Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants

Common error traps in anesthesia for neonatal surgical emergencies

Neonatal surgical emergencies are challenging, often high-risk procedures for the pediatric anesthesiologist. Though each emergency presents different anesthetic challenges, several error traps exist that are common to all procedures in this patient population. These error traps include errors in surgical timing, airway management, maintenance of normothermia and normoglycemia, and recognition of pharmacologic and physiologic differences. In this narrative review, we will discuss each error trap to aid the clinician in recognizing, planning for, and mitigating adverse events.

Comparison of the effects of fentanyls and other μ opioid receptor agonists on the electrical activity of respiratory muscles in the rat

Introduction: Deaths due to overdose of fentanyls result primarily from depression of respiration. These potent opioids can also produce muscle rigidity in the diaphragm and the chest muscles, a phenomenon known as Wooden Chest Syndrome, which further limits ventilation. Methods: We have compared the depression of ventilation by fentanyl and morphine by directly measuring their ability to induce muscle rigidity using EMG recording from diaphragm and external and internal intercostal muscles, in the rat working heart-brainstem preparation. Results: At equipotent bradypnea-inducing concentrations fentanyl produced a greater increase in expiratory EMG amplitude than morphine in all three muscles examined. In order to understand whether this effect of fentanyl was a unique property of the phenylpiperidine chemical structure, or due to fentanyl's high agonist intrinsic efficacy or its lipophilicity, we compared a variety of agonists with different properties at concentrations that were equipotent at producing bradypnea. We compared carfentanil and alfentanil (phenylpiperidines with relatively high efficacy and high to medium lipophilicity, respectively), norbuprenorphine (orvinolmorphinan with high efficacy and lipophilicity) and levorphanol (morphinan with relatively low efficacy and high lipophilicity). Discussion: We observed that, agonists with higher intrinsic efficacy were more likely to increase expiratory EMG amplitude (i.e., produce chest rigidity) than agonists with lower efficacy. Whereas lipophilicity and chemical structure did not appear to correlate with the ability to induce chest rigidity.

Variability of neonatal premedication practices for endotracheal intubation and LISA in the UK (NeoPRINT survey)

OBJECTIVE

The NeoPRINT Survey was designed to assess premedication practices throughout UK NHS Trusts for both neonatal endotracheal intubation and less invasive surfactant administration (LISA).

DESIGN

An online survey consisting of multiple choice and open answer questions covering preferences of premedication for endotracheal intubation and LISA was distributed over a 67-day period. Responses were then analysed using STATA IC 16.0.

SETTING

Online survey distributed to all UK Neonatal Units (NNUs).

PARTICIPANTS

The survey evaluated premedication practices for endotracheal intubation and LISA in neonates requiring these procedures.

MAIN OUTCOME MEASURES

The use of different premedication categories as well as individual medications within each category was analysed to create a picture of typical clinical practice across the UK.

RESULTS

The response rate for the survey was 40.8 % (78/191). Premedication was used in all hospitals for endotracheal intubation but overall, 50 % (39/78) of the units that have responded, use premedications for LISA. Individual clinician preference had an impact on premedication practices within each NNU.

CONCLUSION

The wide variability on first-line premedication for endotracheal intubation noted in this survey could be overcome using best available evidence through consensus guidance driven by organisations such as British Association of Perinatal |Medicine (BAPM). Secondly, the divisive view around LISA premedication practices noted in this survey requires an answer through a randomised controlled trial.

The effects of the administration sequence and the type of hypnotics on the development of remifentanil-induced chest wall rigidity: a randomized controlled trial

BACKGROUND

Research on remifentanil-induced chest wall rigidity is limited. Furthermore, its incidence is unknown, and the clinical factors influencing its development remain unclear. This prospective, double-blind, randomized controlled trial aimed to investigate the effects of the administration sequence of hypnotics and remifentanil as well as the type of hypnotic administered on the development of remifentanil-induced chest wall rigidity.

METHODS

A total of 125 older patients aged [Formula: see text] 65 years, who were scheduled to undergo elective surgery under general anesthesia, were enrolled in this study. Participants were randomly assigned to one of four groups; Thio-Remi, Pro-Remi, Remi-Thio, or Remi-Pro. After confirming the loss of consciousness and achieving a target effect-site concentration of 3 ng/mL remifentanil, the development of remifentanil-induced chest wall rigidity was evaluated.

RESULTS

The incidence of chest wall rigidity was significantly higher in the remifentanil-hypnotic group than in the hypnotic-remifentanil (opposite sequence) group (55.0% vs. 21.7%, P < 0.001). Logistic regression analysis revealed that remifentanil-hypnotic administration was a significant predictor of the development of chest wall rigidity (crude odds ratio 4.42, 95% confidence interval 1.99; 9.81, P < 0.001).

CONCLUSIONS

Pretreatment with hypnotics potentially reduces the development of chest wall rigidity during the induction of balanced anesthesia with remifentanil in older patients.

TRIAL REGISTRATION

This article was registered at WHO International Clinical Trials Registry Platform (Trial number: KCT0006542).

Sedation Prior to Intubation at Birth in Infants with Congenital Diaphragmatic Hernia: An International Survey on Current Practices

INTRODUCTION

Infants with congenital diaphragmatic hernia (CDH) are commonly intubated immediately after birth. Consensus on whether to provide sedation prior to intubation in the delivery room is lacking, although avoidance of stress is especially important in this population with high risk of pulmonary hypertension. We aimed at obtaining an overview of local pharmacological interventions and at providing guidance on delivery room management.

METHODS

An electronic survey was sent to international clinicians in referral centres for prenatal and postnatally diagnosed infants with CDH. This survey addressed demographic information, use of sedation and/or muscle relaxant prior to intubation, and use of pain scales in the delivery room.

