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Suo M, Zhao X, Yu G, Zhang W. Lidocaine loaded nanostructured lipid carriers for prolonged local anesthesia: in vitro and in vivo studies. J DISPER SCI TECHNOL 2022. [DOI: 10.1080/01932691.2020.1844739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Meng Suo
- Department of Anesthesiology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, Shandong, China
| | - Xu Zhao
- Department of Anesthesiology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, Shandong, China
| | - Guanling Yu
- IVF laboratory, Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China
| | - Wenjia Zhang
- Department of Anesthesiology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, Shandong, China
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Campbell-Yeo M, Eriksson M, Benoit B. Assessment and Management of Pain in Preterm Infants: A Practice Update. CHILDREN (BASEL, SWITZERLAND) 2022; 9:244. [PMID: 35204964 PMCID: PMC8869922 DOI: 10.3390/children9020244] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 12/11/2022]
Abstract
Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive little to no pain-relieving interventions. Moreover, parents remain significantly underutilized in provision of pain-relieving interventions, despite the known benefit of their involvement. This narrative review provides an overview of the consequences of early exposure to untreated pain in preterm infants, recommendations for a standardized approach to pain assessment in preterm infants, effectiveness of non-pharmacologic and pharmacologic pain-relieving interventions, and suggestions for greater active engagement of parents in the pain care for their preterm infant.
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Affiliation(s)
- Marsha Campbell-Yeo
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Pediatrics, Psychology and Neuroscience, Dalhousie University, Halifax, NS B3H 4R2, Canada
- IWK Health, Halifax, NS B3K 6R8, Canada
| | - Mats Eriksson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden;
| | - Britney Benoit
- Rankin School of Nursing, St. Francis Xavier University, Antigonish, NS B2G 2N5, Canada;
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Akbari N, Mutlu B, Nadali J. Effect of Non-nutritive Sucking during Heel-stick Procedure in Pain Management of Term Infants in the Neonatal Intensive Care Unit: A Systematic Review and Meta-analysis. Curr Pediatr Rev 2022; 19:90-98. [PMID: 35410609 DOI: 10.2174/1573396318666220410225908] [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] [Received: 10/06/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND This study aimed to evaluate the efficacy of non-nutritive sucking for analgesia in term infants undergoing heel-stick procedures. METHODS Randomized controlled trials and non-randomized studies based on the PICO framework were included in the study. Review articles, commentary, pilot, and non-English articles were excluded. Databases, such as PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane, were searched until January 31st, 2021, using the keywords "Pain management", 'Non-nutritive sucking", and "Heel stick". All studies were reviewed and retrieved by two authors independently using a standardized form according to the inclusion criteria, and any disagreements were examined by a third scholar. Quality assessment was evaluated by using the ROB-2 tool. Data were analyzed using Stata version 12.0 software, and a random-effects model was used for analysis. RESULTS A total of 5,629 articles were retrieved from all databases, and after the screening, finally, 6 relevant articles were included in the analysis. The tools used to control pain in infants in the articles included PIPP, NFCS, NIPS, and NPASS. The results showed that the pain scores were significantly lower in the NNS group compared to the control group (MD, -1.05; 95% CI, -1.53 to -0.57) and NNS had a significant effect on oxygen saturation (O2 Sat) increasing in newborns compared to the control group, but no significant reduction in the heart rate (HR) between two groups was observed. CONCLUSION NNS effectively provides analgesia in full-term neonates undergoing heel-stick procedures; however, its effects on the long-term outcomes of infants are unclear. The results showed that NNS was effective in improving heel-stick pain in infants.
