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Neches SK, DeMartino C, Shay R. Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication. Neoreviews 2023; 24:e783-e796. [PMID: 38036442 DOI: 10.1542/neo.24-12-e783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.
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Affiliation(s)
- Sara K Neches
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Cassandra DeMartino
- Department of Pediatrics, Division of Neonatology, Yale New Haven Hospital, New Haven, CT
| | - Rebecca Shay
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine and Children's Hospital of Colorado, Denver, CO
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Pessano S, Romantsik O, Olsson E, Hedayati E, Bruschettini M. Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants. Cochrane Database Syst Rev 2023; 9:CD015594. [PMID: 37767875 PMCID: PMC10535798 DOI: 10.1002/14651858.cd015594.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Lumbar puncture (LP) is a common invasive procedure, most frequently performed to diagnose infection. Physicians perform LP in newborn infants with the help of an assistant using a strict aseptic technique; it is important to monitor the infant during all the steps of the procedure. Without adequate analgesia, LP can cause considerable pain and discomfort. As newborns have increased sensitivity to pain, it is crucial to adequately manage the procedural pain of LP in this population. OBJECTIVES To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non-pharmacological interventions, or other pharmacological interventions. SEARCH METHODS We searched CENTRAL, PubMed, Embase, and three trial registries in December 2022. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs comparing drugs used for pain management, sedation, or both, during LP. We considered the following drugs suitable for inclusion. • Topical anesthetics (e.g. eutectic mixture of local anesthetics [EMLA], lidocaine) • Opioids (e.g. morphine, fentanyl) • Alpha-2 agonists (e.g. clonidine, dexmedetomidine) • N-Methyl-D-aspartate (NMDA) receptor antagonists (e.g. ketamine) • Other analgesics (e.g. paracetamol) • Sedatives (e.g. benzodiazepines such as midazolam) DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) or standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). Our main outcomes were successful LP on first attempt, total number of LP attempts, episodes of bradycardia, pain assessed with validated scales, episodes of desaturation, number of episodes of apnea, and number of infants with one or more episodes of apnea. We used the GRADE approach to evaluate the certainty of the evidence. MAIN RESULTS We included three studies (two RCTs and one quasi-RCT) that enrolled 206 newborns. One study included only term infants. All studies assessed topical treatment versus placebo or no intervention. The topical anesthetics were lidocaine 4%, lidocaine 1%, and EMLA. We identified no completed studies on opioids, non-steroidal anti-inflammatory drugs, alpha-2 agonists, NMDA receptor antagonists, other analgesics, sedatives, or head-to-head comparisons (drug A versus drug B). Based on very low-certainty evidence from one quasi-RCT of 100 LPs in 76 infants, we are unsure if topical anesthetics (lidocaine), compared to no anesthesia, has an effect on the following outcomes. • Successful LP on first attempt (first-attempts success in 48% of LPs in the lidocaine group and 42% of LPs in the control group) • Number of attempts per LP (mean 1.9 attempts, [standard error of the mean 0.2] in the lidocaine group, and mean 2.1 attempts [standard error of the mean 2.1] in the control group) • Episodes of bradycardia (0% of LPs in the lidocaine group and 4% of LPs in the control group) • Episodes of desaturation (0% of LPs in the lidocaine group and 8% of LPs in the control group) • Occurrence of apnea (RR 3.24, 95% CI 0.14 to 77.79; risk difference [RD] 0.02, 95% CI -0.03 to 0.08). Topical anesthetics compared to placebo may reduce pain assessed with the Neonatal Facial Coding System (NFCS) score (SMD -1.00 standard deviation (SD), 95% CI -1.47 to -0.53; I² = 98%; 2 RCTs, 112 infants; low-certainty evidence). No studies in this comparison reported total number of episodes of apnea. We identified three ongoing studies, which will assess the effects of EMLA, lidocaine, and fentanyl. Three studies are awaiting classification. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effect of topical anesthetics (lidocaine) compared to no anesthesia on successful lumbar puncture on first attempt, the number of attempts per lumbar puncture, episodes of bradycardia, episodes of desaturation, and occurrence of apnea. Compared to placebo, topical anesthetics (lidocaine or EMLA) may reduce pain assessed with the NFCS score. One ongoing study will assess the effects of systemic treatment.