RESULTS

We received 93 relevant responses from 59 centres. Most centres were from Europe (n = 33, 56%), followed by North America (n = 16, 27%), Asia (n = 6, 10%), Australia (n = 2, 3%), and South America (n = 2, 3%). A total of 19% (11/59) of the centres routinely provided sedation prior to intubation in the delivery room, with midazolam and fentanyl being most often used. Methods of administration varied for all medications provided. Only 5 of 11 centres using sedation reported an adequate sedative effect prior to intubation. Muscle relaxants prior to intubation were used in 12% (7/59) of the centres, although not always in combination with sedation.

CONCLUSION

This international survey shows a substantial variation in sedation practices in the delivery room and scarce use of both sedative agents and muscle relaxants prior to intubation of CDH infants. We provide guidance on developing protocols for pre-intubation medication in this population.

Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry

BACKGROUND

Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation.

METHODS

We queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed.

RESULTS

The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening.

CONCLUSIONS

Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients

BACKGROUND

Opioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients. We postulate that FIRCS can occur in this setting and is likely under recognized, leading to increased morbidity and mortality.

METHODS

Patients admitted to the intensive care unit with suspected FIRCS were included in this retrospective analysis. The objective of this analysis is to describe the clinical presentation and treatment strategies for FIRCS.

RESULTS

Forty-two patients exhibiting symptoms of FIRCS were included in this analysis. Twenty-two of the forty-two patients with descriptive documentation had evidence of thoracic or abdominal rigidity on examination (52.4%). Twelve of sixteen (75%) patients treated solely with naloxone had documented ventilator compliance following intervention, compared to six of eleven (55%) managed with cisatracurium alone. Nine of twelve patients who ultimately received naloxone after initial treatment with cisatracurium had documented ventilator compliance following naloxone administration (75%). Standard interventions, including sedation optimization and ventilator adjustments were attempted to rule out and treat other potential causes of dyssynchrony. In most cases, the administration of naloxone resulted in appropriate compliance with both ventilator and patient-initiated breaths, suggesting the ventilator dyssynchrony was due to fentanyl.

CONCLUSIONS

This is the largest case series to date describing FIRCS in the intensive care setting. Recognition and prompt management is necessary for improved patient outcomes. Research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions.

Feasibility and Safety of Remazolam versus Propofol When Inserting Laryngeal Masks Without Muscle Relaxants During Hysteroscopy

Purpose

This study aimed to evaluate the efficacy and safety of remazolam compared with propofol in patients who underwent laryngeal mask airway (LMA) insertion without the use of muscle relaxant agents during hysteroscopic surgery.

Patients and Methods

A total of 72 patients undergoing hysteroscopy with LMA insertion were assigned to two groups. The patients in the remazolam group received 0.3 μg/kg sufentanil, 0.3 mg/kg remazolam and 1.2 mg/kg remifentanil, whereas the patients in the propofol group received 0.3 μg/kg sufentanil, 2.0 mg/kg propofol and 1.2 mg/kg remifentanil for insertion of the LMA. The primary endpoint was the summed score of the insertion conditions. The secondary endpoints included hemodynamics, the duration of induction, the duration of insertion, tidal volume, plateau pressure and adverse events.

Results

No difference was identified between the propofol group and remazolam group in the median summed score [18.0 (18.0, 18.0), 18.0 (17.0, 18.0), respectively, P > 0.05]. The induction duration was significantly longer (P < 0.05) in the remazolam group than propofol group. The cost of dopamine (P < 0.05) was significantly lower in the remazolam group compared with the patients in the propofol group, while the plateau pressure (P < 0.05) and the incidence of transient mild laryngospasm (P < 0.05) were significantly higher in the remazolam group. No differences were identified between the two groups in terms of heart rate, tidal volume, injection pain or hiccups (P > 0.05).

Conclusion

Remazolam provided similar insertion conditions and better hemodynamic stability than propofol during LMA insertion without the use of muscle relaxant agents. However, a higher incidence of transient mild laryngospasm was found in the remazolam group, which should be considered.

Fentanyl-induced muscle rigidity in a dog during weaning from mechanical ventilation after emergency abdominal surgery: A case report

A 22.5-kg, 8.4-year-old female mixed breed dog was presented for an emergency ovariohysterectomy for pyometra. No neurological abnormalities were observed on preoperative physical examination. Surgery was completed uneventfully under fentanyl- and sevoflurane-based anaesthesia. Cardiorespiratory indices remained stable under mechanical ventilation throughout the procedure. Approximately 23 min after the discontinuation of fentanyl infusion, the investigator noticed jaw closure and stiffness and thoraco-abdominal muscle rigidity. To rule out fentanyl-induced muscle rigidity, naloxone was administered. Following administration of naloxone, there was a return of spontaneous respiratory effort, indicated by capnogram and visible chest wall excursion. Based on the clinical signs and response to naloxone administration, the dog was diagnosed with suspected fentanyl-induced muscle rigidity. Six minutes after the return of spontaneous respiration, the dog was extubated uneventfully without additional naloxone administration. During 4 days of postoperative hospitalization, no recurrent muscle rigidity was observed, and the patient was discharged safely. The total dose of fentanyl administered was 0.61 mg (27 μg kg^-1 ).

Case report: Intrapulmonary tidal volumes in a preterm infant with chest wall rigidity

BACKGROUND

Chest wall rigidity is a known side effect of fentanyl use, which is why fentanyl is usually combined with a muscle relaxant such as mivacurium. Verifying endotracheal intubation is difficult in case of a rigid chest wall.