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Affiliation(s)
- Negarin Akbari
- Pediatric Nursing Doctorate Program, Institute of Graduate Studies, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Birsen Mutlu
- Pediatric Nursing Department, Florence Nightingale Nursing Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Javad Nadali
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
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Li W, Zhang G, Wei X. Lidocaine-loaded reduced graphene oxide hydrogel for prolongation of effects of local anesthesia: In vitro and in vivo analyses. J Biomater Appl 2021; 35:1034-1042. [PMID: 33487069 DOI: 10.1177/0885328220988462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Lidocaine is widely used as a local anesthetic for alleviation of post-operative pain and for management of acute and chronic painful conditions. Although several approaches are currently used to prolong the duration of action, an effective strategy to achieve neural blockage for several hours remains to be identified. In this study, a lidocaine-loaded Pluronic® F68-reduced graphene oxide hydrogel was developed to achieve sustained release of lidocaine. Fourier transform infrared spectroscopy, X-ray diffraction, and Raman spectroscopy confirmed the synthesis of Pluronic® F68-reduced graphene oxide. Transmission electron microscopy showed wrinkled, flat nanosheets with micelles attached. The developed hydrogel showed desirable pH, viscosity, adhesiveness, hardness, and cohesiveness for topical application. The ex vivo release study demonstrated the ability of the Pluronic® F68-reduced graphene oxide hydrogel to prolong release up to 10 h, owing to the strong π-π interactions between the graphene oxide and the lidocaine. In comparison with a commercial lidocaine ointment, the developed graphene oxide hydrogel showed sustained anesthetic effect in the radiant heat tail flick test and sciatic nerve block model. Thus, this study demonstrates the potential of using Pluronic® F68-reduced graphene oxide nanocarriers to realize prolonged effects of local anesthesia for effective pain management.
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Affiliation(s)
- Weifan Li
- Department of Anesthesiology, Jinan Second People's Hospital, Jinan, China
| | - Guangqi Zhang
- Department of Anesthesiology, Jinan Second People's Hospital, Jinan, China
| | - Xiaoxia Wei
- Department of Anesthesiology, Jinan Second People's Hospital, Jinan, China
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Gross JL, Perate AR, Elkassabany NM. Pain Management in Trauma in the Age of the Opioid Crisis. Anesthesiol Clin 2018; 37:79-91. [PMID: 30711235 DOI: 10.1016/j.anclin.2018.09.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
It is imperative to find the balance between pain control and addressing the opioid epidemic. Opioids, although effective in the acute pain management, have multiple side effects and can lead to dependence, abuse, overdose, or death. Physicians should identify patients who abuse opioids, using their states' prescription drug-monitoring programs and use screening tools to identify patients at increased risk of developing opioid dependence. Multimodal analgesic plans, incorporating regional techniques, and nonopioid medications should be employed to reduce the amount of opioids received by patients.
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Affiliation(s)
- Jessica Lynn Gross
- Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston Salem, NC 27157, USA
| | - Alison R Perate
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA.
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Hartley C, Duff EP, Green G, Mellado GS, Worley A, Rogers R, Slater R. Nociceptive brain activity as a measure of analgesic efficacy in infants. Sci Transl Med 2018; 9:9/388/eaah6122. [PMID: 28469039 DOI: 10.1126/scitranslmed.aah6122] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/30/2016] [Accepted: 03/21/2017] [Indexed: 01/08/2023]
Abstract
Pain in infants is undertreated and poorly understood, representing a major clinical problem. In part, this is due to our inability to objectively measure pain in nonverbal populations. We present and validate an electroencephalography-based measure of infant nociceptive brain activity that is evoked by acute noxious stimulation and is sensitive to analgesic modulation. This measure should be valuable both for mechanistic investigations and for testing analgesic efficacy in the infant population.
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Affiliation(s)
- Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Eugene P Duff
- Functional Magnetic Resonance Imaging of the Brain Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Gabrielle Green
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | | | - Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Richard Rogers
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK.
