1
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Tomlinson C, Vlasova R, Al-Ali K, Young JT, Shi Y, Lubach GR, Alexander AL, Coe CL, Styner M, Fine J. Effects of anesthesia exposure on postnatal maturation of white matter in rhesus monkeys. Dev Psychobiol 2023; 65:e22396. [PMID: 37338252 PMCID: PMC11000522 DOI: 10.1002/dev.22396] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 09/21/2022] [Accepted: 03/24/2023] [Indexed: 06/21/2023]
Abstract
There is increasing concern about the potential effects of anesthesia exposure on the developing brain. The effects of relatively brief anesthesia exposures used repeatedly to acquire serial magnetic resonance imaging scans could be examined prospectively in rhesus macaques. We analyzed magnetic resonance diffusion tensor imaging (DTI) of 32 rhesus macaques (14 females, 18 males) aged 2 weeks to 36 months to assess postnatal white matter (WM) maturation. We investigated the longitudinal relationships between each DTI property and anesthesia exposure, taking age, sex, and weight of the monkeys into consideration. Quantification of anesthesia exposure was normalized to account for variation in exposures. Segmented linear regression with two knots provided the best model for quantifying WM DTI properties across brain development as well as the summative effect of anesthesia exposure. The resulting model revealed statistically significant age and anesthesia effects in most WM tracts. Our analysis indicated there were major effects on WM associated with low levels of anesthesia even when repeated as few as three times. Fractional anisotropy values were reduced across several WM tracts in the brain, indicating that anesthesia exposure may delay WM maturation, and highlight the potential clinical concerns with even a few exposures in young children.
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Affiliation(s)
- Chalmer Tomlinson
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Roza Vlasova
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Khalid Al-Ali
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeffrey T Young
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yundi Shi
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gabriele R Lubach
- Harlow Center for Biological Psychology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Andrew L Alexander
- Waisman Laboratory for Brain Imaging and Behavior, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Christopher L Coe
- Harlow Center for Biological Psychology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Martin Styner
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jason Fine
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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2
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Arpacı AH, Özkoçer SE, Güneş E, Elmas Ç, Işık B. Effects of recurrent ketamine exposure on brain histopathology in juvenile rats. Turk J Med Sci 2023; 53:19-28. [PMID: 36945933 PMCID: PMC10388022 DOI: 10.55730/1300-0144.5554] [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: 05/26/2022] [Accepted: 09/12/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Ketamine (KET) is a commonly used anesthetic agent. However, several previous studies reported that KET leads to neuronal damage in neurodevelopmental stages and has neuroprotective effects. The present experimental study aimed to determine the undesirable histopathological effects of KET in the cerebral cortex, striatum, and hippocampus after recurrent KET administration in juvenile rats. METHODS After ethical approval was obtained, 32 juvenile male Wistar Albino rats were randomized into four groups: 1 mg/kg serum saline intraperitoneally (i.p.), 5 mg/kg KET i.p., 20 mg/kg KET i.p., and 50 mg/kg KET i.p. KET was administered for three consecutive days at three-h intervals in three doses. Ten days after the last KET dose, the rats were sacrificed. Cerebral hemispheres were fixed. Hematoxylin and eosin stain was used for morphometric analysis. Hippocampi were evaluated by immunohistochemistry with anticleaved caspase-3 antibodies. Statistical analysis was conducted with SPSS 21 software using the ANOVA test and Bonferroni post hoc analysis method. RESULTS The experimental study findings revealed no difference between the groups' cell counts or sizes in cortical morphometry. No degenerative changes were observed in pyramidal and granular cells in the striatum. Mild gliosis was observed in the 20 mg/kg and 50 mg/kg KET administration groups. Immuno-histo-chemical analysis was conducted to determine apoptosis in the CA1 region of the hippocampus and revealed that caspase-3 positivity increased with the KET dose. However, there was no statistical difference between the groups. While it was lower than the control group in the 5 mg/kg KET group, it was similar to the control group in the 20 mg/kg KET group and higher in the 50 mg/kg KET group (p > 0.05). DISCUSSION : Repetitive KET exposure did not significantly affect juvenile cerebral morphology and apoptosis in hippocampal cells.