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Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Olga Romantsik
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Ehsan Hedayati
- Nezam Mafi Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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Stróżyk A, Paraskevas T, Romantsik O, Calevo MG, Banzi R, Ley D, Bruschettini M. Pharmacological pain and sedation interventions for the prevention of intraventricular hemorrhage in preterm infants on assisted ventilation - an overview of systematic reviews. Cochrane Database Syst Rev 2023; 8:CD012706. [PMID: 37565681 PMCID: PMC10421735 DOI: 10.1002/14651858.cd012706.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND Germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH) may contribute to neonatal morbidity and mortality and result in long-term neurodevelopmental sequelae. Appropriate pain and sedation management in ventilated preterm infants may decrease the risk of GMH-IVH; however, it might be associated with harms. OBJECTIVES To summarize the evidence from systematic reviews regarding the effects and safety of pharmacological interventions related to pain and sedation management in order to prevent GMH-IVH in ventilated preterm infants. METHODS We searched the Cochrane Library August 2022 for reviews on pharmacological interventions for pain and sedation management to prevent GMH-IVH in ventilated preterm infants (< 37 weeks' gestation). We included Cochrane Reviews assessing the following interventions administered within the first week of life: benzodiazepines, paracetamol, opioids, ibuprofen, anesthetics, barbiturates, and antiadrenergics. Primary outcomes were any GMH-IVH (aGMH-IVH), severe IVH (sIVH), all-cause neonatal death (ACND), and major neurodevelopmental disability (MND). We assessed the methodological quality of included reviews using the AMSTAR-2 tool. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included seven Cochrane Reviews and one Cochrane Review protocol. The reviews on clonidine and paracetamol did not include randomized controlled trials (RCTs) matching our inclusion criteria. We included 40 RCTs (3791 infants) from reviews on paracetamol for patent ductus arteriosus (3), midazolam (3), phenobarbital (9), opioids (20), and ibuprofen (5). The quality of the included reviews was high. The certainty of the evidence was moderate to very low, because of serious imprecision and study limitations. Germinal matrix hemorrhage-intraventricular hemorrhage (any grade) Compared to placebo or no intervention, the evidence is very uncertain about the effects of paracetamol on aGMH-IVH (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.38 to 2.07; 2 RCTs, 82 infants; very low-certainty evidence); midazolam may result in little to no difference in the incidence of aGMH-IVH (RR 1.68, 95% CI 0.87 to 3.24; 3 RCTs, 122 infants; low-certainty evidence); the evidence is very uncertain about the effect of phenobarbital on aGMH-IVH (RR 0.99, 95% CI 0.83 to 1.19; 9 RCTs, 732 infants; very low-certainty evidence); opioids may result in little to no difference in aGMH-IVH (RR 0.85, 95% CI 0.65 to 1.12; 7 RCTs, 469 infants; low-certainty evidence); ibuprofen likely results in little to no difference in aGMH-IVH (RR 0.99, 95% CI 0.81 to 1.21; 4 RCTs, 759 infants; moderate-certainty evidence). Compared to ibuprofen, the evidence is very uncertain about the effects of paracetamol on aGMH-IVH (RR 1.17, 95% CI 0.31 to 4.34; 1 RCT, 30 infants; very low-certainty evidence). Compared to midazolam, morphine may result in a reduction in aGMH-IVH (RR 0.28, 95% CI 0.09 to 0.87; 1 RCT, 46 infants; low-certainty evidence). Compared to diamorphine, the evidence is very uncertain about the effect of morphine on aGMH-IVH (RR 0.65, 95% CI 0.40 to 1.07; 1 RCT, 88 infants; very low-certainty evidence). Severe intraventricular hemorrhage (grade 3 to 4) Compared to placebo or no intervention, the evidence is very uncertain about the effect of paracetamol on sIVH (RR 1.80, 95% CI 0.43 to 7.49; 2 RCTs, 82 infants; very low-certainty evidence) and of phenobarbital (grade 3 to 4) (RR 0.91, 95% CI 0.66 to 1.25; 9 RCTs, 732 infants; very low-certainty evidence); opioids may result in little to no difference in sIVH (grade 3 to 4) (RR 0.98, 95% CI 0.71 to 1.34; 6 RCTs, 1299 infants; low-certainty evidence); ibuprofen may result in little to no difference in sIVH (grade 3 to 4) (RR 0.82, 95% CI 0.54 to 1.26; 4 RCTs, 747 infants; low-certainty evidence). No studies on midazolam reported this outcome. Compared to ibuprofen, the evidence is very uncertain about the effects of paracetamol on sIVH (RR 2.65, 95% CI 0.12 to 60.21; 1 RCT, 30 infants; very low-certainty evidence). Compared to midazolam, the evidence is very uncertain about the effect of morphine on sIVH (grade 3 to 4) (RR 0.08, 95% CI 0.00 to 1.43; 1 RCT, 46 infants; very low-certainty evidence). Compared to fentanyl, the evidence is very uncertain about the effect of morphine on sIVH (grade 3 to 4) (RR 0.59, 95% CI 0.18 to 1.95; 1 RCT, 163 infants; very low-certainty evidence). All-cause