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Dave S, Afshar K, Braga LH, Anderson P. Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (abridged version). Can Urol Assoc J 2018; 12:18-28. [PMID: 29381455 PMCID: PMC5937397 DOI: 10.5489/cuaj.5034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Sumit Dave
- Department of Surgery (Urology), Western University, London, ON; Canada
| | - Kourosh Afshar
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC; Canada
| | - Luis H. Braga
- Department of Surgery (Urology), McMaster University, Hamilton, ON; Canada
| | - Peter Anderson
- Department of Urology, Dalhousie University, Halifax, NS; Canada
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Dave S, Afshar K, Braga LH, Anderson P. Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version). Can Urol Assoc J 2018; 12:E76-E99. [PMID: 29381458 PMCID: PMC5937400 DOI: 10.5489/cuaj.5033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sumit Dave
- Department of Surgery (Urology), Western University, London, ON; Canada
| | - Kourosh Afshar
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC; Canada
| | - Luis H. Braga
- Department of Surgery (Urology), McMaster University, Hamilton, ON; Canada
| | - Peter Anderson
- Department of Urology, Dalhousie University, Halifax, NS; Canada
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Qiu J, Jiang YF, Li F, Tong QH, Rong H, Cheng R. Effect of combined music and touch intervention on pain response and β-endorphin and cortisol concentrations in late preterm infants. BMC Pediatr 2017; 17:38. [PMID: 28125980 PMCID: PMC5270209 DOI: 10.1186/s12887-016-0755-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 12/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preterm neonates undergo many painful procedures as part of their standard care in the neonatal intensive care unit. However, pain treatment is inadequate in many of these routine procedures. In the present study, we investigated the impact and mechanism of combined music and touch intervention (CMT) on the pain response in premature infants. METHODS Sixty-two preterm neonates (gestational age of <37 weeks) were randomly assigned to either the experimental or control group. Infants in the experimental group underwent painful procedures with CMT, and those in the control group underwent painful procedures without CMT. Blood samples were collected from all infants at the beginning of hospitalization and 2 weeks later to assess the cortisol and β-endorphin concentrations. Differences in the levels of cortisol and β-endorphin between two groups were examined using analysis of covariance (ANCOVA). RESULTS In total, 3707 painful procedures were performed on 62 neonates during their hospitalization. The average number of painful procedures in the control group (n = 35.5) was higher than that in the experimental group (n = 29.0) during hospitalization, although no significant difference was reached (P > 0.05). After 2 weeks, the Premature Infant Pain Profile scores were significantly higher in the control group than experimental group (13.000 ± 0.461 vs 10.500 ± 0.850, respectively; P < 0.05). The cortisol concentration was not significantly different between the control and experimental groups either at the beginning of hospitalization (131.000 ± 18.190 vs 237.200 ± 43.860, respectively; P > 0.05) or 2 weeks later (162.400 ± 23.580 vs 184.600 ± 21.170, respectively; P > 0.05). However, the serum β-endorphin concentration was higher in the experimental group than in the control group both at the beginning of hospitalization (1.640 ± 0.390 vs 1.179 ± 0.090, respectively; P < 0.05) and 2 weeks later (2.290 ± 0.740 vs 1.390 ± 0.410, respectively; P < 0.05). CONCLUSIONS CMT might decrease the pain response of preterm neonates by significantly improving the β-endorphin concentration, but not the blood cortisol concentration. TRIAL REGISTRATION Current Controlled Trials ISRCTN14131492 . Registered on 01 Aug 2016.
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Affiliation(s)
- Jie Qiu
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Yun-Fei Jiang
- Department of Pediatrics, Yixing People's Hospital Affiliated to Jiangsu University, Yixing, 214200, China
| | - Fang Li
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Qian-Hong Tong
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Hui Rong
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Rui Cheng
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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Boybeyi Ö, Gunal YD, Atasoy P, Kısa U, Aslan MK. Investigation of the effect of dorsal penile block to penile tissue. J Pediatr Urol 2015; 11:268.e1-5. [PMID: 26096438 DOI: 10.1016/j.jpurol.2015.04.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 04/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Dorsal penile block (DPB) is a frequently used technique for regional anesthesia, but the effect of DPB on penile tissue has not been reported so far. OBJECTIVE An experimental study was conducted to evaluate the acute effects of DPB on penile tissue. METHODS Eighteen male rats were included and randomly assigned to three groups. No intervention was made in the control group (CG, n = 6). In the sham group (SG, n = 6) 1 ml normal saline, and in DPB group (PBG, n = 6) 1 ml of 0.25% bupivacaine without adrenaline (0.5 mg/kg), was infused with a 30 mm, 23 gauge needle. DPB was performed by inserting the needle in the midline when pulling down the penis and directing the needle to the 11 and 1 o'clock positions. Another puncture was done at the midline on the ventral side and the remaining drug was infused slowly. The penile tissues were harvested for biochemical (malonyldialdehyde: MDA; nitric oxide: NO; superoxide dismutase: SOD) and histopathological examination. Histopathological assessments were made of inflammation, edema and fibrosis; epithelial degradation in the urethra; vascular obliteration in periurethral tissue; and the peripheral nerve cells. RESULTS Concentrations of NO and SOD were significantly decreased in the PBG compared with the CG and SG (p < 0.05). The concentration of MDA was significantly increased in the PBG compared with the CG and SG (p < 0.05) (Table). Histopathological examination revealed no significant difference between groups regarding edema, inflammation, or fibrosis (p > 0.05). In hematoxylin and eosin stain samples, vascular structures of the corpus cavernosa were slightly decreased in number in the SG and PBG compared with the CG, but that difference was not statistically significant (p > 0.05). The S-100 staining was significantly higher in the PBG and SG compared with the CG (p < 0.05), and significantly higher in the SG compared with the PBG (p < 0.05). DISCUSSION DPB causes alteration in oxidative stress markers because of an unknown effect. Although the results revealed increased inflammatory reaction in penile tissue after DPB, they are not enough to suggest not using bupivacaine for DPB in clinical practice. CONCLUSION Although DPB does not cause any major histopathological alteration, it results in an increase in inflammatory response in the penile tissue in the short term.
