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Lugli L, Garetti E, Goffredo BM, Candia F, Crestani S, Spada C, Guidotti I, Bedetti L, Miselli F, Della Casa EM, Roversi MF, Simeoli R, Cairoli S, Merazzi D, Lago P, Iughetti L, Berardi A. Continuous Fentanyl Infusion in Newborns with Hypoxic-Ischemic Encephalopathy Treated with Therapeutic Hypothermia: Background, Aims, and Study Protocol for Time-Concentration Profiles. Biomedicines 2023; 11:2395. [PMID: 37760835 PMCID: PMC10525845 DOI: 10.3390/biomedicines11092395] [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: 08/05/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Therapeutic hypothermia (TH) is the standard of care for newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE). Discomfort and pain during treatment are common and may affect the therapeutic efficacy of TH. Opioid sedation and analgesia (SA) are generally used in clinical practice, and fentanyl is one of the most frequently administered drugs. However, although fentanyl's pharmacokinetics (PKs) may be altered by hypothermic treatment, the PK behavior of this opioid drug in cooled newborns with HIE has been poorly investigated. The aim of this phase 1 study protocol (Trial ID: FentanylTH; EUDRACT number: 2020-000836-23) is to evaluate the fentanyl time-concentration profiles of full-term newborns with HIE who have been treated with TH. Newborns undergoing TH receive a standard fentanyl regimen (2 mcg/Kg of fentanyl as a loading dose, followed by a continuous infusion-1 mcg/kg/h-during the 72 h of TH and subsequent rewarming). Fentanyl plasma concentrations before bolus administration, at the end of the loading dose, and 24-48-72-96 h after infusion are measured. The median, maximum, and minimum plasma concentrations, together with drug clearance, are determined. This study will explore the fentanyl time-concentration profiles of cooled, full-term newborns with HIE, thereby helping to optimize the fentanyl SA dosing regimen during TH.
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Affiliation(s)
- Licia Lugli
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Elisabetta Garetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Francesco Candia
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Sara Crestani
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Caterina Spada
- Neonatal Unit, Women’s and Children’s Department, Bufalini Hospital of Cesena, 47521 Cesena, Italy;
| | - Isotta Guidotti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Luca Bedetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Francesca Miselli
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy;
| | - Elisa Muttini Della Casa
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Maria Federica Roversi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Daniele Merazzi
- Neonatal Unit, Women’s and Children’s Department, Valduce Hospital, 22100 Como, Italy;
| | - Paola Lago
- Neonatal Intensive Care Unit, Women’s and Children’s Department, Ca’ Foncello Hospital, 31100 Treviso, Italy;
| | - Lorenzo Iughetti
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
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Nakhleh-Philippe P, Zores C, Stern-Delfils A, Escande B, Astruc D, Severac F, Kuhn P. Adequacy of sedation analgesia to support the comfort of neonates undergoing therapeutic hypothermia and its impact on short-term neonatal outcomes. Front Pediatr 2023; 11:1057724. [PMID: 36969279 PMCID: PMC10034099 DOI: 10.3389/fped.2023.1057724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
Objectives We aimed to evaluate (1) whether sedation analgesia (SA) used during therapeutic hypothermia (TH) was efficient to support the wellbeing of neonates with hypoxic-ischemic encephalopathy, (2) the SA level and its adjustment to clinical pain scores, and (3) the impact of inadequate SA on short-term neonatal outcomes evaluated at discharge. Methods This was an observational retrospective study performed between 2011 and 2018 in two level III centers in Alsace, France. We analyzed the wellbeing of infants by using the COMFORT-Behavior (COMFORT-B) clinical score and SA level during TH, according to which we classified infants into four groups: those with excess SA, adequate SA, lack of SA, and variability of SA. We analyzed the variations in doses of SA and their justification. We also determined the impact of inadequate SA on neonatal outcomes at discharge by multivariate analyses with multinomial regression, with adequate SA as the reference. Results A total of 110 patients were included, 89 from Strasbourg university hospital and 21 from Mulhouse hospital. The COMFORT-B score was assessed 95.5% of the time. Lack of SA was mainly found on the first day of TH (15/110, 14%). In all, 62 of 110 (57%) infants were in excess of SA over the entire duration of TH. Most dose variations were related to clinical pain scores. Inadequate SA was associated with negative short-term consequences. Infants with excess of SA had a longer duration of mechanical ventilation [mean ratio 1.46, 95% confidence interval (CI), 1.13-1.89, p = 0.005] and higher incidence of abnormal neurological examination at discharge (odds ratio 2.61, 95% CI, 1.10-6.18, p = 0.029) than infants with adequate SA. Discussion Adequate SA was not easy to achieve during TH. Close and regular monitoring of SA level may help achieve adequate SA. Excess of SA can be harmful for newborns with hypoxic-ischemic encephalopathy who are undergoing TH.