neonatal death Compared to placebo or no intervention, the evidence is very uncertain about the effect of phenobarbital on ACND (RR 0.94, 95% CI 0.51 to 1.72; 3 RCTs, 203 infants; very low-certainty evidence); opioids likely result in little to no difference in ACND (RR 1.12, 95% CI 0.80 to 1.55; 5 RCTs, 1189 infants; moderate-certainty evidence); the evidence is very uncertain about the effect of ibuprofen on ACND (RR 1.00, 95% CI 0.38 to 2.64; 2 RCTs, 112 infants; very low-certainty evidence). Compared to midazolam, the evidence is very uncertain about the effect of morphine on ACND (RR 0.31, 95% CI 0.01 to 7.16; 1 RCT, 46 infants; very low-certainty evidence). Compared to diamorphine, the evidence is very uncertain about the effect of morphine on ACND (RR 1.17, 95% CI 0.43 to 3.19; 1 RCT, 88 infants; very low-certainty evidence). Major neurodevelopmental disability Compared to placebo, the evidence is very uncertain about the effect of opioids on MND at 18 to 24 months (RR 2.00, 95% CI 0.39 to 10.29; 1 RCT, 78 infants; very low-certainty evidence) and at five to six years (RR 1.6, 95% CI 0.56 to 4.56; 1 RCT, 95 infants; very low-certainty evidence). No studies on other drugs reported this outcome. AUTHORS' CONCLUSIONS None of the reported studies had an impact on aGMH-IVH, sIVH, ACND, or MND. The certainty of the evidence ranged from moderate to very low. Large RCTs of rigorous methodology are needed to achieve an optimal information size to assess the effects of pharmacological interventions for pain and sedation management for the prevention of GMH-IVH and mortality in preterm infants. Studies might compare interventions against either placebo or other drugs. Reporting of the outcome data should include the assessment of GMH-IVH and long-term neurodevelopment.
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Affiliation(s)
- Agata Stróżyk
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Olga Romantsik
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, Scientific Directorate, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Rita Banzi
- Center for Health Regulatory Policies, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy
| | - David Ley
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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Vesselinova IV, Jensen KN, Hansen TG. Propofol and thiopental for intravenous induction in neonates: Study protocol for a dose-finding trial. Acta Anaesthesiol Scand 2023; 67:820-828. [PMID: 36919345 DOI: 10.1111/aas.14238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Propofol and thiopental are commonly used induction agents in neonatal anesthesia. Even though both hypnotics have been used off-label for many years, pharmacological knowledge regarding these agents is scarce in neonates. The significant variability in neonates' body composition, organ function, and maturation makes pharmacological studies highly relevant albeit challenging. As a result, there is currently limited data about the anesthetic induction dose of thiopental and propofol in neonates. In addition, a knowledge gap exists concerning the pharmacodynamics of induction doses. OBJECTIVE To determine the median effective anesthetic induction dose of propofol and thiopental in neonatal patients of different gestational and postnatal ages and evaluate the pharmacodynamics of the anesthesia induction doses on the neonatal systemic and cerebral hemodynamics. METHODS This is a single-center, prospective, open-label, interventional, dose-finding study, including neonatal patients from birth up to 28 postnatal days undergoing general anesthesia for surgical or diagnostic procedures. The patients will be stratified according to their gestational and postnatal age and allocated to one of the two trial arms: anesthesia induction with propofol or anesthesia induction with thiopental. We will use Dixon's up-and-down method to estimate the median effective anesthesia induction dose of both agents in neonates of different gestational and postnatal ages. In addition, we will study the relationship between anesthesia induction doses and changes in systemic and cerebral hemodynamics. DISCUSSION Alterations in the systemic and cerebral regional hemodynamics secondary to anesthesia induction may be harmful in neonates, especially premature and critically ill newborns, due to their immature organ systems, reduced physiological reserves, and impaired cerebral autoregulation. Perfusion homeostasis is considered one of the significant and modifiable determinants of anesthesia-related neurocognitive outcomes. Therefore, dose-finding and safety pharmacological studies of the anesthetic induction agents in neonates are urgently needed and acknowledged as a high priority by the European Medicine Agency. Estimating adequate induction doses to ensure optimal depth of anesthesia while avoiding systemic and cerebral hemodynamic disturbances will help ensure safe anesthesia and potentially improve anesthesia-related outcomes in this group of patients. TRIAL REGISTRATION EudraCT (EudraCT Identifier: 2019-001534-34), 05.07.2022.