CASE PRESENTATION

We present the case of a preterm infant (29 completed weeks gestation, birth weight 1,150 g) with a prolonged chest wall rigidity after fentanyl administration for intubation despite adequate doses of mivacurium. This resulted in a pronounced desaturation without any effect on heart rate. Clinically, the infant showed no chest wall movement despite intubation and common tools to verify intubation (including end-tidal carbon dioxide measurement and auscultation) were inconclusive. However, using electrical impedance tomography (EIT), we were able to demonstrate minimal tidal volumes at lung level and thereby, EIT was able to accurately show correct placement of the endotracheal tube.

CONCLUSIONS

This case may increase vigilance for fentanyl-induced chest wall rigidity in the neonatal population even when simultaneously administering mivacurium. Higher airway pressures exceeding 30 mmHg and the use of μ-receptor antagonists such as naloxone should be considered to reverse opioid-induced chest wall rigidity. Most importantly, our data may imply a relevant clinical benefit of using EIT during neonatal intubation as it may accurately show correct endotracheal tube placement.

Anesthesia protocols for "bedside" preterm patent ductus arteriosus ligation: A single-institutional experience

Background :

Hemodynamically significant patent ductus arteriosus (PDA) is frequently encountered in preterm infants sometimes requiring surgical attention. Although PDA ligation is regularly performed in the operating room, conducting it at the bedside in a neonatal intensive care unit (NICU) and its anesthetic management remains challenging.

Aim :

We aim to discuss the anesthetic considerations in patients undergoing bedside PDA ligation and describe our experience highlighting the feasibility and safety of this procedure.

Setting and Design :

The study was conducted in the NICU in a tertiary care hospital; This was a retrospective, observational study.

Methods :

Preterm infants scheduled for bedside PDA ligation using a predefined anesthesia protocol between August 2005 and October 2020 were included.

Statistical Analysis Used:

Quantitative data were presented as median with interquartile range and categorical data were presented as numbers and percentage thereof.

Results :

Sixty-six premature infants underwent bedside PDA ligation. Thirty-day mortality was 4.5% (3 infants), but there were no procedural deaths. One (1.5%) patient had intraoperative endotracheal tube dislodgement. Three (4.5%) infants had postoperative pneumothorax requiring an additional chest tube insertion. Twenty-one (32%) patients required initiation of postoperative inotrope/vasodilator therapy within 6 h. Three postligation cardiac syndromes (≥ Grade-III mitral regurgitation with left ventricular dysfunction and hypotension) occurred.

Conclusions :

Although anesthesia for preterm neonates undergoing bedside PDA ligation poses unique challenges, it can be safely conducted by following a predetermined standardized anesthesia protocol. Its successful conduct requires utmost vigilance and pristine understanding of the principles of neonatal and cardiac care.

Pediatric Palliative Care Pharmacy Pearls—A Focus on Pain and Sedation

Determining the optimal dosing regimen for pediatric patients is a challenge due to the lack of dosing guidelines and studies. In addition, many developmental pharmacology changes that occur throughout childhood that have profound impacts on the absorption, distribution, metabolism, and elimination of medications are commonly used in palliative care. Adding to that complexity, certain medications have different effects in the pediatric patient compared to the adult patient. Being aware of the pharmacokinetic changes, impact on neurodevelopment and unique medication factors that are present in pediatric patients helps clinicians treat the pediatric palliative care patient in the best and safest way possible.

[Overdose from a patch]

HISTORY AND CLINICAL FINDINGS

We present the case of an 89-year-old patient with impaired consciousness for whom the emergency services were called. She was soporose and showed a pronounced generalized muscle rigidity. Due to a third-party history the incorrect use of a fentanyl patch was found out to be at cause.

TREATMENT AND CLINICAL COURSE

The antidote administration of naloxone led to restoration. The need for repetitive administration confirmed the clinical hypothesis.

CONCLUSION

The application of fentanyl via the skin in the form of transdermal therapeutic systems (TTS) has become more popular over the years. Incorrect administration causes intoxication with the leading symptoms of loss of consciousness and respiratory depression. This case report extends the spectrum of symptoms to include skeletal muscle rigidity otherwise only described in connection with intravenous administration, especially in anaesthetic settings.

International consensus is needed on premedication for non-emergency neonatal intubation after survey found wide-ranging policies and practices in 70 countries

AIM

This study evaluated whether practitioners from 70 countries used premedication for non-emergency neonatal intubation and identified attitudes and experience regarding the safety, side effects and efficiency of neonatal intubation.

METHODS

Invitations to take part in the survey were issued between December 18, 2018 and February 4, 2019 to the users of neonatal-based websites and Facebook groups, members of professional societies and the authors of relevant publications in the last five years.

RESULTS

We analysed 718 completed questionnaires from 40 European and 30 non-European countries. Most of the responses were from neonatologists (69.6%) and paediatric or neonatal trainees (10.3%). In units without a protocol (31.6%), more than half of the practitioners (60.4%) chose premedication according to personal preference and 37.0%-11.9% of the overall respondents did not use any drugs for non-emergency intubation. The most frequently reported drug combination was fentanyl, atropine and succinylcholine (6.8%). Most of the practitioners (78.5%) use the same drugs for term and preterm infants. Only 24.8% of the physicians were fully satisfied with their premedication practices.

CONCLUSION

Nearly 12% of the respondents did not use premedication for non-emergency neonatal intubation. The wide-ranging policies and practices found among the respondents highlight the need for international consensus guidelines.

Propofol versus placebo (with rescue with ketamine) before less invasive surfactant administration: study protocol for a multicenter, double-blind, placebo controlled trial (PROLISA)

Background

One major limitation for less invasive surfactant administration (LISA) is the difficulty in providing sedation before this procedure and the competitive risk of respiratory depression versus avoidance of intubation for most sedative or analgesic drugs used in this context.

