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Selvanathan T, Miller SP. Effects of pain, sedation and analgesia on neonatal brain injury and brain development. Semin Perinatol 2024; 48:151928. [PMID: 38937163 DOI: 10.1016/j.semperi.2024.151928] [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: 06/29/2024]
Abstract
Critically ill newborns experience numerous painful procedures as part of lifesaving care in the Neonatal Intensive Care Unit. However, painful exposures in the neonatal period have been associated with alterations in brain maturation and poorer neurodevelopmental outcomes in childhood. The most frequently used medications for pain and sedation in the NICU are opioids, benzodiazepines and sucrose; these have also been associated with abnormalities in brain maturation and neurodevelopment making it challenging to know what the best approach is to treat neonatal pain. This article provides clinicians with an overview of how neonatal exposure to pain as well as analgesic and sedative medications impact brain maturation and neurodevelopmental outcomes in critically ill infants. We also highlight areas in need of future research to develop standardized neonatal pain monitoring and management strategies.
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Affiliation(s)
- Thiviya Selvanathan
- Pediatrics, BC Children's Hospital Research Institute and University of British Columbia, Vancouver, BC, Canada; Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Steven P Miller
- Pediatrics, BC Children's Hospital Research Institute and University of British Columbia, Vancouver, BC, Canada; Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada; Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
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Acun C, Ali M, Liu W, Karnati S, Fink K, Aly H. Effectiveness and Safety of Dexmedetomidine in Neonates With Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia. J Pediatr Pharmacol Ther 2024; 29:232-240. [PMID: 38863848 PMCID: PMC11163906 DOI: 10.5863/1551-6776-29.3.232] [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: 07/06/2023] [Accepted: 10/15/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVE The objective of this study was to evaluate and compare the effectiveness and safety of dexmedetomidine as monotherapy between neonates with mild hypoxic ischemic encephalopathy (HIE) and moderate to severe HIE treated with therapeutic hypothermia (TH). METHODS This retrospective study included neonates of gestational age ≥36 weeks with a diagnosis of HIE and undergoing TH between January 2014 and December 2021. Patients were included if they received at least 6 hours of continuous sedation with dexmedetomidine. Baseline characteristics, dose and duration of medication, adverse events, liver and kidney function tests, and hospital course were reviewed. RESULTS Of the 97 neonates included, 46 had mild, 42 had moderate, and 9 had severe HIE. Dexmedetomidine was initiated at a median 5 hours of life, and the median infusion duration was 77 (46-87) hours. Fifty-two (53.6%) required at least 1 breakthrough opioid or sedative during the first 24 hours of dexmedetomidine infusion. Overall, 40 patients (41.2%) had at least 1 bradycardia episode with heart rate <80 beats/min and 14 patients (14.4%) had heart rate <70 beats/min. Hypotension was experienced by 7 patients (7.2%). Fifty-two patients (53.6%) were intubated in the delivery room and 33/52 (63.5%) were extubated on day of life 1 during dexmedetomidine infusion. CONCLUSIONS Dexmedetomidine as monotherapy was effective and safe sedation for infants with HIE undergoing hypothermia. The most common side effect of dexmedetomidine was bradycardia. -Dexmedetomidine may be considered as first and single agent for neonates with HIE undergoing TH.
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Affiliation(s)
- Ceyda Acun
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Mahmoud Ali
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Wei Liu
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Sreenivas Karnati
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Kelsey Fink
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
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Portelli K, Kandraju H, Ryu M, Shah PS. Efficacy and safety of dexmedetomidine for analgesia and sedation in neonates: a systematic review. J Perinatol 2024; 44:164-172. [PMID: 37845426 DOI: 10.1038/s41372-023-01802-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/25/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
Opioids and benzodiazepines have historically been employed for pain relief; however, they are associated with detrimental long-term neurodevelopmental consequences. Dexmedetomidine, a highly selective alpha-2-adrenoreceptor agonist, has piqued interest as a viable alternative for neonates, owing to its potential analgesic and neuroprotective attributes. We conducted a systematic review to assess the efficacy and safety of dexmedetomidine utilization in neonates. We conducted a comprehensive search of Ovid, MEDLINE, EMBASE, PubMed, Cochrane, and CINAHL, spanning from January 2010 to September 2022. Our review encompassed six studies involving 252 neonates. Overall, dexmedetomidine may be effective in achieving sedation and analgesia. Furthermore, it may reduce the need for adjunctive sedation or analgesia, shorten the time to extubation, decrease the duration of mechanical ventilation, and accelerate the attainment of full enteral feeds. Notably, no significant adverse effects associated with dexmedetomidine were reported. Nevertheless, additional well-designed studies to establish both the efficacy and safety of dexmedetomidine in neonatal care are needed.