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Affiliation(s)
| | - Kristian Nørholm Jensen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Tom Giedsing Hansen
- Department of Anesthesiology and Intensive Care, Akershus University Hospital, Lørenskog, Norway, and Oslo University, Oslo, Norway
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5
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Pessano S, Romantsik O, Hedayati E, Olsson E, Bruschettini M. Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015594. [PMCID: PMC9749080 DOI: 10.1002/14651858.cd015594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non‐pharmacological interventions, or other pharmacological interventions.
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Affiliation(s)
| | - Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and ChildIRCCS Istituto Giannina GasliniGenoaItaly
| | - Olga Romantsik
- Department of Clinical Sciences Lund, PaediatricsLund University, Skåne University HospitalLundSweden
| | - Ehsan Hedayati
- Nezam Mafi HospitalAhvaz Jundishapur University of Medical SciencesAhvazIran
| | | | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University HospitalLundSweden,Cochrane Sweden, Lund University, Skåne University HospitalLundSweden
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Disma N, Engelhardt T, Hansen TG, de Graaff JC, Virag K, Habre W. Neonates undergoing pyloric stenosis repair are at increased risk of difficult airway management: secondary analysis of the NEonate and Children audiT of Anaesthesia pRactice IN Europe. Br J Anaesth 2022; 129:734-739. [PMID: 36085092 DOI: 10.1016/j.bja.2022.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hypertrophic pyloric stenosis in otherwise healthy neonates frequently requires urgent surgical procedure but anaesthesia care may result in respiratory complications, such as hypoxaemia, pulmonary aspiration of gastric contents, and postoperative apnoea. The primary aim was to study whether or not the incidence of difficult airway management and of hypoxaemia in neonates undergoing pyloric stenosis repair was higher than that in neonates undergoing other surgeries. METHODS Data on neonates and infants undergoing anaesthesia and surgery for pyloric stenosis were extracted from the NEonate and Children audiT of Anesthesia pRactice In Europe (NECTARINE) database, for secondary analysis. RESULTS We identified 310 infants who had anaesthesia for surgery for pyloric stenosis. Difficult airway management (more than two attempts at laryngoscopy) was higher in children with pyloric stenosis when compared with the entire NECTARINE cohort (7.9% [95% confidence interval {CI}, 5.22-11.53] vs 4.4% [95% CI, 1.99-6.58]; relative risk [RR]=1.81 [95% CI, 1.21-2.69]; P=0.004), whereas transient hypoxaemia with oxygen saturation <90% was comparable between the two cohorts. Postoperative complications occurred in 16 children (5.6%) within the 30-day follow-up. No mortality was reported at 30 and 90 days. CONCLUSIONS Children undergoing surgery for pyloric stenosis had a higher incidence of difficult intubation compared with the entire NECTARINE cohort. CLINICAL TRIAL REGISTRATION NCT02350348.
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Affiliation(s)
- Nicola Disma
- Unit for Research and Innovation, Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy.
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, Canada
| | - Tom G Hansen
- Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Centre, Rotterdam, the Netherlands
| | - Katalin Virag
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Unit for Anaesthesiological Research, University of Geneva, Geneva, Switzerland
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Unit for Anaesthesiological Research, University of Geneva, Geneva, Switzerland
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Shay R, Weikel BW, Grover T, Barry JS. Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes. J Perinatol 2022; 42:132-138. [PMID: 34584197 DOI: 10.1038/s41372-021-01215-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/26/2021] [Accepted: 09/10/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We sought to standardize and improve compliance with evidence-based premedication for non-emergent neonatal intubations in two academic-affiliated Neonatal Intensive Care Units. STUDY DESIGN A multidisciplinary team created guidelines and electronic medical record order sets for intubation. Compliance with recommended premedication, number of intubation attempts, and frequency of bradycardia and desaturation were assessed. RESULTS 387 intubation procedures were reviewed. Provision of recommended premedication increased by 36% and 75% at the level III and IV units, respectively. Decreased frequency of bradycardia during intubation (p = 0.0003) occurred in the level III unit. A reduction in number of intubation attempts (p ≤ 0.001), improvement in first-attempt intubation success (p ≤ 0.001), and decreased frequency of bradycardia (p = 0.01) and desaturation (p = 0.02) during intubation occurred in the level IV unit. CONCLUSIONS This quality improvement initiative improved standardized premedication compliance and decreased adverse events associated with non-emergent neonatal intubations in two separate units.