The objective of this study is to compare the need for mechanical ventilation within 72 h of life following premedication with propofol, versus placebo (rescue with ketamine), for the LISA procedure in preterm neonates born before 32 weeks gestational age (wGA).

Methods

ProLISA is a phase III, non-inferiority, multicenter, double blind, randomized, placebo controlled trial designed according to the SPIRIT Statement. Neonates born before 32 wGA in 12 geographically dispersed Neonatal Intensive Care Units in France needing surfactant will be included from September 2019 to September 2022. A sample of 542 patients is needed. The neonate is randomized to the intervention (propofol) or control placebo group. Open label rescue treatment with ketamine is possible in both groups if FANS (Faceless Acute Neonatal pain Scale) is ≥6. To guide drug administration, FANS is scored before attempting laryngoscopy. Once an adequate score has been obtained, LISA is performed according to a standardized protocol. The primary outcome is the need for mechanical ventilation within 72 h of life. Secondary outcomes are tolerance of the procedure, pain evaluation, hemodynamic and neurologic parameters after the intervention, morbidities before discharge and neurodevelopmental assessment at 2 years of age.

Discussion

This paper describes the first multicenter, double-blind, randomized, placebo-controlled trial on this topic and will provide crucial information to support implementation of the LISA procedure.

Trial registration

ClinicalTrials.gov: NCT04016246. Registered 06 June 2019, N°EUDRACT: 2018–002876-41.

Laryngeal reflex responses in pediatric anesthesia

Laryngeal and respiratory reflexes are vitally important defense mechanisms against foreign body aspiration, safeguarding airway patency, and ventilation. These highly preserved automatisms easily overrule external influences like willpower or (anesthetic) medication. Prevention and anticipation are, therefore, the essential strategies to avoid adverse events and damage, and treatment is most effective in the early stage of the reflex response. The physiology and pathophysiology of the various defensive reflexes as well as a comprehensive anesthetic approach to prevention and treatment are outlined in this review.

Considerations for neonatal and pediatric pain management

PURPOSE

Current literature and clinical practice guidelines on pediatric pain management are reviewed.

SUMMARY

Acute pain is commonly present in neonatal and pediatric patients due to underlying disease states or procedures. Especially in institutions with limited pediatric pain services, it is imperative to describe the appropriate management of pain and pharmacotherapy options that are effective and safe in pediatric patients. Despite the knowledge of pain being an important aspect in the management of children, barriers exist, leading to suboptimal treatment. Addressing these barriers through education of healthcare practitioners, families, and patients will lead to optimizing the patient pain experience. Tools for pain assessment vary depending on the type of pain, the child's age and understanding of pain, and the clinical situation. Pharmacotherapy options for pain management in neonates and pediatric patients include opioid and nonopioid agents. Efficacy and safety data on the use of medications for the treatment of pain in pediatric patients is described. The delivery of medication encompasses patient-specific factors and preferences. Strategies for opioid stewardship and management of iatrogenic withdrawal pose a unique challenge in pediatric patients.

CONCLUSION

The management of acute pain in neonates and pediatric patients should be a priority for all practitioners caring for these patients. Use of age-appropriate pain assessment tools and understanding of the mechanisms of action and roles in therapy of various nonopioid and opioid therapies can help optimize treatment of pain in neonatal and pediatric patients.

Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit

In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.

Noradrenergic Mechanisms in Fentanyl-Mediated Rapid Death Explain Failure of Naloxone in the Opioid Crisis

In December 2018, the Centers for Disease Control declared fentanyl the deadliest drug in America. Opioid overdose is the single greatest cause of death in the United States adult population (ages 18-50), and fentanyl and its analogs [fentanyl/fentanyl analogs (F/FAs)] are currently involved in >50% of these deaths. Anesthesiologists in the United States were introduced to fentanyl in the early 1970s when it revolutionized surgical anesthesia by combining profound analgesia with hemodynamic stability. However, they quickly had to master its unique side effect. F/FAs can produce profound rigidity in the diaphragm, chest wall and upper airway within an extremely narrow dosing range. This clinical effect was called wooden chest syndrome (WCS) by anesthesiologists and is not commonly known outside of anesthesiology or to clinicians or researchers in addiction research/medicine. WCS is almost routinely fatal without expert airway management. This review provides relevant clinical human pharmacology and animal data demonstrating that the significant increase in the number of F/FA-induced deaths may involve α-adrenergic and cholinergic receptor-mediated mechanical failure of the respiratory and cardiovascular systems with rapid development of rigidity and airway closure. Although morphine and its prodrug, heroin, can cause mild rigidity in abdominal muscles at high doses, neither presents with the distinct and rapid respiratory failure seen with F/FA-induced WCS, separating F/FA overdose from the slower onset of respiratory depression caused by morphine-derived alkaloids. This distinction has significant consequences for the design and implementation of new pharmacologic strategies to effectively prevent F/FA-induced death. SIGNIFICANCE STATEMENT: Deaths from fentanyl and F/FAs are increasing in spite of availability and awareness of the opioid reversal drug naloxone. This article reviews literature suggesting that naloxone may be ineffective against centrally mediated noradrenergic and cholinergic effects of F/FAs, which clinically manifest as severe muscle rigidity and airway compromise (e.g., wooden chest syndrome) that is rapid and distinct from respiratory depression seen with morphine-derived alkaloids. A physiologic model is proposed and implications for new drug development and treatment are discussed.

Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events

OBJECTIVE

To determine the impact of premedication for tracheal intubation (TI) on adverse TI associated events, severe oxygen desaturations, and first attempt success STUDY DESIGN: Retrospective cohort study in neonatal intensive care units (NICU) participating in the National Emergency Airway Registry for Neonates from 10/2014 to 6/2017. Premedication for TI was categorized as sedation with neuromuscular blockade, sedation only, or no medication.