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Affiliation(s)
- Katelyn Portelli
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Hemasree Kandraju
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Michelle Ryu
- Library and knowledge services, Trillium Health Partners, Ontario, Canada
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada.
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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Elliott M, Fairchild K, Zanelli S, McPherson C, Vesoulis Z. Dexmedetomidine During Therapeutic Hypothermia: A Multicenter Quality Initiative. Hosp Pediatr 2024; 14:30-36. [PMID: 38115800 PMCID: PMC10750168 DOI: 10.1542/hpeds.2023-007403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVES Sedation is typically used during neonatal therapeutic hypothermia (TH). This report describes a quality improvement (QI) initiative with the aim of decreasing opioid exposure during TH by implementing dexmedetomidine as the primary sedative agent. METHODS This dual-center QI initiative used a multidisciplinary team to create a sedation algorithm for safe implementation of dexmedetomidine as first-line therapy during TH. The primary measure in this initiative was cumulative opioid exposure during TH; balancing measures included safety parameters, primarily the rate of dexmedetomidine discontinuation because of bradycardia. Baseline demographic and clinical data were collected retrospectively for the period before implementation and prospectively during the QI period. Data were analyzed using statistical process control charts to identify change over time. RESULTS One-hundred and fifty-four neonates in the 2-year pre-QI period were compared with 135 neonates in the 2 years after guideline implementation. Guideline compliance with dexmedetomidine initiation was 99% and compliance with initial dosing increased from 70% to 91% during the QI period. The cumulative dose of opioid during TH decreased by >90% by the end of the QI period. Dexmedetomidine was discontinued for transient bradycardia in 9.6% of the study population. No other adverse effects were observed. CONCLUSIONS Dexmedetomidine may be used as the primary sedative during neonatal TH with a low incidence of adverse effects. Clinical trials evaluating the impact of sedation during TH on neurologic outcomes are needed.
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Affiliation(s)
- Megan Elliott
- Division of Neonatology, Department of Pediatrics, University of Virginia Children’s Hospital, Charlottesville, Virginia
| | - Karen Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia Children’s Hospital, Charlottesville, Virginia
| | - Santina Zanelli
- Division of Neonatology, Department of Pediatrics, University of Virginia Children’s Hospital, Charlottesville, Virginia
| | - Christopher McPherson
- Department of Pharmacy, St Louis Children’s Hospital, St Louis, Missouri
- Division of Newborn Medicine, Department of Pediatrics, Washington University St Louis, St Louis, Missouri
| | - Zachary Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University St Louis, St Louis, Missouri
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Chen X, Chen A, Wei J, Huang Y, Deng J, Chen P, Yan Y, Lin M, Chen L, Zhang J, Huang Z, Zeng X, Gong C, Zheng X. Dexmedetomidine alleviates cognitive impairment by promoting hippocampal neurogenesis via BDNF/TrkB/CREB signaling pathway in hypoxic-ischemic neonatal rats. CNS Neurosci Ther 2024; 30:e14486. [PMID: 37830170 PMCID: PMC10805444 DOI: 10.1111/cns.14486] [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: 04/15/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023] Open
Abstract
AIMS Dexmedetomidine (DEX) has been reported to alleviate hypoxic-ischemic brain damage (HIBD) in neonates. This study aimed to investigate whether DEX improves cognitive impairment by promoting hippocampal neurogenesis via the BDNF/TrkB/CREB signaling pathway in neonatal rats with HIBD. METHODS HIBD was induced in postnatal day 7 rats using the Rice-Vannucci method, and DEX (25 μg/kg) was administered intraperitoneally immediately after the HIBD induction. The BDNF/TrkB/CREB pathway was regulated by administering the TrkB receptor antagonist ANA-12 through intraperitoneal injection or by delivering adeno-associated virus (AAV)-shRNA-BDNF via intrahippocampal injection. Western blot was performed to measure the levels of BDNF, TrkB, and CREB. Immunofluorescence staining