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Affiliation(s)
- Ayşe Hande Arpacı
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara University, Ankara, Turkey
| | - Süheyla Esra Özkoçer
- Department of Histology and Embryology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Emel Güneş
- Department of Physiology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Çiğdem Elmas
- Department of Histology and Embryology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Berrin Işık
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Gazi University, Ankara, Turkey
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3
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Velumula PK, Elbakoush F, Tabb C, Farooqi A, Lulic-Botica M, Jani S, Natarajan G, Bajaj M. Breast milk vs 24% sucrose for procedural pain relief in preterm neonates: a non-inferiority randomized controlled trial. J Perinatol 2022; 42:914-919. [PMID: 35197549 DOI: 10.1038/s41372-022-01352-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To compare the pain scores between the two groups, breast milk (BM) and 24% sucrose, in preterm neonates undergoing automated heel lance for the blood draw. METHODS The study is designed as a randomized, single-blinded, non-inferiority trial. Infants born between 30 1/7weeks and 36 6/7 weeks of gestation were randomly assigned to receive either 24% sucrose or expressed BM. The Premature Infant Pain Profile-Revised (PIPP-R) was utilized to provide pain scores. RESULTS No differences were noted in the baseline characteristics between the two groups. The quantile regression estimates for PIPP-R scores during the procedure were statistically non-significant at all percentile levels of distribution (50%ile coefficient 0, 95% CI -0.49 to 0.49). CONCLUSION We conclude that BM is not inferior to 24% sucrose in providing analgesia during heel lance in moderate and late preterm infants. TRIAL REGISTRATION This trial was registered at www. CLINICALTRIALS gov (identifier NCT04898881).
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Affiliation(s)
| | - Faesal Elbakoush
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA
| | - Carl Tabb
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA
| | | | - Mirjana Lulic-Botica
- Hutzel Women's Hospital, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
| | - Sanket Jani
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Girija Natarajan
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Monika Bajaj
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
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4
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Dutriez-Casteloot I, Emmanuelli V, Wiart JF, Tavernier A, Besengez C, Storme L, Houfflin-Debarge V. Long-Lasting Analgesia With Transdermal Fentanyl: A New Approach in Rat Neonatal Research. Front Pharmacol 2022; 13:798011. [PMID: 35370716 PMCID: PMC8968727 DOI: 10.3389/fphar.2022.798011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background: With advances in neonatal care, management of prolonged pain in newborns is a daily concern. In addition to ethical considerations, pain in early life would have long-term effects and consequences. However, its treatment remains inadequate. It was therefore important to develop an experimental model of long-lasting analgesia for neonatal research. Materials and Methods: Experiments were performed in six groups of rats with transdermal fentanyl 0, 3, 12, 50, 100, or 200 μg/kg/h from second postnatal day (P2) until weaning. Assessment of analgesia was carried out at P21, with behavioral scores (ranging from 0 to 3) using a 4% formalin test. Plasma levels of fentanyl were determined by UPLC/TQD at P22. Growth rate was investigated. Results: Fentanyl 100 and 200 μg/kg/h reduced scores of formalin-evoked behavioral pain. They increased time spent in pain score 0 (8 min 55 s and 6 min 34 s versus 23 s in controls) as in low pain scores 1 and 2, and decreased time in the most severe pain score 3 (19 min 56 s and 17 min 39 s versus 44 min 15 s). Fentanylemia increased in a dose-dependent manner from 50 μg/kg/h (2.36 ± 0.64 ng/ml) to 200 μg/kg/h (8.66 ± 1.80 ng/ml). Concerning growth, no difference was observed except weaker growth from P17 to P22 with 200 μg/kg/h. Clinically, we noticed no visible side effect from 3 to 100 μg/kg/h. Concomitantly, 200 μg/kg/h was responsible for ophthalmological side effects with appearance of corneal bilateral clouding in 90% pups. No difference was observed between male and female rats. Conclusion: Altogether, results indicate that transdermal fentanyl 100 μg/kg/h is an efficient therapeutic for long-lasting analgesia in lactating pups. This new model provides a useful tool for protection and welfare, and future opportunity for studying long-term health consequences of sustainable neonatal analgesia.