RESULTS

2260 TIs were reported from 11 NICUs. Adverse TI associated events occurred less often in sedation with neuromuscular blockade group (10%) as compared to sedation only (29%), or no medication group (23%), p < 0.001. The adjusted odds ratio (aOR) for adverse TI associated events were: sedation with neuromuscular blockade aOR 0.48 (95%CI 0.34-0.65, p < 0.001) compared to no medication.

CONCLUSION

Use of sedation with neuromuscular blockade was associated with favorable TI outcomes. This study supports the recommendation for the standard use of sedation with neuromuscular blockade in non-emergency TIs.

Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R ² = 0.71, B _max 876 mL/min, K ₅₀ 16.3 kg) and alfentanil (R ² = 0.70, B _{max (fixed)} 420 mL/min, K ₅₀ 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R ² = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R ² = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.

Clinical and Economic Analysis of Morphine Versus Fentanyl in Managing Ventilated Neonates With Respiratory Distress Syndrome in the Intensive Care Setting

PURPOSE

Morphine and fentanyl opioids are common analgesic agents for consideration in the neonatal intensive care unit (NICU) for neonates with respiratory distress syndrome (RDS) and undergoing mechanical ventilation (MV). The aim of this study was to evaluate the clinical and economic impact of morphine versus fentanyl in neonates with RDS undergoing MV.

METHODS

Retrospective cost-effectiveness analysis of critically ill neonates with RDS receiving standard doses of morphine versus fentanyl at Women's Wellness and Research Center, Qatar. Clinical data of neonates were extracted from medical records of patients from 2014 to 2016. A decision analytic model based on the hospital's perspective was constructed to follow possible consequences of the initial dosing of analgesia, before potential titration. Primary end points were successful pain relief rate based on the Premature Infant Pain Profile scale and overall direct medical cost of therapy. Study population of 126 neonates was used to achieve results with 80% power and 0.05 significance. Sensitivity analysis was conducted to enhance robustness of conclusions against input uncertainties and to increase generalizability of results.

FINDINGS

Morphine achieved a success of 68% versus 43% with fentanyl (risk ratio = 1.72; 95% CI, 1.16-2.56; P = 0.0075). Morphine was associated with a minimal incremental cost-effectiveness ratio of USD 135 per additional case of successful pain relief over fentanyl. Higher morphine cost was reported in 2% of cases. Sensitivity analysis found model insensitivity to input uncertainties except NICU stay and cost of MV.

IMPLICATIONS

This is the first cost-effectiveness evaluation of morphine versus fentanyl in the NICU. Morphine significantly improved the relieve of pain over fentanyl. It had 98% probability of dominance over fentanyl. Results in this study support the use of morphine over fentanyl as first-line monotherapy with MV in NICU settings.

Turkish Neonatal Society guideline on the neonatal pain and its management

Pain control is an important ethical issue to be considered and constitutes the basis of treatment in premature and term newborns. The inadequacy of pain control in these infants in neonatal intensive care units leads to neurodevelopmental and behavioral problems in the long term. For this reason, it is extremely important to raise awareness of the presence of pain in newborn infants, to reduce invasive procedures applied to infants as much as possible, and to minimize pain with non-pharmacologic or pharmacologic treatments when it is inevitable.

Premedication for Endotracheal Intubation in the Neonate

Endotracheal intubation, a common procedure in neonatal intensive care, results in distress and disturbs physiologic homeostasis in the newborn. Analgesics, sedatives, vagolytics, and/or muscle relaxants have the potential to blunt these adverse effects, reduce the duration of the procedure, and minimize the number of attempts necessary to intubate the neonate. The medical care team must understand efficacy, safety, and pharmacokinetic data for individual medications to select the optimal cocktail for each clinical situation. Although many units utilize morphine for analgesia, remifentanil has a superior pharmacokinetic profile and efficacy data. Because of hypotensive effects in preterm neonates, sedation with midazolam should be restricted to near-term and term neonates. A vagolytic, generally atropine, blunts bradycardia induced by vagal stimulation. A muscle relaxant improves procedural success when utilized by experienced practitioners; succinylcholine has an optimal pharmacokinetic profile, but potentially concerning adverse effects; rocuronium may be the agent of choice based on more robust safety data despite a relatively prolonged duration of action. In the absence of an absolute contraindication, neonates should receive analgesia with consideration of sedation, a vagolytic, and a muscle relaxant before endotracheal intubation. Neonatal units must develop protocols for premedication and optimize logistics to ensure safe and timely administration of appropriate agents.

Effects of fentanyl for pain control and neuroprotection in very preterm newborns on mechanical ventilation

Objective: This study aimed to evaluate the cerebral protection effect of fentanyl infusion in very preterm infants in the first 72 h of mechanical ventilation. Methods: In this double-blind, randomized, controlled trial, mechanically ventilated newborns (<32 weeks' gestational age) were randomized to fentanyl (continuous infusion of fentanyl) or placebo (continuous infusion of glucose, controls) in the first 72 h of the mechanical ventilation period. The premature infant pain profile (PIPP), cerebral blood flow velocity, neuron-specific enolase (NSE) concentrations in plasma samples, and cerebral function monitoring (CFM) recordings were evaluated. Results: Twenty-seven infants were allocated to the fentanyl group and 26 to the control group. The fentanyl group had significantly lower PIPP scores than did the control group at 12, 24, 48, and 72 h after the start of infusion (all p < .05). No significant changes in hemodynamic parameters were observed during the observation period using transcranial Doppler flow measurements (p > .05). The fentanyl group had lower NSE levels and higher total CFM scores compared with the control group (both p < .05). Conclusion: In very preterm infants on mechanical ventilation, continuous fentanyl infusion might protect the developing brain by relieving pain during the first 72 h of mechanical ventilation.