was utilized to identify the polarization of astrocytes and evaluate the levels of neurogenesis in the dentate gyrus of the hippocampus. Nissl and TTC staining were performed to evaluate the extent of neuronal damage. The MWM test was conducted to evaluate spatial learning and memory ability. RESULTS The levels of BDNF and neurogenesis exhibited a notable decrease in the hippocampus of neonatal rats after HIBD, as determined by RNA-sequencing technology. Our results demonstrated that treatment with DEX effectively increased the protein expression of BDNF and the phosphorylation of TrkB and CREB, promoting neurogenesis in the dentate gyrus of the hippocampus in neonatal rats with HIBD. Specifically, DEX treatment significantly augmented the expression of BDNF in hippocampal astrocytes, while decreasing the proportion of detrimental A1 astrocytes and increasing the proportion of beneficial A2 astrocytes in neonatal rats with HIBD. Furthermore, inhibiting the BDNF/TrkB/CREB pathway using either ANA-12 or AAV-shRNA-BDNF significantly counteracted the advantageous outcomes of DEX on hippocampal neurogenesis, neuronal survival, and cognitive improvement. CONCLUSIONS DEX promoted neurogenesis in the hippocampus by activating the BDNF/TrkB/CREB pathway through the induction of polarization of A1 astrocytes toward A2 astrocytes, subsequently mitigating neuronal damage and cognitive impairment in neonates with HIBD.
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Affiliation(s)
- Xiaohui Chen
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Andi Chen
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Jianjie Wei
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Yongxin Huang
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Jianhui Deng
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Pinzhong Chen
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Yanlin Yan
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Mingxue Lin
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Lifei Chen
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Jiuyun Zhang
- Fujian Provincial Key Laboratory of Emergency MedicineFuzhouChina
| | - Zhibin Huang
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Xiaoqian Zeng
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Cansheng Gong
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
| | - Xiaochun Zheng
- Department of AnesthesiologyShengli Clinical Medical College of Fujian Medical University, Fujian Provincial HospitalFuzhouChina
- Fujian Provincial Key Laboratory of Emergency MedicineFuzhouChina
- Fujian Emergency Medical Center, Fujian Provincial Key Laboratory of Critical Care MedicineFujian Provincial Co‐Constructed Laboratory of “Belt and Road”FuzhouChina
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Tervonen M, Cajanus J, Kallio M, Huhtamäki H, Pokka T, Peltoniemi O. Adverse cardiovascular events are common during dexmedetomidine administration in neonates and infants during intensive care. Acta Paediatr 2023; 112:2338-2345. [PMID: 37531450 DOI: 10.1111/apa.16933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 08/04/2023]
Abstract
AIM This study aimed to assess the safety of a commonly used sedative, dexmedetomidine in neonates and infants during intensive care. METHODS A retrospective cohort study was conducted in the paediatric intensive care unit at Oulu University Hospital. The study population consisted of all children from birth up to 6 months of age who received dexmedetomidine during 2010-2016. Adverse cardiovascular outcomes were defined as abnormal heart rates or blood pressure values according to the Paediatric Early Warning Score. RESULTS Of the 172 infants, 56% had congenital malformation, and 48% had undergone surgery. Neonates and 1-3-month-olds experienced bradycardia (86% vs. 73% in 1-3-month-olds and 50% in 3-6-month-olds, p = 0.001) and severe bradycardia (17% vs. 14% in 1-3-month-olds and 0% in 3-6-month-olds, p = 0.005) more often than older patients. The median maximum rate of dexmedetomidine infusion was 0.86 μg/kg/h (IQR = 0.60-1.71 μg/kg/h). A dose-dependent increase in bradycardia and severe hypotension was found. Adverse cardiovascular events were managed with additional fluid boluses and discontinuation of the infusion. CONCLUSION Adverse cardiovascular events were common during dexmedetomidine administration in neonates and infants. Lower dexmedetomidine doses may be required in sedating neonates.