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Affiliation(s)
- Isabelle Dutriez-Casteloot
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France.,Department of Biology, Faculty of Sciences and Technology, University of Lille, Lille, France
| | - Virginie Emmanuelli
- Department of Obstetrics, Jeanne de Flandre Hospital, University Hospital Center of Lille, Lille, France
| | - Jean-François Wiart
- Department of Toxicology, University Hospital Center of Lille, Lille, France
| | - Annabelle Tavernier
- Department of Biology, Faculty of Sciences and Technology, University of Lille, Lille, France
| | - Capucine Besengez
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
| | - Laurent Storme
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
| | - Véronique Houfflin-Debarge
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France.,Department of Obstetrics, Jeanne de Flandre Hospital, University Hospital Center of Lille, Lille, France
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5
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Young JT, Vlasova RM, Howell BR, Knickmeyer RC, Morin E, Kuitchoua KI, Lubach GR, Noel J, Hu X, Shi Y, Caudill G, Alexander AL, Niethammer M, Paule MG, Coe CL, Sanchez M, Styner M. General anaesthesia during infancy reduces white matter micro-organisation in developing rhesus monkeys. Br J Anaesth 2021; 126:845-853. [PMID: 33549320 DOI: 10.1016/j.bja.2020.12.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 12/04/2020] [Accepted: 12/24/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Non-human primates are commonly used in neuroimaging research for which general anaesthesia or sedation is typically required for data acquisition. In this analysis, the cumulative effects of exposure to ketamine, Telazol® (tiletamine and zolazepam), and the inhaled anaesthetic isoflurane on early brain development were evaluated in two independent cohorts of typically developing rhesus macaques. METHODS Diffusion MRI scans were analysed from 43 rhesus macaques (20 females and 23 males) at either 12 or 18 months of age from two separate primate colonies. RESULTS Significant, widespread reductions in fractional anisotropy with corresponding increased axial, mean, and radial diffusivity were observed across the brain as a result of repeated anaesthesia exposures. These effects were dose dependent and remained after accounting for age and sex at time of exposure in a generalised linear model. Decreases of up to 40% in fractional anisotropy were detected in some brain regions. CONCLUSIONS Multiple exposures to commonly used anaesthetics were associated with marked changes in white matter microstructure. This study is amongst the first to examine clinically relevant anaesthesia exposures on the developing primate brain. It will be important to examine if, or to what degree, the maturing brain can recover from these white matter changes.
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Affiliation(s)
- Jeffrey T Young
- Department of Psychiatry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roza M Vlasova
- Department of Psychiatry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Brittany R Howell
- Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Rebecca C Knickmeyer
- Department of Psychiatry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elyse Morin
- Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Kaela I Kuitchoua
- Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Gabriele R Lubach
- Harlow Center for Biological Psychology, University of Wisconsin-Madison, Madison, WI, USA
| | - Jean Noel
- Department of Psychiatry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xiaoping Hu
- Department of Bioengineering, University of California, Riverside, CA, USA
| | - Yundi Shi
- Department of Psychiatry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gibson Caudill
- Department of Psychiatry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew L Alexander
- Waisman Laboratory for Brain Imaging and Behavior, University of Wisconsin-Madison, Madison, WI, USA
| | - Marc Niethammer
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Merle G Paule
- Division of Neurotoxicology, National Center for Toxicological Research, US Food & Drug Administration, Jefferson, AR, USA
| | - Christopher L Coe
- Harlow Center for Biological Psychology, University of Wisconsin-Madison, Madison, WI, USA
| | - Mar Sanchez
- Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Martin Styner
- Department of Psychiatry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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6
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Lyu D, Tang N, Womack AW, He YJ, Lin Q. Neonatal ketamine exposure-induced hippocampal neuroapoptosis in the developing brain impairs adult spatial learning ability. Neural Regen Res 2020; 15:880-886. [PMID: 31719253 PMCID: PMC6990767 DOI: 10.4103/1673-5374.268929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 02/25/2019] [Accepted: 06/10/2019] [Indexed: 12/19/2022] Open
Abstract
Ketamine exposure can lead to selective neuroapoptosis in the developing brain. p66ShcA, the cellular adapter protein expressed selectively in immature neurons, is a known pro-apoptotic molecule that triggers neuroapoptosis when activated. Sprague-Dawley rats at postnatal day 7 were subcutaneously injected in the neck with ketamine 20 mg/kg, six times at 2-hour intervals. At 0, 1, 3, and 6 hours after final injection, western blot assay was used to detect the expression of cleaved caspase-3, p66ShcA, and phosphorylated p66ShcA. We found that the expression of activated p66ShcA and caspase-3 increased after ketamine exposure and peaked at 3 hours. The same procedure was performed on a different group of rats. At the age of 4 weeks, spatial learning and memory abilities were tested with the Morris water maze. Latency to find the hidden platform for these rats was longer than it was for control rats, although the residence time in the target quadrant was similar. These findings indicate that ketamine exposure resulted in p66ShcA being activated in the course of an apoptotic cascade during the neonatal period. This may have contributed to the deficit in spatial learning and memory that persisted into adulthood. The experimental protocol was approved by the Institutional Animal Care and Use Committee at the University of Texas at Arlington, USA (approval No. A13.008) on January 22, 2013.