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Affiliation(s)
- Rebecca Shay
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA. .,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA.
| | - Blair W Weikel
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Theresa Grover
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - James S Barry
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
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Durrmeyer X, Walter-Nicolet E, Chollat C, Chabernaud JL, Barois J, Chary Tardy AC, Berenguer D, Bedu A, Zayat N, Roué JM, Beissel A, Bellanger C, Desenfants A, Boukhris R, Loose A, Massudom Tagny C, Chevallier M, Milesi C, Tauzin M. Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN). Front Pediatr 2022; 10:1075184. [PMID: 36683794 PMCID: PMC9846576 DOI: 10.3389/fped.2022.1075184] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/01/2022] [Indexed: 01/06/2023] Open
Abstract
CONTEXT Laryngoscopy is frequently required in neonatal intensive care. Awake laryngoscopy has deleterious effects but practice remains heterogeneous regarding premedication use. The goal of this statement was to provide evidence-based good practice guidance for clinicians regarding premedication before tracheal intubation, less invasive surfactant administration (LISA) and laryngeal mask insertion in neonates. METHODS A group of experts brought together by the French Society of Neonatology (SFN) addressed 4 fields related to premedication before upper airway access in neonates: (1) tracheal intubation; (2) less invasive surfactant administration; (3) laryngeal mask insertion; (4) use of atropine for the 3 previous procedures. Evidence was gathered and assessed on predefined questions related to these fields. Consensual statements were issued using the GRADE methodology. RESULTS Among the 15 formalized good practice statements, 2 were strong recommendations to do (Grade 1+) or not to do (Grade 1-), and 4 were discretionary recommendations to do (Grade 2+). For 9 good practice statements, the GRADE method could not be applied, resulting in an expert opinion. For tracheal intubation premedication was considered mandatory except for life-threatening situations (Grade 1+). Recommended premedications were a combination of opioid + muscle blocker (Grade 2+) or propofol in the absence of hemodynamic compromise or hypotension (Grade 2+) while the use of a sole opioid was discouraged (Grade 1-). Statements regarding other molecules before tracheal intubation were expert opinions. For LISA premedication was recommended (Grade 2+) with the use of propofol (Grade 2+). Statements regarding other molecules before LISA were expert opinions. For laryngeal mask insertion and atropine use, no specific data was found and expert opinions were provided. CONCLUSION This statement should help clinical decision regarding premedication before neonatal upper airway access and favor standardization of practices.
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Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, GRC CARMAS, Créteil, France
| | - Elizabeth Walter-Nicolet
- Neonatal Medicine and Intensive Care Unit, Saint Joseph Hospital, Paris, France.,University of Paris-Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Paris, France
| | - Clément Chollat
- Department of Neonatology, Hôpital Armand Trousseau, APHP, Sorbonne Université, Paris, France
| | - Jean-Louis Chabernaud
- Division of Neonatal and Pediatric Critical Care Transportation, Hôpital Antoine Beclere, AP-HP, Paris - Saclay University Hospital, Clamart, France
| | - Juliette Barois
- Department of Neonatology and Neonatal Intensive Care, CH de Valenciennes, Valenciennes, France
| | - Anne-Cécile Chary Tardy
- Department of Neonatology and Neonatal Intensive Care, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Daniel Berenguer
- Department of Pediatric Anesthesia and Pediatric Transport (SMUR Pédiatrique), Hôpital des Enfants, CHU de Bordeaux, Bordeaux, France
| | - Antoine Bedu
- Department of Neonatal Pediatrics and Intensive Care, Limoges University Hospital, Limoges, France
| | - Noura Zayat
- Department of Neonatal Intensive Care and Pediatric Transport, CHU de Nantes, Nantes, France
| | - Jean-Michel Roué
- Department of Pediatric and Neonatal Critical Care, Brest University Hospital, Brest, France
| | - Anne Beissel
- Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Claire Bellanger
- Department of Neonatology and Neonatal Intensive Care, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
| | - Aurélie Desenfants
- Department of Neonatology, CHU Nimes, Université Montpellier, Nimes, France
| | - Riadh Boukhris
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Loose
- Department of Neonatology, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | - Clarisse Massudom Tagny
- Department of Neonatology and Neonatal Intensive Care, Grand Hôpital de L'Est Francilien, Meaux, France
| | - Marie Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France.,TIMC-IMAG Research Department, Grenoble Alps University, Grenoble, France
| | - Christophe Milesi