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Affiliation(s)
- Miikka Tervonen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Johanna Cajanus
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Merja Kallio
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Heikki Huhtamäki
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Tytti Pokka
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Outi Peltoniemi
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
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Tucker MH, Tiwari P, Carter BS. The physiology, assessment, and treatment of neonatal pain. Semin Fetal Neonatal Med 2023; 28:101465. [PMID: 37236846 DOI: 10.1016/j.siny.2023.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Studies have clearly shown that development of pain receptors starts as early as 20-weeks' gestation. Despite contrary belief, the human fetus develops a similar number of receptive pain fibers as seen in adults. These receptors' maturation is based on response to sensory stimuli received after birth which makes the NICU a critical place for developing central nervous system's pain perception. In practice, the assessment of pain relies mostly on bedside staff. In this review we will discuss the various developing features of pain pathways in the neonatal brain and the modification of pain perception secondary to various interactions immediately after birth. We also discuss the various tools utilized in the NICU for pain assessment that rely on physiological and behavioral patterns. Finally, we address the management of pain in the NICU by either pharmacological or non-pharmacological intervention while highlighting potential benefits, disadvantages, and situations where one may be preferred over another.
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Affiliation(s)
- Megan H Tucker
- Department of Pediatrics, Division of Neonatology, Children's Mercy-Kansas City, Kansas City, MO, USA
| | - Priya Tiwari
- Department of Pediatrics, Division of Neonatology, Children's Mercy-Kansas City, Kansas City, MO, USA
| | - Brian S Carter
- Department of Pediatrics, Division of Neonatology, Children's Mercy-Kansas City, Kansas City, MO, USA; Bioethics Center, Children's Mercy-Kansas City, Kansas City, MO, USA; Department of Medical Humanities & Bioethics, University of Missouri-Kansas City, Kansas City, MO, USA.
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Puls R, von Haefen C, Bührer C, Endesfelder S. Protective Effect of Dexmedetomidine against Hyperoxia-Damaged Cerebellar Neurodevelopment in the Juvenile Rat. Antioxidants (Basel) 2023; 12:antiox12040980. [PMID: 37107355 PMCID: PMC10136028 DOI: 10.3390/antiox12040980] [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: 03/10/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Impaired cerebellar development of premature infants and the associated impairment of cerebellar functions in cognitive development could be crucial factors for neurodevelopmental disorders. Anesthetic- and hyperoxia-induced neurotoxicity of the immature brain can lead to learning and behavioral disorders. Dexmedetomidine (DEX), which is associated with neuroprotective properties, is increasingly being studied for off-label use in the NICU. For this purpose, six-day-old Wistar rats (P6) were exposed to hyperoxia (80% O2) or normoxia (21% O2) for 24 h after DEX (5 µg/kg, i.p.) or vehicle (0.9% NaCl) application. An initial detection in the immature rat cerebellum was performed after the termination of hyperoxia at P7 and then after recovery in room air at P9, P11, and P14. Hyperoxia reduced the proportion of Calb1+-Purkinje cells and affected the dendrite length at P7 and/or P9/P11. Proliferating Pax6+-granule progenitors remained reduced after hyperoxia and until P14. The expression of neurotrophins and neuronal transcription factors/markers of proliferation, migration, and survival were also reduced by oxidative stress in different manners. DEX demonstrated protective effects on hyperoxia-injured Purkinje cells, and DEX without hyperoxia modulated neuronal transcription in the short term without any effects at the cellular level. DEX protects hyperoxia-damaged Purkinje cells and appears to differentially affect cerebellar granular cell neurogenesis following oxidative stress.