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Affiliation(s)
- Pauline Nakhleh-Philippe
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Department of Neonatology, Hospital of Mulhouse, Mulhouse, France
| | - Claire Zores
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
| | | | - Benoît Escande
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - Dominique Astruc
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - François Severac
- Department of Public Health and Epidemiology, University Hospital of Strasbourg, Strasbourg, France
| | - Pierre Kuhn
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Correspondence: Kuhn Pierre
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Cochrane Database Syst Rev 2022; 11:CD015023. [PMID: 36354070 PMCID: PMC9647594 DOI: 10.1002/14651858.cd015023.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Newborn infants affected by hypoxic-ischemic encephalopathy (HIE) undergo therapeutic hypothermia. As this treatment seems to be associated with pain, and intensive and invasive care is needed, pharmacological interventions are often used. Moreover, painful procedures in the newborn period can affect pain responses later in life, impair brain development, and possibly have a long-term negative impact on neurodevelopment and quality of life. OBJECTIVES To determine the effects of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. SEARCH METHODS We searched CENTRAL, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial register ISRCTN in August 2021. We also checked the reference lists of relevant articles to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCT), quasi-RCTs and cluster-randomized trials comparing drugs used for the management of pain or sedation, or both, during therapeutic hypothermia: any opioids (e.g. morphine, fentanyl), alpha-2 agonists (e.g. clonidine, dexmedetomidine), N-Methyl-D-aspartate (NMDA) receptor antagonist (e.g. ketamine), other analgesics (e.g. paracetamol), and sedatives (e.g. benzodiazepines such as midazolam) versus another drug, placebo, no intervention, or non-pharmacological interventions. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified by the search strategy for inclusion. We planned to use the GRADE approach to assess the certainty of evidence. We planned to assess the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We planned to evaluate treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. MAIN RESULTS: We did not find any completed studies for inclusion. Amongst the four excluded studies, topiramate and atropine were used in two and one trial, respectively; one study used dexmedetomidine and was initially reported in 2019 to be a randomized trial. However, it was an observational study (correction in 2021). We identified one ongoing study comparing dexmedetomidine to morphine. AUTHORS' CONCLUSIONS We found no studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Baserga M, DuPont TL, Ostrander B, Minton S, Sheffield M, Balch AH, Bahr TM, Watt KM. Dexmedetomidine Use in Infants Undergoing Cooling Due to Neonatal Encephalopathy (DICE Trial): A Randomized Controlled Trial: Background, Aims and Study Protocol. FRONTIERS IN PAIN RESEARCH 2021; 2:770511. [PMID: 35295519 PMCID: PMC8915736 DOI: 10.3389/fpain.2021.770511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/01/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Neonatal hypoxia-ischemia encephalopathy (HIE) is the leading cause of neonatal death and poor neurodevelopmental outcomes worldwide. Therapeutic hypothermia (TH), while beneficial, still leaves many HIE treated infants with lifelong disabilities. Furthermore, infants undergoing TH often require treatment for pain and agitation which may lead to further brain injury. For instance, morphine use in animal models has been shown to induce neuronal apoptosis. Dexmedetomidine is a potent α2-adrenergic receptor agonist that may be a better alternative to morphine for newborns with HIE treated with TH. Dexmedetomidine provides sedation, analgesia, and prevents shivering but does not suppress ventilation. Importantly, there is increasing evidence that dexmedetomidine has neuroprotective properties. Even though there are limited data on pharmacokinetics (PK), safety and efficacy of dexmedetomidine in infants with HIE, it has been increasingly administered in many centers. Objectives: To review the current approach to treatment of pain, sedation and shivering in infants with HIE undergoing TH, and to describe a new phase II safety and pharmacokinetics randomized controlled trial that proposes the use of dexmedetomidine vs. morphine in this population. Methods: This article presents an overview of the current management of pain and sedation in critically ill infants diagnosed with HIE and undergoing TH for 72 h. The article describes the design and methodology of a randomized, controlled, unmasked multicenter trial of dexmedetomidine vs. morphine administration enrolling 50 (25 per arm) neonates ≥36 weeks of gestation with moderate or severe HIE undergoing TH and that require pain/sedation treatment. Results and Conclusions: Dexmedetomidine may be a better alternative to morphine for the treatment of pain and sedation in newborns with HIE treated with TH. There is increasing evidence that dexmedetomidine has neuroprotective properties in several preclinical studies of injury models including ischemia-reperfusion, inflammation, and traumatic brain injury as well as adult clinical trials of brain trauma. The Dexmedetomidine Use in Infants undergoing Cooling due to Neonatal Encephalopathy (DICE) trial will evaluate whether administration of dexmedetomidine vs. morphine is safe, establish dexmedetomidine optimal dosing by collecting opportunistic PK data, and obtain preliminary neurodevelopmental data to inform a large Phase III efficacy trial with long term neurodevelopment impairment as the primary outcome.
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Affiliation(s)
- Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
- *Correspondence: Mariana Baserga
| | - Tara L. DuPont
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Betsy Ostrander
- Division of Neurology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | | | | | - Alfred H. Balch
- Division of Pediatric Clinical Pharmacology, University of Utah, Salt Lake City, UT, United States
| | | | - Kevin M. Watt
- Division of Pediatric Clinical Pharmacology and Division of Critical Care, University of Utah, Salt Lake City, UT, United States
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Hippokratia 2021. [DOI: 10.1002/14651858.cd015023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit; University Hospital; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden; Lund University, Skåne University Hospital; Lund Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department; Poznan University of Medical Sciences; Poznan Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit; University Hospital; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health; Örebro University; Örebro Sweden
- Faculty of Medicine and Health, School of Health Sciences; Örebro University; Örebro Sweden
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