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Affiliation(s)
- Özlem Boybeyi
- Department of Pediatric Surgery, Kırıkkale University, Medical Faculty, Kırıkkale, Turkey.
| | - Yasemin Dere Gunal
- Department of Pediatric Surgery, Kırıkkale University, Medical Faculty, Kırıkkale, Turkey.
| | - Pınar Atasoy
- Department of Pathology, Kırıkkale University, Medical Faculty, Kırıkkale, Turkey.
| | - Ucler Kısa
- Department of Biochemistry, Kırıkkale University, Medical Faculty, Kırıkkale, Turkey.
| | - Mustafa Kemal Aslan
- Department of Pediatric Surgery, Kırıkkale University, Medical Faculty, Kırıkkale, Turkey.
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Shen M, El-Chaar G. Reducing pain from heel lances in neonates following education on oral sucrose. Int J Clin Pharm 2015; 37:529-36. [DOI: 10.1007/s11096-015-0090-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/24/2015] [Indexed: 11/24/2022]
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Abstract
Preclinical and clinical studies have demonstrated the adverse consequences of untreated pain and stress on brain development in the preterm infant. Sucrose has widely been implemented as standard therapy for minor procedural pain. Anesthetics are commonly utilized in preterm infants during major surgery. Pharmacologic agents (benzodiazepines and opioids) have been examined in clinical trials of preterm infants requiring invasive mechanical ventilation. Controversy exists regarding the safety and long-term impact of these interventions. Ongoing multidisciplinary research will help define the impact of these agents and identify potential alternative therapies.
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Campbell-Yeo M, Johnston C, Benoit B, Latimer M, Vincer M, Walker CD, Streiner D, Inglis D, Caddell K. Trial of repeated analgesia with Kangaroo Mother Care (TRAKC Trial). BMC Pediatr 2013; 13:182. [PMID: 24284002 PMCID: PMC3828622 DOI: 10.1186/1471-2431-13-182] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 10/09/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Skin-to-skin contact (SSC) between mother and infant, commonly referred to as Kangaroo Mother Care (KMC), is recommended as an intervention for procedural pain. Evidence demonstrates its consistent efficacy in reducing pain for a single painful procedure. The purpose of this study is to examine the sustained efficacy of KMC, provided during all routine painful procedures for the duration of Neonatal Intensive Care Unit (NICU) hospitalization, in diminishing behavioral pain response in preterm neonates. The efficacy of KMC alone will be compared to standard care of 24% oral sucrose, as well as the combination of KMC and 24% oral sucrose. METHODS/DESIGN Infants admitted to the NICU who are less than 36 6/7 weeks gestational age (according to early ultrasound), that are stable enough to be held in KMC, will be considered eligible (N = 258). Using a single-blinded randomized parallel group design, participants will be assigned to one of three possible interventions: 1) KMC, 2) combined KMC and sucrose, and 3) sucrose alone, when they undergo any routine painful procedure (heel lance, venipuncture, intravenous, oro/nasogastric insertion). The primary outcome is infant's pain intensity, which will be assessed using the Premature Infant Pain Profile (PIPP). The secondary outcome will be maturity of neurobehavioral functioning, as measured by the Neurobehavioral Assessment of the Preterm Infant (NAPI). Gestational age, cumulative exposure to KMC provided during non-pain contexts, and maternal cortisol levels will be considered in the analysis. Clinical feasibility will be accounted for from nurse and maternal questionnaires. DISCUSSION This will be the first study to examine the repeated use of KMC for managing procedural pain in preterm neonates. It is also the first to compare KMC to sucrose, or the interventions in combination, across time. Based on the theoretical framework of the brain opioid theory of attachment, it is expected that KMC will be a preferred standard of care. However, current pain management guidelines are based on minimal data on repeated use of either intervention. Therefore, regardless of the outcomes of this study, results will have important implications for guidelines and practices related to management of procedural pain in preterm infants. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01561547.