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Affiliation(s)
- Dan Lyu
- Department of Pain Management, Tianjin First Center Hospital, Tianjin, China
- Department of Psychology, College of Science, University of Texas at Arlington, Arlington, TX, USA
| | - Ning Tang
- Department of Psychology, College of Science, University of Texas at Arlington, Arlington, TX, USA
- Reproductive Medicine Center, the 960 Hospital of the PLA Joint Logistics Support Force, Jinan, Shandong Province, China
| | - Andrew W. Womack
- Department of Psychology, College of Science, University of Texas at Arlington, Arlington, TX, USA
| | - Yong-Jin He
- Department of Pain Management, Tianjin First Center Hospital, Tianjin, China
| | - Qing Lin
- Department of Psychology, College of Science, University of Texas at Arlington, Arlington, TX, USA
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7
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Vinks AA, Punt NC, Menke F, Kirkendall E, Butler D, Duggan TJ, Cortezzo DE, Kiger S, Dietrich T, Spencer P, Keefer R, Setchell KD, Zhao J, Euteneuer JC, Mizuno T, Dufendach KR. Electronic Health Record-Embedded Decision Support Platform for Morphine Precision Dosing in Neonates. Clin Pharmacol Ther 2020; 107:186-194. [PMID: 31618453 PMCID: PMC7378965 DOI: 10.1002/cpt.1684] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
Morphine is the opioid most commonly used for neonatal pain management. In intravenous form, it is administered as continuous infusions and intermittent injections, mostly based on empirically established protocols. Inadequate pain control in neonates can cause long-term adverse consequences; however, providing appropriate individualized morphine dosing is particularly challenging due to the interplay of rapid natural physiological changes and multiple life-sustaining procedures in patients who cannot describe their symptoms. At most institutions, morphine dosing in neonates is largely carried out as an iterative process using a wide range of starting doses and then titrating to effect based on clinical response and side effects using pain scores and levels of sedation. Our background data show that neonates exhibit large variability in morphine clearance resulting in a wide range of exposures, which are poorly predicted by dose alone. Here, we describe the development and implementation of an electronic health record-integrated, model-informed decision support platform for the precision dosing of morphine in the management of neonatal pain. The platform supports pharmacokinetic model-informed dosing guidance and has functionality to incorporate real-time drug concentration information. The feedback is inserted directly into prescribers' workflows so that they can make data-informed decisions. The expected outcomes are better clinical efficacy and safety with fewer side effects in the neonatal population.
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Affiliation(s)
- Alexander A. Vinks
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Frank Menke
- Department Information Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Eric Kirkendall
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Wake Forest Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, N.C
| | - Dawn Butler
- Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas J. Duggan
- Division of Neonatology and Pulmonary Biology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - DonnaMaria E. Cortezzo
- Division of Neonatology and Pulmonary Biology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Pain and Palliative Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sam Kiger
- Department Information Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Tom Dietrich
- Department of Interactive Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | - Rob Keefer
- Pomiet, Health IT Systems, Cincinnati, OH, USA
| | - Kenneth D.R. Setchell
- Division of Pathology and Laboratory Medicine, Clinical Mass Spectrometry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Junfang Zhao
- Division of Pathology and Laboratory Medicine, Clinical Mass Spectrometry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. USA
| | | | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Children’s Hospital & Medical Center and Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kevin R. Dufendach
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Neonatology and Pulmonary Biology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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8
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Perry M, Tan Z, Chen J, Weidig T, Xu W, Cong XS. Neonatal Pain: Perceptions and Current Practice. Crit Care Nurs Clin North Am 2019; 30:549-561. [PMID: 30447813 DOI: 10.1016/j.cnc.2018.07.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neonates may experience more than 300 painful procedures throughout their hospitalizations. Prior to 1980, there was a longstanding misconception that neonates do not experience pain. Current studies demonstrate that not only do neonates experience pain but also, due to their immature nervous systems, they are hypersensitive to painful stimuli. Poorly treated pain may lead to negative long-term consequences. Proper assessment of neonate pain is vital. The use of nonpharmacologic treatments may be beneficial in alleviating neonate pain. Pharmacologic treatments in the neonate have been well established. Pharmacologic and nonpharmacologic interventions can be used in conjunction to increase the efficacy of analgesia.