Effect of Atropine With Propofol vs Atropine With Atracurium and Sufentanil on Oxygen Desaturation in Neonates Requiring Nonemergency Intubation: A Randomized Clinical Trial

IMPORTANCE

Propofol or a combination of a synthetic opioid and muscle relaxant are both recommended for premedication before neonatal intubation but have yet to be compared.

OBJECTIVE

To compare prolonged desaturation during neonatal nasotracheal intubation after premedication with atropine-propofol vs atropine-atracurium-sufentanil treatment.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, double-blind, randomized clinical trial (2012-2016) in 6 NICUs in France that included 173 neonates requiring nonemergency intubation. The study was interrupted due to expired study kits and lack of funding.

INTERVENTIONS

Eighty-nine participants were randomly assigned to the atropine-propofol group and 82 to the atropine-atracurium-sufentanil group before nasotracheal intubation.

MAIN OUTCOMES AND MEASURES

The primary outcome was prolonged desaturation (Spo2 <80% lasting > 60 seconds), using intention-to-treat analysis using mixed models. Secondary outcomes assessed the characteristics of the procedure and its tolerance.

RESULTS

Of 173 neonates randomized (mean gestational age, 30.6 weeks; mean birth weight, 1502 g; 71 girls), 171 (99%) completed the trial. Of 89 infants, 53 (59.6%) in the atropine-propofol group vs 54 of 82 (65.9%) in the atropine-atracurium-sufentanil group achieved the primary outcome (adjusted RD, -6.4; 95% CI, -21.0 to 8.1; P = .38). The atropine-propofol group had a longer mean procedure duration than did the atropine-atracurium-sufentanil group (adjusted RD, 1.7 minutes; 95% CI, 0.1-3.3 minutes; P = .04); a less frequent excellent quality of sedation rate, 51.7% (45 of 87) vs 92.6% (75 of 81; P < .001); a shorter median time to respiratory recovery, 14 minutes (IQR, 8-34 minutes) vs 33 minutes (IQR, 15-56 minutes; P = .002), and shorter median time to limb movement recovery, 18 minutes (IQR, 10-43 minutes) vs 36 minutes (IQR, 19-65 minutes; P = .003). In the 60 minutes after inclusion, Spo2 was preserved significantly better in the atropine-propofol group (time × treatment interaction P  = .02). Of the atropine-propofol group 20.6% had head ultrasound scans that showed worsening intracranial hemorrhaging (any or increased intraventricular hemorrhage) in the 7 days after randomization vs 17.6% in the atropine-atracurium-sufentanil group (adjusted RD, 1.2; 95% CI, -13.1 to 15.5, P = .87). Severe adverse events occurred in 11% of the atropine-propofol group and in 20% of the atropine-atracurium-sufentanil group.

CONCLUSIONS AND RELEVANCE

Among neonates undergoing nonemergency nasotracheal intubation, the frequency of prolonged desaturation did not differ significantly between atropine used with propofol or atropine used with atracurium and sufentanil. However, the study may have been underpowered to detect a clinically important difference, and further research may be warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01490580, EudraCT number: 2009-014885-25.

Correction to: Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R ² = 0.71, B _max 876 mL/min, K ₅₀ 16.3 kg) and alfentanil (R ² = 0.70, B _{max (fixed)} 420 mL/min, K ₅₀ 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R ² = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R ² = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.

Heroin uncertainties: Exploring users' perceptions of fentanyl-adulterated and -substituted 'heroin'

BACKGROUND

The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use.

METHODS

A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin.

RESULTS

(1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports.

CONCLUSION

Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.

Neonatal pain management

Pain management in the neonatal ICU remains challenging for many clinicians and in many complex care circumstances. The authors review general pain management principles and address the use of pain scales, non-pharmacologic management, and various agents that may be useful in general neonatal practice, procedurally, or at the end of life. Chronic pain and neonatal abstinence are also noted.

Use of naloxone to minimize extubation failure after premedication for INSURE procedure in preterm neonates

OBJECTIVES

A new guideline for the early respiratory management of preterm infants that included early nCPAP and INSURE was recently introduced in our NICU. This case series describes the clinical courses of a group of preterm infants managed according to this guideline, and reports the rates of successful extubation within 30 minutes of surfactant administration with and without the use of naloxone and adverse events encountered.

STUDY DESIGN

Descriptive case series of all preterm babies admitted to our unit who were candidates for INSURE procedure with premedication from August 2012 to August 2013.

RESULTS

A total of 31 infants were included with a mean birth weight of 1178 grams and a mean gestational age of 28.4 weeks. Twelve out of thirteen (92%) infants in the naloxone group were extubated within 30 minutes of surfactant administration while only 12/18 (67%) in the non-naloxone group were extubated within the same time frame. No adverse reactions were noted with naloxone usage in this context.

CONCLUSION

Naloxone can be effective in reversing the respiratory depressive effect of analgesic premedication and in turn facilitates expeditious extubation in some preterm infants intubated for INSURE procedure.

