat.2014.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
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Abstract
Neonatal anesthesia is fraught with potential risk for the patient and stress for the anesthesiologist. Where possible, recognition of these risks, avoidance of, and being able to manage them appropriately, must impact positively on perioperative outcomes in this vulnerable group of patients. Good communication with the parents, as well as with other healthcare providers, is crucial to safe and successful anesthetic care.
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Affiliation(s)
- Jenny Thomas
- Department of Paediatric Anaesthesia, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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15
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