- Department of Neonatal Medicine and Pediatric Intensive Care, Montpellier University Hospital, Université de Montpellier, Montpellier, France
| | - Manon Tauzin
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
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9
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Badr M, Goulard M, Theret B, Roubertie A, Badiou S, Pifre R, Bres V, Cambonie G. Fatal accidental lipid overdose with intravenous composite lipid emulsion in a premature newborn: a case report. BMC Pediatr 2021; 21:584. [PMID: 34930217 PMCID: PMC8686371 DOI: 10.1186/s12887-021-03064-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/08/2021] [Indexed: 01/30/2023] Open
Abstract
Background Tenfold or more overdose of a drug or preparation is a dreadful adverse event in neonatology, often due to an error in programming the infusion pump flow rate. Lipid overdose is exceptional in this context and has never been reported during the administration of a composite intravenous lipid emulsion (ILE). Case presentation Twenty-four hours after birth, a 30 weeks’ gestation infant with a birthweight of 930 g inadvertently received 28 ml of a composite ILE over 4 h. The ILE contained 50% medium-chain triglycerides and 50% soybean oil, corresponding to 6 g/kg of lipids (25 mg/kg/min). The patient developed acute respiratory distress with echocardiographic markers of pulmonary hypertension and was treated with inhaled nitric oxide and high-frequency oscillatory ventilation. Serum triglyceride level peaked at 51.4 g/L, 17 h after the lipid overload. Triple-volume exchange transfusion was performed twice, decreasing the triglyceride concentration to < 10 g/L. The infant’s condition remained critical, with persistent bleeding and shock despite supportive treatment and peritoneal dialysis. Death occurred 69 h after the overdose in a context of refractory lactic acidosis. Conclusions Massive ILE overdose is life-threatening in the early neonatal period, particularly in premature and hypotrophic infants. This case highlights the vigilance required when ILEs are administered separately from other parenteral intakes. Exchange transfusion should be considered at the first signs of clinical or biological worsening to avoid progression to multiple organ failure. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-03064-6.
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Affiliation(s)
- Maliha Badr
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Marion Goulard
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Bénédicte Theret
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Agathe Roubertie
- Department of Neuropaediatrics, Gui de Chauliac Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Stéphanie Badiou
- Department of Biochemistry and Hormonology, Lapeyronie Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Roselyne Pifre
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Virginie Bres
- Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Gilles Cambonie
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France. .,Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France.
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10
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Reynolds P, Bustani P, Darby C, Fernandez Alvarez JR, Fox G, Jones S, Robertson SJ, Vasu V, Roehr CC. Less-Invasive Surfactant Administration for Neonatal Respiratory Distress Syndrome: A Consensus Guideline. Neonatology 2021; 118:586-592. [PMID: 34515188 DOI: 10.1159/000518396] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/09/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Less-invasive surfactant administration (LISA) is a method of surfactant delivery to preterm infants for treating respiratory distress syndrome (RDS), which can reduce the composite risk of death or bronchopulmonary dysplasia and the time on mechanical ventilation. METHODS A systematic literature search of studies published up to April 2021 on minimally invasive catheter surfactant delivery in preterm infants with RDS was conducted. Based on these studies, with parental feedback sought via an online questionnaire, 9 UK-based specialists in neonatal respiratory disease developed their consensus for implementing LISA. Recommendations were developed following a modified, iterative Delphi process using a questionnaire employing a 9-point Likert scale and an a priori level of agreement/disagreement. RESULTS Successful implementation of LISA can be achieved by training the multidisciplinary team and following locally agreed guidance. From the time of the decision to administer surfactant, LISA should take <30 min. The comfort of the baby and requirements to maintain non-invasive respiratory support are important. While many infants can be managed without requiring additional sedation/analgesia, fentanyl along with atropine may be considered. Parents should be provided with sufficient information about medication side effects and involved in treatment discussions. CONCLUSION LISA has the potential to improve outcomes for preterm infants with RDS and can be introduced as a safe and effective part of UK-based neonatal care with appropriate training.