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Affiliation(s)
- Mallory Perry
- School of Nursing, University of Connecticut, 231 Glenbrook Road, Unit 4026, Storrs, CT 06269, USA
| | - Zewen Tan
- Department of Molecular and Cell Biology, University of Connecticut, 91 North Eagleville Road, Unit 3125, Storrs, CT 06269-3125, USA
| | - Jie Chen
- School of Nursing, University of Connecticut, 231 Glenbrook Road, Unit 4026, Storrs, CT 06269, USA
| | - Tessa Weidig
- School of Nursing, University of Connecticut, 231 Glenbrook Road, Unit 4026, Storrs, CT 06269, USA
| | - Wanli Xu
- School of Nursing, University of Connecticut, 231 Glenbrook Road, Unit 4026, Storrs, CT 06269, USA
| | - Xiaomei S Cong
- Center for Advancement in Managing Pain, School of Nursing, University of Connecticut, 231 Glenbrook Road, Unit 4026, Storrs, CT 06269, USA.
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9
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Witt N, Coynor S, Edwards C, Bradshaw H. A Guide to Pain Assessment and Management in the Neonate. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016; 4:1-10. [PMID: 27073748 PMCID: PMC4819510 DOI: 10.1007/s40138-016-0089-y] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Newborn infants experience acute pain with various medical procedures. Evidence demonstrates that controlling pain in the newborn period is beneficial, improving physiologic, behavioral, and hormonal outcomes. Multiple validated scoring systems exist to assess pain in a neonate; however, there is no standardized or universal approach for pain management. Healthcare facilities should establish a neonatal pain control program. The first step is to minimize the total number of painful iatrogenic events when possible. If a procedure cannot be avoided, a tiered approach to manage pain using environmental, non-pharmacologic, and pharmacologic modalities is recommended. This systematic approach should decrease acute neonatal pain, poor outcomes, and provider and parent dissatisfaction.
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Affiliation(s)
- Norina Witt
- />Department of Pediatrics, The University of Arizona, PO Box 245073, Tuscon, 85724 AZ USA
| | - Seth Coynor
- />Department of Pediatrics, The University of Arizona, PO Box 245073, Tuscon, 85724 AZ USA
| | - Christopher Edwards
- />Departments of Pediatrics and Emergency Medicine, The University of Arizona, PO Box 245057, Tucson, 85724-5057 AZ USA
- />College of Pharmacy, The University of Arizona, Department of Pharmacy Services, Banner-University Medical Center, PO Box 210202, Tucson, AZ USA
| | - Hans Bradshaw
- />Departments of Pediatrics and Emergency Medicine, The University of Arizona, PO Box 245057, Tucson, 85724-5057 AZ USA
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10
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Groves A, Traube C, Silver G. Detection and Management of Delirium in the Neonatal Unit: A Case Series. Pediatrics 2016; 137:e20153369. [PMID: 26908706 DOI: 10.1542/peds.2015-3369] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2015] [Indexed: 11/24/2022] Open
Abstract
Delirium is increasingly recognized as a common syndrome in critically ill children, but in our experience, it is rarely considered in the NICU. Delirium is independently associated with prolonged length of stay and adverse long-term outcomes in children. We report the cases of 3 infants cared for in our NICU at corrected gestational ages of 4, 11, and 17 weeks who presented with classic symptoms of delirium. All 3 children had complex medical problems and were receiving multiple analgesic and sedative medications. All 3 children exhibited agitation that was unresponsive to increasing doses of medications, and they all appeared to improve after treatment with quetiapine, allowing weaning of other medications. It is possible that with increased vigilance, delirium will be increasingly recognized in newborns, thus allowing tailored intervention. Further research is needed to investigate the prevalence and associated risk factors for developing delirium in the NICU and to explore possible treatment options.