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Abstract
Optimal pain management can significantly impact the surgical outcome and length of stay in the neonatal intensive care unit (NICU). Regional anesthesia is an effective alternative that can be used in both term and preterm neonates. A variety of neuraxial and peripheral nerve blocks have been used for specific surgical and NICU procedures. Ultrasound guidance has increased the feasibility of using these techniques in neonates. Education and training staff in the use of continuous epidural infusions are important prerequisites for successful implementation of regional anesthesia in NICU management protocols.
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Affiliation(s)
- Adrian Bosenberg
- Department of Anesthesiology and Pain Management, Faculty Health Sciences, Seattle Children's Hospital, University Washington, 4800 Sandpoint Way Northeast, Seattle, WA 98105, USA
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Schwartz SM, Anand KJS, Portman MA, Crow S, Nelson DP, Zimmerman JJ. Endocrinopathies in the cardiac ICU. World J Pediatr Congenit Heart Surg 2013; 2:400-10. [PMID: 23803992 DOI: 10.1177/2150135111406941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The past several years have seen an increased appreciation of the potential role of the endocrine system in the recovery process following surgery for congenital heart disease. Many of the hormonal changes following cardiac surgery are adaptive and necessary, whereas activation of proinflammatory cytokine and chemokine responses and some of the metabolic changes following surgery are likely mediators leading to detrimental outcomes. Additionally, other hormonal perturbations may contribute to adverse outcomes. This review examines the pain and the stress response, thyroid function and hyperglycemia following cardiopulmonary bypass (CPB), and the potential role of corticosteroids in the pediatric cardiac critical care unit.
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Affiliation(s)
- Steven M Schwartz
- Department of Critical Care Medicine and The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
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Badr LK. Pain Interventions in Premature Infants: What Is Conclusive Evidence and What Is Not. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.nainr.2012.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.
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Boettcher M, Göttler S, Stoffel L, Schwab K, Berger S, Mérat M. Schmerzmanagement bei Kindern in der Schweiz. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-012-2680-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Berde CB, Walco GA, Krane EJ, Anand KJS, Aranda JV, Craig KD, Dampier CD, Finkel JC, Grabois M, Johnston C, Lantos J, Lebel A, Maxwell LG, McGrath P, Oberlander TF, Schanberg LE, Stevens B, Taddio A, von Baeyer CL, Yaster M, Zempsky WT. Pediatric analgesic clinical trial designs, measures, and extrapolation: report of an FDA scientific workshop. Pediatrics 2012; 129:354-64. [PMID: 22250028 PMCID: PMC9923552 DOI: 10.1542/peds.2010-3591] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Analgesic trials pose unique scientific, ethical, and practical challenges in pediatrics. Participants in a scientific workshop sponsored by the US Food and Drug Administration developed consensus on aspects of pediatric analgesic clinical trial design. The standard parallel-placebo analgesic trial design commonly used for adults has ethical and practical difficulties in pediatrics, due to the likelihood of subjects experiencing pain for extended periods of time. Immediate-rescue designs using opioid-sparing, rather than pain scores, as a primary outcome measure have been successfully used in pediatric analgesic efficacy trials. These designs maintain some of the scientific benefits of blinding, with some ethical and practical advantages over traditional designs. Preferred outcome measures were recommended for each age group. Acute pain trials are feasible for children undergoing surgery. Pharmacodynamic responses to opioids, local anesthetics, acetaminophen, and nonsteroidal antiinflammatory drugs appear substantially mature by age 2 years. There is currently no clear evidence for analgesic efficacy of acetaminophen or nonsteroidal antiinflammatory drugs in neonates or infants younger than 3 months of age. Small sample designs, including cross-over trials and N of 1 trials, for particular pediatric chronic pain conditions and for studies of pain and irritability in pediatric palliative care should be considered. Pediatric analgesic trials can be improved by using innovative study designs and outcome measures specific for children. Multicenter consortia will help to facilitate adequately powered pediatric analgesic trials.