Effects of anaesthesia techniques and drugs on pulmonary function

The primary task of the lungs is to maintain oxygenation of the blood and eliminate carbon dioxide through the network of capillaries alongside alveoli. This is maintained by utilising ventilatory reserve capacity and by changes in lung mechanics. Induction of anaesthesia impairs pulmonary functions by the loss of consciousness, depression of reflexes, changes in rib cage and haemodynamics. All drugs used during anaesthesia, including inhalational agents, affect pulmonary functions directly by acting on respiratory system or indirectly through their actions on other systems. Volatile anaesthetic agents have more pronounced effects on pulmonary functions compared to intravenous induction agents, leading to hypercarbia and hypoxia. The posture of the patient also leads to major changes in pulmonary functions. Anticholinergics and neuromuscular blocking agents have little effect. Analgesics and sedatives in combination with volatile anaesthetics and induction agents may exacerbate their effects. Since multiple agents are used during anaesthesia, ultimate effect may be different from when used in isolation. Literature search was done using MeSH key words ‘anesthesia’, ‘pulmonary function’, ‘respiratory system’ and ‘anesthesia drugs and lungs’ in combination in PubMed, Science Direct and Google Scholar filtered by review and research articles sorted by relevance.

Sedation methods for intra-articular corticosteroid injections in Juvenile Idiopathic Arthritis: a review

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. Intra-articular corticosteroid injection (IASI), one of the cornerstones of treatment for this disease, is usually associated with anxiety and pain. IASI in JIA may be performed under general anesthesia, conscious sedation, or local anesthesia alone. Currently, there is no widely accepted standard of care regarding the sedation method for IASI. This review discusses the different methods of anesthesia and sedation in this procedure, emphasizing the advantages and shortcomings of each method.

Clinical pharmacology of fentanyl in preterm infants. A review

Fentanyl is a synthetic opioid that is very important in anesthetic practice because of its relatively short time to peak analgesic effect and the rapid termination of action after small bolus doses. The objective of this survey is to review the clinical pharmacology of fentanyl in preterm infants. The bibliographic search was performed using PubMed and EMBASE databases as search engines. In addition, the books Neofax: A manual of drugs used in neonatal care and Neonatal formulary were consulted. Fentanyl is N-dealkylated by CYP3A4 into the inactive norfentanyl. Fentanyl may be administered as bolus doses or as a continuous infusion. In neonates, there is a remarkable interindividual variability in the kinetic parameters. In neonates, fentanyl half-life ranges from 317 minutes to 1266 minutes and in adults it is 222 minutes. Respiratory depression occurs when fentanyl doses are >5 μg/kg. Chest wall rigidity may occur in neonates and occasionally is associated with laryngospasm. Tolerance to fentanyl may develop after prolonged use of this drug. Significant withdrawal symptoms have been reported in infants treated with continuous infusion for 5 days or longer. Fentanyl is an extremely potent analgesic and is the opioid analgesic most frequently used in the neonatal intensive care unit.

Pain management in newborns

As a standard of care for preterm/term newborns effective pain management may improve their clinical and neurodevelopmental outcomes. Neonatal pain is assessed using context-specific, validated, and objective pain methods, despite the limitations of currently available tools. Therapeutic approaches reducing invasive procedures and using pharmacologic, behavioral, or environmental measures are used to manage neonatal pain. Nonpharmacologic approaches like kangaroo care, facilitated tucking, non-nutritive sucking, sucrose, and others can be used for procedural pain or adjunctive therapy. Local/topical anesthetics, opioids, NSAIDs/acetaminophen and other sedative/anesthetic agents can be incorporated into NICU protocols for managing moderate/severe pain or distress in all newborns.

Treatment of tetralogy of Fallot hypoxic spell with intranasal fentanyl

We present the case of a 3-month-old girl who had unrepaired Tetralogy of Fallot who presented to the emergency department with an acute hypoxic episode. The patient was hyperpneic and cyanotic, with an initial oxygen saturation of 56%. She did not respond to knee-to-chest positioning. A single dose of intranasal fentanyl was administered with subsequent resolution of her symptoms and improvement of her oxygen saturation to 78% within 10 minutes. To our knowledge, this is the first report of the successful treatment of a hypoxic episode of Tetralogy of Fallot using intranasal fentanyl.

Evaluation of fentanyl disposition and effects in newborn piglets as an experimental model for human neonates

Background

Fentanyl is widely used off-label in NICU. Our aim was to investigate its cerebral, cardiovascular and pulmonary effects as well as pharmacokinetics in an experimental model for neonates.

Methods

Fentanyl (5 µg/kg bolus immediately followed by a 90 minute infusion of 3 µg/kg/h) was administered to six mechanically ventilated newborn piglets. Cardiovascular, ventilation, pulmonary and oxygenation indexes as well as brain activity were monitored from T = 0 up to the end of experiments (T = 225–300 min). Also plasma samples for quantification of fentanyl were drawn.

Results

A “reliable degree of sedation” was observed up to T = 210–240 min, consistent with the selected dosing regimen and the observed fentanyl plasma levels. Unlike cardiovascular parameters, which were unmodified except for an increasing trend in heart rate, some of the ventilation and oxygenation indexes as well as brain activity were significantly altered. The pulmonary and brain effects of fentanyl were mostly recovered from T = 210 min to the end of experiment.

Conclusion

The newborn piglet was shown to be a suitable experimental model for studying fentanyl disposition as well as respiratory and cardiovascular effects in human neonates. Therefore, it could be extremely useful for further investigating the drug behaviour under pathophysiological conditions.

Sedation and analgesia in critically ill children

The interplay of pain, discomfort, and fear can cause agitation in critically ill children. Therefore, sedation and analgesia are essential components in the intensive care unit setting and are best managed with a multidisciplinary team approach. No one standard approach exists to assess and manage pain and anxiety. Many tools are available for the assessment of pain and sedation, but each tool has its advantages and disadvantages. Clinicians should consider adopting a validated tool for routine continuous assessment. Multiple pharmacological therapies are available to manage pain, anxiety, fear, and agitation. Dosing of these agents can be influenced by age-related pharmacokinetic and pharmacodynamic changes. Agents should be selected on the basis of the child's disease state, desired level of sedation, and cardiac and respiratory status.