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Affiliation(s)
| | | | - Gabrielle Silver
- Child Psychiatry, Weill Cornell Medical College, New York, New York
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11
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Aymar CLGD, Lima LSD, Santos CMRD, Moreno EAC, Coutinho SB. Pain assessment and management in the NICU: analysis of an educational intervention for health professionals. J Pediatr (Rio J) 2014; 90:308-15. [PMID: 24560962 DOI: 10.1016/j.jped.2013.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/17/2013] [Accepted: 09/17/2013] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE to study the perception of a Neonatal Intensive Care team on pain assessment and management before and after an educational intervention created and implemented in the unit. METHODS intervention study developed as action research, in three phases. In Phase 1, a quantitative study was performed to identify how professionals perceive pain management in the unit. In Phase 2, an educational intervention was carried out, using the Operational Group (OG), which defined strategies to be adopted to seek improvements in pain assessment and management. In Phase 3, the initial questionnaire was reapplied to assess professionals' perceptions about the subject after the intervention. All professionals directly working in newborn care were included. RESULTS the perception of professionals about pain management and assessment in the unit showed a statistically significant difference between the two phases of research, highlighting the increase in frequency of reference for evaluation and use of some method of pain relief procedures for most analyzed procedures. Participation in training (one of the strategies defined by the operational group) was reported by 86.4% of the professionals. They reported the use of scales for pain assessment, established by the protocol adopted in the service after the intervention, with a frequency of 94.4%. Changes in pain assessment and management were perceived by 79.6% of the participants. CONCLUSION the professionals involved in the educational intervention observed changes in pain management in the unit and related them to the strategies defined and implemented by the OG.
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Affiliation(s)
| | - Luciane S de Lima
- Department of Nursing, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
| | | | | | - Sônia B Coutinho
- Maternal-Child Departament, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
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de Aymar CL, de Lima LS, dos Santos CM, Moreno EA, Coutinho SB. Pain assessment and management in the NICU: analysis of an educational intervention for health professionals. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2013.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Jin J, Gong K, Zou X, Wang R, Lin Q, Chen J. The blockade of NMDA receptor ion channels by ketamine is enhanced in developing rat cortical neurons. Neurosci Lett 2013; 539:11-5. [PMID: 23395831 DOI: 10.1016/j.neulet.2013.01.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 12/03/2012] [Accepted: 01/18/2013] [Indexed: 10/27/2022]
Abstract
Ketamine is a non-competitive antagonist of NMDA receptors (NMDARs) commonly used as a dissociative anesthetic in many pediatric procedures. Ketamine acts primarily by blocking NMDA ligand-gated channels. Experimental studies indicate that ketamine administration used for inducing clinically relevant anesthesia can lead to neurotoxic effects, such as apoptosis, selectively on immature brain neurons. However, the underlying mechanisms remain unclear. This study used whole-cell patch-clamp recordings in an in vitro preparation of forebrain slices to analyze pharmacologically the differences in the effects of ketamine administration on the NMDAR channel activity between immature and mature neurons. NMDAR channel activity was recorded in the form of evoked NMDAR-mediated excitatory postsynaptic currents (eEPSCs) from the forebrain of both neonatal and adult rats. Results show that ketamine inhibited eEPSCs in a dose-dependent manner in both immature and mature neurons. However, at each concentration of ketamine applied to the brain slice, a more extensive inhibition could be seen in neonatal neurons than in adult neurons. Further, the blocking effect of ketamine on eEPSCs was measured during the period of 1, 3, and 6h after ketamine washout. Inhibition of eEPSCs in immature neurons was still evident 6h after washout. In contrast, the blockade of eEPSCs in mature neurons recovered completely from the inhibition by ketamine in a time-dependent manner. These results indicate that ketamine produces a greater and longer blocking effect on NMDAR channels in immature neurons than in mature neurons. This differential effect is likely to be a critical link to the higher vulnerability to ketamine-induced neurotoxicity in neurons of the developing brain.