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Affiliation(s)
- Charles B. Berde
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Children's Hospital, Boston, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts;,Address correspondence to Charles Berde, MD, PhD, Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital, Boston, 333 Longwood Ave, 5th floor, Boston, MA 02115. E-mail:
| | - Gary A. Walco
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington;,University of Washington School of Medicine, Seattle, Washington
| | - Elliot J. Krane
- Stanford University School of Medicine, Stanford, California;,Lucile Packard Children's Hospital, Stanford, California
| | - K. J. S. Anand
- Division of Pediatric Critical Care Medicine, Le Bonheur Children's Hospital, Memphis, Tennessee;,University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jacob V. Aranda
- The Children's Hospital of Brooklyn, State University of New York, New York, New York;,Pediatric Pharmacology Research Unit Network, Children's Hospital of Michigan, Detroit, Michigan
| | - Kenneth D. Craig
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carlton D. Dampier
- Emory University School of Medicine, Atlanta, Georgia;,Atlanta Clinical Translational Science Institute, Atlanta, Georgia
| | - Julia C. Finkel
- Department of Anesthesiology George Washington University, Washington, District of Columbia;,Division of Anesthesiology and Pain Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Martin Grabois
- Baylor College of Medicine, Houston, Texas;,University of Texas Health Science Center-Houston, Houston, Texas
| | | | - John Lantos
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri;,University of Missouri–Kansas City, Kansas City, Missouri
| | - Alyssa Lebel
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Children's Hospital, Boston, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts
| | - Lynne G. Maxwell
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;,Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Patrick McGrath
- IWK Health Centre, Halifax, Nova Scotia, Canada;,Dalhousie University, Halifax, Nova Scotia, Canada
| | - Timothy F. Oberlander
- Division of Developmental Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada;,BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Bonnie Stevens
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anna Taddio
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carl L. von Baeyer
- Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Myron Yaster
- Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Medical and Surgical Center, The Johns Hopkins Hospital, Baltimore, Maryland; and
| | - William T. Zempsky
- Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, Connecticut
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Taddio A, Shah V, Stephens D, Parvez E, Hogan ME, Kikuta A, Koren G, Katz J. Effect of liposomal lidocaine and sucrose alone and in combination for venipuncture pain in newborns. Pediatrics 2011; 127:e940-7. [PMID: 21402628 DOI: 10.1542/peds.2010-2914] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the relative effectiveness of liposomal lidocaine, sucrose, and their combination for reducing pain in term newborns. METHODS Ours was a double-blind, randomized, controlled, double-dummy trial of 330 healthy term newborns. Before venipuncture for the newborn screening test, neonates received (1) 1 g of liposomal lidocaine cream topically, (2) 2 mL of 24% sucrose solution orally, or (3) sucrose and liposomal lidocaine. The facial grimacing score (0-100) was used to assess pain. Adverse events and lidocaine levels were used to assess safety. RESULTS Infant characteristics did not differ among groups. Facial grimacing scores were lower in the sucrose group compared with those in the liposomal lidocaine group (mean difference: -27 [95% confidence interval (CI): -36 to -19; P < .001) and for the sucrose plus liposomal lidocaine group compared with those in the liposomal lidocaine group (mean difference: -23 [95% CI: -31 to -14]; P < .001). The sucrose and sucrose plus liposomal lidocaine groups did not differ (mean difference: -5 [95% CI: -13 to 4]; P = .3). Local skin reactions were not observed, and the incidence of spitting up did not differ between sucrose-exposed and non-sucrose-exposed infants (1.4% vs 2.7%, respectively; P = .22). The mean (SD) plasma lidocaine level was 44.6 (55.3) ng/mL. CONCLUSIONS Sucrose was more effective than liposomal lidocaine for reducing pain during venipuncture in newborns. The addition of liposomal lidocaine to sucrose did not confer any additional benefit to sucrose alone. There was no evidence of harm from liposomal lidocaine or sucrose.
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Affiliation(s)
- Anna Taddio
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario, Canada M5S 3M2.
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Abstract
A large number of published studies have shown that the use of diverse regional anaesthetic techniques is associated with high-quality pain relief following the different types of surgery and painful procedures that are commonly performed in neonatal patients. Apart from pain, few studies have examined other outcomes in this setting. Some data suggest a benefit with regional anaesthesia. In a retrospective study, Bosenberg et al. found that the use of epidural analgesia in neonatal patients undergoing tracheo-oesophageal fistula repair resulted in a reduced need for postoperative mechanical ventilation. Furthermore, epidural analgesia was found to be associated with a significant and beneficial modification of the neuroendocrine surgical stress response after major abdominal surgery in infants when compared to postoperative morphine infusions. The use of local anaesthetics in association with neonatal circumcision has also shown a benefit as neonates not treated with eutectic mixture of lidocaine and prilocaine (EMLA) or a penile block had an exaggerated pain response to later vaccinations as compared with neonates treated with a local anaesthetic technique. Finally, safety data generated from large, prospective studies and audits clearly show that the use of paediatric regional anaesthetic techniques is associated with adequate safety also in neonatal patients. In conclusion, a large variety of local and regional anaesthetic techniques can be safely used in neonatal patients. The use of such techniques must obviously be associated with sufficient knowledge about the various techniques, as well as adherence to adequate dosage guidelines and other safety precautions. However, if these prerequisites are met, regional anaesthesia may offer great advantages to our smallest and most vulnerable patients.