Efficacy and safety of continuous infusion of fentanyl for pain control in preterm newborns on mechanical ventilation

OBJECTIVE

To evaluate the analgesic superiority and the safety equivalence of continuous fentanyl infusions versus fentanyl boluses in preterm infants on mechanical ventilation.

STUDY DESIGN

In this multicenter, double-blind, randomized controlled trial, mechanically ventilated newborns (≤ 32(+6) weeks gestational age) were randomized to fentanyl (continuous infusion of fentanyl plus open-label boluses of fentanyl) or placebo (continuous infusion of placebo plus open-label boluses of fentanyl). The primary endpoint was analgesic efficacy, as evaluated by the Echelle Douleur Inconfort Nouveau-Né (EDIN) and Premature Infant Pain Profile scales. Safety variables were evaluated as well.

RESULTS

Sixty-four infants were allocated to the fentanyl group, and 67 were allocated to the placebo group. The need for open-label boluses of fentanyl was similar in the 2 groups (P = .949). EDIN scores were comparable in the 2 groups; 65 of 961 (6.8%) EDIN scores were >6 in the fentanyl group and 91 of 857 (10.6%) in the placebo group (P = .003). The median Premature Infant Pain Profile score was clinically and statistically higher in the placebo group compared with the fentanyl group on days 1, 2, and 3 of treatment (P < .05). Mechanical ventilation at age 1 week was required in 27 of 64 infants in the fentanyl group (42.2%), compared with 17 of 67 infants in the placebo group (25.4%) (P = .042). The first cycle of mechanical ventilation was longer and the first meconium passage occurred later in the fentanyl group (P = .019 and .027, respectively).

CONCLUSION

In very preterm infants on mechanical ventilation, continuous fentanyl infusion plus open-label boluses of fentanyl does not reduce prolonged pain, but does reduce acute pain and increase side effects compared with open-label boluses of fentanyl alone.

Fentanyl-induced chest wall rigidity

Fentanyl and other opiates used in procedural sedation and analgesia are associated with several well-known complications. We report the case of a man who developed the uncommon complication of chest wall rigidity and ineffective spontaneous ventilation following the administration of fentanyl during an elective bronchoscopy. His ventilation was assisted and the condition was reversed with naloxone. Although this complication is better described in pediatric patients and with anesthetic doses, chest wall rigidity can occur with analgesic doses of fentanyl and related compounds. Management includes ventilatory support and reversal with either naloxone or a short-acting neuromuscular blocking agent. This reaction does not appear to be a contraindication to future use of fentanyl or related compounds. Chest wall rigidity causing respiratory compromise should be readily recognized and treated by bronchoscopists.

Evidence-based comfort care for neonates towards the end of life

The provision of care to the newborn or young infant at the end of life is primarily motivated by concern and compassion. When examining the evidence base for most interventions, it is lacking - but this is not unique to this aspect of neonatal care. Nevertheless, a redirection of care from cure-oriented and life-extending measures to comfort and limitations of life-sustaining technologic interventions requires the neonatologist to apply practical knowledge skillfully and with prudence. Clinicians can acknowledge that patient needs require managing their end-of-life symptoms now; neither these patients nor their families should have to wait for research to catch up to their current needs.

Sedation and analgesia in mechanically ventilated preterm neonates: continue standard of care or experiment?

Attention to comfort and pain control are essential components of neonatal intensive care. Preterm neonates are uniquely susceptible to pain and agitation, and these exposures have a negative impact on brain development. In preterm neonates, chronic pain and agitation are common adverse effects of mechanical ventilation, and opiates or benzodiazepines are the pharmacologic agents most often used for treatment. Questions remain regarding the efficacy, safety, and neurodevelopmental impact of these therapies. Both preclinical and clinical data suggest troubling adverse drug reactions and the potential for adverse longterm neurodevelopmental impact. The negative impacts of standard pharmacologic agents suggest that alternative agents should be investigated. Dexmedetomidine is a promising alternative therapy that requires further interprofessional and multidisciplinary research in this population.

Procedural sedation: A review of sedative agents, monitoring, and management of complications

Given the continued increase in the complexity of invasive and noninvasive procedures, healthcare practitioners are faced with a larger number of patients requiring procedural sedation. Effective sedation and analgesia during procedures not only provides relief of suffering, but also frequently facilitates the successful and timely completion of the procedure. However, any of the agents used for sedation and/or analgesia may result in adverse effects. These adverse effects most often affect upper airway patency, ventilatory function or the cardiovascular system. This manuscript reviews the pharmacology of the most commonly used agents for sedation and outlines their primary effects on respiratory and cardiovascular function. Suggested guidelines for the avoidance of adverse effects through appropriate pre-sedation evaluation, early identification of changes in respiratory and cardiovascular function, and their treatment are outlined.

Intranasal Fentanyl for Breakthrough Pain Control

Breakthrough pain (BTP) is experienced by approximately 65% of children and adults with chronic pain. Undiagnosed or untreated BTP produces negative emotional, physical, and economic consequences. BTP episodes have a rapid onset and short duration. Short acting oral opioids are the cornerstone of BTP management. Oral medications available to treat BTP episodes like immediate-release morphine or oxycodone have a delayed onset of action so that there is a mismatch between the episode of BTP and the effect of the oral opioids. Novel fentanyl delivery systems for BTP offer pharmacokinetic properties that match the time profile of BTP. Among the transmucosal routes, intranasal fentanyl has gained popularity due to its high bioavailability, rapid onset of action, high potency, short duration, and ease of administration. Its efficacy and safety have been demonstrated in adults who are opioid tolerant. Although children with chronic cancer pain also experience BTP, there is paucity of data on the use of intranasal fentanyl for BTP in this age group.