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Affiliation(s)
- Peter Reynolds
- Neonatal Intensive Care Unit, St. Peter's Hospital, Ashford & St. Peter's Hospitals NHS Foundation Trust, Chertsey, United Kingdom
| | - Porus Bustani
- Children's and Adolescent Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Colm Darby
- Neonatal Unit, Craigavon Area Hospital, Portadown, United Kingdom
| | | | - Grenville Fox
- Evelina London Children's Hospital Neonatal Unit, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Steve Jones
- Neonatology, Royal United Hospital, Bath, United Kingdom
| | - Sara Jane Robertson
- Neonatal Intensive Care Unit, St. Peter's Hospital, Ashford & St. Peter's Hospitals NHS Foundation Trust, Chertsey, United Kingdom
| | - Vimal Vasu
- Neonatal Medicine, East Kent Hospitals University NHS Foundation Trust, William Harvey Hospital, Ashford, United Kingdom
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Medical Sciences Division, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.,Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
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11
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Krajewski P, Szpecht D, Hożejowski R. Premedication practices for less invasive surfactant administration - results from a nationwide cohort study. J Matern Fetal Neonatal Med 2020; 35:4750-4754. [PMID: 33356691 DOI: 10.1080/14767058.2020.1863365] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS There are no established premedication schemes for less invasive surfactant administration (LISA) in neonatal RDS. The aim was to describe "real-world" practices and to assess the safety of premedication and its impact on the technical ease of the LISA procedure. METHODS Data from the prospective LISA cohort study conducted in 31 tertiary neonatal units were evaluated for premedication practices. Infants who received analgesics and/or sedatives before LISA and those receiving non-pharmacological sedation with sublingual 30% glucose were compared versus nonpremedicated neonates, acting as a reference. Safety of premedication was assessed with the rate of adverse events during LISA, changes in oxygenation status, the need for rescue intubation, and mechanical ventilation in the first 24 h of life. Ease of conducting LISA was an efficacy endpoint. RESULTS Of 500 enrolled newborns, 102 (20.4%) received premedication for LISA; 88 infants were given analgesics/sedatives and 14 sublingual glucose. Pharmacological sedation was most often performed with ketamine (51/88; 57.9%), midazolam (16/88; 18.2%) and propofol (8/88; 1.6%). Compared to non-premedication, the use of analgesics/sedatives was associated with a significant increase in the rate of apnea (9.1 vs 2.6%; p = 0.009) and a significantly higher decrease in SpO2/FiO2 (-55 ± 62 vs -32 ± 50; p < 0.001). However, the rates of rescue intubation and the need for early mechanical ventilation were not significantly different. Sedation with glucose did not affect the frequency of adverse events. LISA procedures had a similar level of ease regardless of the premedication used and were rated as easy or very easy in 69% of non-premedicated infants, 65.9% of the analgesics/sedatives group and 78.5% of the glucose group (p = ns). CONCLUSION Analgesics/sedatives prior to LISA increased the rate of apnea and decreased blood oxygenation but did not lead to tracheal intubation and early mechanical ventilation. Trials addressing the impact on LISA-related stress are necessary to determine the ultimate usefulness of premedication.
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Affiliation(s)
- Paweł Krajewski
- Department of Neonatology, University Center for Mother and Newborn's Health, Warsaw, Poland
| | - Dawid Szpecht
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
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12
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Kort EHM, Twisk JWR, t Verlaat EPG, Reiss IKM, Simons SHP, Weissenbruch MM. Propofol in neonates causes a dose-dependent profound and protracted decrease in blood pressure. Acta Paediatr 2020; 109:2539-2546. [PMID: 32248549 PMCID: PMC7754147 DOI: 10.1111/apa.15282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 12/01/2022]
Abstract
AIM To analyse the effects of different propofol starting doses as premedication for endotracheal intubation on blood pressure in neonates. METHODS Neonates who received propofol starting doses of 1.0 mg/kg (n = 30), 1.5 mg/kg (n = 23) or 2.0 mg/kg (n = 26) as part of a previously published dose-finding study were included in this analysis. Blood pressure in the 3 dosing groups was analysed in the first 60 minutes after start of propofol. RESULTS Blood pressure declined after the start of propofol in all 3 dosing groups and was not restored 60 minutes after the start of propofol. The decline in blood pressure was highest in the 2.0 mg/kg dosing group. Blood pressure decline was mainly dependent on the initial propofol starting dose rather than the cumulative propofol dose. CONCLUSION Propofol causes a dose-dependent profound and prolonged decrease in blood pressure. The use of propofol should be carefully considered. When using propofol, starting with a low dose and titrating according to sedative effect seems the safest strategy.