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Walter-Nicolet E, Annequin D, Biran V, Mitanchez D, Tourniaire B. Pain management in newborns: from prevention to treatment. Paediatr Drugs 2010; 12:353-65. [PMID: 21028915 DOI: 10.2165/11318900-000000000-00000] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
All neonates in the Neonatal Intensive Care Unit (NICU) or during the first days of life undergo painful and stressful procedures. Epidemiologic studies have shown that pain induced by these procedures is not effectively prevented or is inadequately treated. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates. Prevention is the first step of pain management, and practical guidelines should be used in the NICU. Assessment must be done with adequate tools that take into account the infant's pathology and gestational age. Distinguishing between acute and prolonged pain is important for both assessment and treatment. The most common drugs that have been studied for the treatment of pain and stress are opioids, hypnosedatives, and NMDA receptor antagonists. Morphine and fentanyl are most frequently used for acute or prolonged pain in the NICU. They have potent analgesic effects and few immediate or long-term adverse effects. Midazolam is a commonly used hypnosedative, but its adverse effects limit its use. Drugs such as propofol and ketamine have been used for acute painful procedures; however, further research is needed to assess their long-term effects. Use of non-pharmacologic pain management techniques has increased in recent years. These methods are easy, inexpensive, and effective in helping newborns recover from painful procedures. Sweet solutions and non-nutritive sucking, breastfeeding, skin-to-skin mother care, swaddling, and facilitated tucking are the most commonly employed and evaluated non-pharmacologic methods. Hospitals should promote and improve parent involvement in pain management. In-service education and well organized hospital teams are crucial for successful implementation of pain protocols in newborns.
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Affiliation(s)
- Elizabeth Walter-Nicolet
- Unité Fonctionnelle de lutte contre la douleur, Hôpital d'enfants Armand Trousseau, Assistance Publique Hôpitaux de Paris, Paris, France
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Johnston CC, Fernandes AM, Campbell-Yeo M. Pain in neonates is different. Pain 2010; 152:S65-S73. [PMID: 20971562 DOI: 10.1016/j.pain.2010.10.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 09/30/2010] [Accepted: 10/05/2010] [Indexed: 12/16/2022]
Abstract
Pain processing and management in neonates, especially preterm neonates, differs from older populations. In this review, a brief background on pain processing in neonatal life, pain exposure in Neonatal Intensive Care Units (NICU), the consequences of untreated pain, and the difficulties in treating procedural pain pharmacologically will be presented. A more detailed review of non-pharmacological interventions for procedural pain in neonates will include sensory stimulation approaches, oral sweet solutions, and maternal interventions. Some possible mechanisms for the effectiveness of non-pharmacological interventions are offered. Finally, avenues of research into similar interventions as adjuvant therapies or drug-sparing effects in older populations are suggested.
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Affiliation(s)
- Celeste C Johnston
- McGill University School of Nursing, Montreal, Canada Coimbra School of Nursing, Coimbra, Portugal IWK Health Centre, Halifax, Canada
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De Lima J, Carmo KB. Practical pain management in the neonate. Best Pract Res Clin Anaesthesiol 2010; 24:291-307. [DOI: 10.1016/j.bpa.2010.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Brenner GM, Stevens CW. Local and General Anesthetics. Pharmacology 2010. [DOI: 10.1016/b978-1-4160-6627-9.00021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shah VS, Taddio A, Hancock R, Shah P, Ohlsson A. Topical amethocaine gel 4% for intramuscular injection in term neonates: A double-blind, placebo-controlled, randomized trial. Clin Ther 2008; 30:166-74. [DOI: 10.1016/j.clinthera.2008.01.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2007] [Indexed: 11/16/2022]
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