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Affiliation(s)
- Robert Puls
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Clarissa von Haefen
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Stefanie Endesfelder
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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Dexmedetomidine: An Alternative to Pain Treatment in Neonatology. CHILDREN 2023; 10:children10030454. [PMID: 36980013 PMCID: PMC10047358 DOI: 10.3390/children10030454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/19/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023]
Abstract
Infants might be exposed to pain during their admissions in the neonatal intensive care unit [NICU], both from their underlying conditions and several invasive procedures required during their stay. Considering the particularities of this population, recognition and adequate management of pain continues to be a challenge for neonatologists and investigators. Diverse therapies are available for treatment, including non-pharmacological pain management measures and pharmacological agents (sucrose, opioids, midazolam, acetaminophen, topical agents…) and research continues. In recent years one of the most promising drugs for analgesia has been dexmedetomidine, an alpha-2 adrenergic receptor agonist. It has shown a promising efficacy and safety profile as it produces anxiolysis, sedation and analgesia without respiratory depression. Moreover, studies have shown a neuroprotective role in animal models which could be beneficial to neonatal population, especially in preterm newborns. Side effects of this therapy are mainly cardiovascular, but in most studies published, those were not severe and did not require specific therapeutic measures for their resolution. The main objective of this article is to summarize the existing literature on neonatal pain management strategies available and review the efficacy of dexmedetomidine as a new therapy with increasing use in the NICU.
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Dexmedetomidine - An emerging option for sedation in neonatal patients. J Perinatol 2022; 42:845-855. [PMID: 35197548 DOI: 10.1038/s41372-022-01351-3] [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: 07/30/2021] [Revised: 01/26/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022]
Abstract
Dexmedetomidine is a sedative agent with limited dosing, safety, and efficacy information in the neonatal population. This comprehensive review describes the available evidence summarizing the use of dexmedetomidine in various neonatal populations. We identified 21 studies and 1 case report supporting the efficacy and short-term safety of DEX in neonates. Reported dosing ranges from 0.5-1.5 mcg/kg/h with or without loading doses. Clinically relevant adverse effects include bradycardia and hypotension. Future studies are needed to determine long-term safety and facilitate clinical applicability.
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Naveed M, Bondi DS, Shah PA. Dexmedetomidine Versus Fentanyl for Neonates With Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia. J Pediatr Pharmacol Ther 2022; 27:352-357. [PMID: 35558346 PMCID: PMC9088436 DOI: 10.5863/1551-6776-27.4.352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/12/2021] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Therapeutic hypothermia reduces the risk of death and major disability in neonates with moderate-to-severe hypoxic ischemic encephalopathy (HIE). Opioids and benzodiazepines are used to manage agitation but contribute to hemodynamic and respiratory instability. The objective of this study was to evaluate the safety and efficacy of dexmedetomidine (DEX) compared with fentanyl (FENT) in neonates with HIE undergoing therapeutic hypothermia. METHODS This was a retrospective, single-center study comparing outcomes in neonates with HIE undergoing therapeutic hypothermia who received FENT to those who received DEX. RESULTS A total of 45 neonates were included (FENT, n = 19; DEX, n = 26). The DEX group had a decreased need for sedative bolus doses during therapeutic hypothermia compared with the FENT group; however, there was no difference in number of uncontrolled agitation scores or need for additional scheduled sedatives. The DEX group had a shorter time to discontinuation of sedatives after rewarming compared with the FENT group (0.52 versus 5 days, respectively; p = 0.001), shorter time to extubation after birth (3.1 versus 11.3 days, respectively; p = 0.004), and earlier time to resumption of feeds (8.5 versus 13 days, respectively; p = 0.03). A non-statistically significant reduction in seizures was noted (3 versus 7 subjects, respectively; p = 0.07). There was no difference in baseline characteristics, mortality, or adverse effects. CONCLUSIONS The use of DEX during therapeutic hypothermia for HIE appears to provide comparable control of agitation to FENT with a reduced need for additional sedatives and may lead to an earlier time to extubation and discontinuation of sedatives.