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Affiliation(s)
- Jianhui Jin
- Institute for Biomedical Sciences of Pain, Capital Medical University, Beijing, China
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Allegaert K, Tibboel D, van den Anker J. Pharmacological treatment of neonatal pain: in search of a new equipoise. Semin Fetal Neonatal Med 2013; 18:42-7. [PMID: 23107602 PMCID: PMC4709244 DOI: 10.1016/j.siny.2012.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Inadequate management of pain in early human life contributes to impaired neurodevelopmental outcome and alters pain thresholds, pain or stress-related behavior and physiological responses. However, there are also emerging animal experimental data on the impact of exposure to analgo-sedatives on the incidence and extent of neuro-apoptosis. Since this association has also been suggested in humans, the pharmacological treatment of neonatal pain is in search of a new equipoise since these 'conflicting' observations are the main drivers to further reconsider our current treatment regimens. This review focuses on new data concerning clinical pharmacology of morphine, followed by data on more recently introduced opioids like remifentanil and tramadol, locoregional anesthesia and minimally invasive techniques in neonates, and finally with data on intravenous paracetamol. Since the available data are still incomplete, priorities for both clinical management and future research will be proposed.
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit, University Hospital, Herestraat 49, 3000 Leuven, Belgium.
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Wheeler B, Broadbent R, Reith D. Premedication for neonatal intubation in Australia and New Zealand: a survey of current practice. J Paediatr Child Health 2012; 48:997-1000. [PMID: 23039075 DOI: 10.1111/j.1440-1754.2012.02589.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This study aims to describe the current approach to intubation premedication in neonatal intensive care units (NICUs) in Australia and New Zealand. METHODS A literature review regarding intubation premedication in the newborn was carried out to inform questionnaire design. A web-based survey of 28 NICUs and two neonatal emergency transport services was conducted and supplemented by telephone contact to ensure completion. RESULTS All the tertiary NICUs and neonatal emergency transport services in Australia and New Zealand use premedication for elective intubation of neonates. Eighty per cent of units have a written policy. There were 28 of 30 units (93%) that use muscle relaxants, mostly suxamethonium. The choice of sedative medication is varied. CONCLUSIONS Australian and New Zealand neonatal units have a high use of intubation premedication including muscle relaxants, but vary considerably in their choice of sedative medication.
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Affiliation(s)
- Ben Wheeler
- Department of Women's and Child Health, University of Otago, Dunedin, New Zealand.
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Ketamine anesthesia during the first week of life can cause long-lasting cognitive deficits in rhesus monkeys. Neurotoxicol Teratol 2011; 33:220-30. [PMID: 21241795 DOI: 10.1016/j.ntt.2011.01.001] [Citation(s) in RCA: 403] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 12/17/2010] [Accepted: 01/10/2011] [Indexed: 01/30/2023]
Abstract
Previously our laboratory has shown that ketamine exposure (24h of clinically relevant anesthesia) causes significant increases in neuronal cell death in perinatal rhesus monkeys. Sensitivity to this ketamine-induced neurotoxicity was observed on gestational days 120-123 (in utero exposure via maternal anesthesia) and on postnatal days (PNDs) 5-6, but not on PNDs 35-37. In the present study, six monkeys were exposed on PND 5 or 6 to intravenous ketamine anesthesia to maintain a light surgical plane for 24h and six control animals were unexposed. At 7 months of age all animals were weaned and began training to perform a series of cognitive function tasks as part of the National Center for Toxicological Research (NCTR) Operant Test Battery (OTB). The OTB tasks used here included those for assessing aspects of learning, motivation, color discrimination, and short-term memory. Subjects responded for banana-flavored food pellets by pressing response levers and press-plates during daily (M-F) test sessions (50 min) and were assigned training scores based upon their individual performance. As reported earlier (Paule et al., 2009) beginning around 10 months of age, control animals significantly outperformed (had higher training scores than) ketamine-exposed animals for approximately the next 10 months. For animals now over 3 and one-half years of age, the cognitive impairments continue to manifest in the ketamine-exposed group as poorer performance in the OTB learning and color and position discrimination tasks, as deficits in accuracy of task performance, but also in response speed. There are also apparent differences in the motivation of these animals which may be impacting OTB performance. These observations demonstrate that a single 24-h episode of ketamine anesthesia, occurring during a sensitive period of brain development, results in very long-lasting deficits in brain function in primates and provide proof-of-concept that general anesthesia during critical periods of brain development can result in subsequent functional deficits. Supported by NICHD, CDER/FDA and NCTR/FDA.
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