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Affiliation(s)
- Maryam Naveed
- Department of Pharmacy, University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Deborah S. Bondi
- Department of Pharmacy, University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Pooja A. Shah
- Department of Pharmacy, University of Chicago Medicine Comer Children's Hospital, Chicago, IL
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13
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Ojha S, Abramson J, Dorling J. Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice? BMJ Paediatr Open 2022; 6:e001460. [PMID: 36053596 PMCID: PMC9092181 DOI: 10.1136/bmjpo-2022-001460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/22/2022] [Indexed: 01/09/2023] Open
Abstract
Mechanical ventilation is an uncomfortable and potentially painful intervention. Opioids, such as morphine and fentanyl, are used for analgesia and sedation but there is uncertainty whether they reduce pain in mechanically ventilated infants. Moreover, there may be short-term and long-term adverse consequences such as respiratory depression leading to prolonged mechanical ventilation and detrimental long-term neurodevelopmental effects. Despite this, opioids are widely used, possibly due to a lack of alternatives.Dexmedetomidine, a highly selective alpha-2-adrenergic agonist with analgesic and sedative effects, currently approved for adults, has come into use in newborn infants. It provides analgesia and simulates natural sleep with maintenance of spontaneous breathing and upper airway tone. Although data on pharmacokinetics-pharmacodynamics in preterm infants are scant, observational studies report that using dexmedetomidine in conjunction with opioids/benzodiazepines or on its own can reduce the cumulative exposure to opioids/benzodiazepines. As it does not cause respiratory depression, dexmedetomidine could enable quicker weaning and extubation. Dexmedetomidine has also been suggested as an adjunct to therapeutic hypothermia in hypoxic ischaemic encephalopathy and others have used it during painful procedures and surgery. Dexmedetomidine infusion can cause bradycardia and hypotension although most report clinically insignificant effects.The increasing number of publications of observational studies and clinical use demonstrates that dexmedetomidine is being used in newborn infants but data on safety and efficacy are scant and not of high quality. Importantly, there are no data on long-term neurodevelopmental impact on preterm or term-born infants. The acceptance of dexmedetomidine in routine clinical practice must be preceded by clinical evidence. We need adequately powered and well-designed randomised controlled trials investigating whether dexmedetomidine alone or with opioids/benzodiazepines in infants on mechanical ventilation reduces the need for opioids/benzodiazepine and improves neurodevelopment at 24 months and later as compared with the use of opioids/benzodiazepines alone.
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Affiliation(s)
- Shalini Ojha
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Janine Abramson
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon Dorling
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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14
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Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
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Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
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15
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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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16
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McPherson C, Frymoyer A, Ortinau CM, Miller SP, Groenendaal F. Management of comfort and sedation in neonates with neonatal encephalopathy treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101264. [PMID: 34215538 PMCID: PMC8900710 DOI: 10.1016/j.siny.2021.101264] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ensuring comfort for neonates undergoing therapeutic hypothermia (TH) after neonatal encephalopathy (NE) exemplifies a vital facet of neonatal neurocritical care. Physiologic markers of stress are frequently present in these neonates. Non-pharmacologic comfort measures form the foundation of care, benefitting both the neonate and parents. Pharmacological sedatives may also be indicated, yet have the potential to both mitigate and intensify the neurotoxicity of a hypoxic-ischemic insult. Morphine represents current standard of care with a history of utilization and extensive pharmacokinetic data to guide safe and effective dosing. Dexmedetomidine, as an alternative to morphine, has several appealing characteristics, including neuroprotective effects in animal models; robust pharmacokinetic studies in neonates with NE treated with TH are required to ensure a safe and effective standard dosing approach. Future studies in neonates treated with TH must address comfort, adverse events, and long-term outcomes in the context of specific sedation practices.
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Affiliation(s)
- Christopher McPherson
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA.
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, 750 Welch Road, Suite 315, Palo Alto, CA, 94304, USA.
| | - Cynthia M Ortinau
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA.
| | - Steven P Miller
- Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, 555 University Avenue, Toronto, ON, Canada.
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Lundlaan 6, 3584 EA, Utrecht, Netherlands.
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