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Affiliation(s)
- Ellen H. M. Kort
- Division of Neonatology Department of Pediatrics Máxima Medical Center Veldhoven The Netherlands
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Jos W. R. Twisk
- Department of Epidemiology and Biostatistics Amsterdam UMC Location VU University Medical Center Amsterdam The Netherlands
| | - Ellen P. G. t Verlaat
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Irwin K. M. Reiss
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Sinno H. P. Simons
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Mirjam M. Weissenbruch
- Division of Neonatology Department of Pediatrics Amsterdam UMC Location VU University Medical Center Amsterdam The Netherlands
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13
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Introduction of less invasive surfactant administration (LISA), impact on diagnostic and therapeutic procedures in early life: a historical cohort study. BMC Pediatr 2020; 20:421. [PMID: 32883280 PMCID: PMC7470444 DOI: 10.1186/s12887-020-02325-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/27/2020] [Indexed: 11/21/2022] Open
Abstract
Background In preterm infants with Respiratory Distress Syndrome (RDS), Less Invasive Surfactant Administration (LISA) has been established to reduce the need of mechanical ventilation and might improve survival rates without bronchopulmonary dysplasia. The aim of this study was to investigate whether NICU care has changed after introduction of less invasive surfactant administration (LISA), with regard to diagnostic and therapeutic procedures in the first week of life. Methods Infants with gestational age < 32 weeks who received surfactant by LISA (June 2014 – December 2017, n = 169) were retrospectively compared to infants who received surfactant after intubation (January 2012 – May 2014, n = 155). Local protocols on indication for surfactant, early onset sepsis, blood transfusions and enteral feeding did not change between both study periods. Besides, as secondary outcome complications of prematurity were compared. Data was collected from electronic patient files and compared by univariate analysis through Students T-test, Mann Whitney-U test, Pearson Chi-Square test or Linear by Linear Association. Results All baseline characteristics of both groups were comparable. Compared to controls, LISA patients received a higher total surfactant dose (208 vs.160 mg/kg; p < 0.001), required redosing more frequently (32.5% vs. 21.3%; p = 0.023), but needed less mechanical ventilation (35.5% vs. 76.8%; p < 0.001). After LISA, infants underwent fewer X-rays (1.0 vs. 3.0, p < 0.001), blood gas examinations (3.0 vs. 5.0, p < 0.001), less inotropic drugs (9.5% vs. 18.1%; p = 0.024), blood transfusions (24.9% vs. 41.9%, p = 0.003) and had shorter duration of antibiotic therapy for suspected early onset sepsis (3.0 vs. 5.0 days, p < 0.001). Moreover, enteral feeding was advanced faster (120 vs. 100 mL/kg/d, p = 0.048) at day seven. There were no differences in complications of prematurity. Conclusion The introduction of LISA is associated with significantly fewer diagnostic and therapeutic procedures in the first week of life, which emphasizes the beneficial effects of LISA.
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14
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de Kort EH, Prins SA, Reiss IK, Willemsen SP, Andriessen P, van Weissenbruch MM, Simons SH. Propofol for endotracheal intubation in neonates: a dose-finding trial. Arch Dis Child Fetal Neonatal Ed 2020; 105:489-495. [PMID: 31932363 PMCID: PMC7547906 DOI: 10.1136/archdischild-2019-318474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/21/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To find propofol doses providing effective sedation without side effects in neonates of different gestational ages (GA) and postnatal ages (PNA). DESIGN AND SETTING Prospective multicentere dose-finding study in 3 neonatal intensive care units. PATIENTS Neonates with a PNA <28 days requiring non-emergency endotracheal intubation. INTERVENTIONS Neonates were stratified into 8 groups based on GA and PNA. The first 5 neonates in every group received a dose of 1.0 mg/kg propofol. Based on sedative effect and side effects, the dose was increased or decreased in the next 5 patients until the optimal dose was found. MAIN OUTCOME MEASURES The primary outcome was the optimal single propofol starting dose that provides effective sedation without side effects in each age group. RESULTS After inclusion of 91 patients, the study was prematurely terminated because the primary outcome was only reached in 13% of patients. Dose-finding was completed in 2 groups, but no optimal propofol dose was found. Effective sedation without side effects was achieved more often after a starting dose of 2.0 mg/kg (28%) than after 1.0 mg/kg (3%) and 1.5 mg/kg (9%). Propofol-induced hypotension occurred in 59% of patients. Logistic regression analyses showed that GA and PNA did not predict effective sedation or the occurrence of hypotension. CONCLUSIONS Effective sedation without side effects is difficult to achieve with propofol and the optimal dose in different age groups of neonates could not be determined. The sedative effect of propofol and the occurrence of hypotension are unpredictable and show large inter-individual variability in the neonatal population.
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Affiliation(s)
- Ellen H.M. de Kort
- Neonatology, Maxima Medical Center, Veldhoven, The Netherlands,Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sandra A. Prins
- Neonatology, Amsterdam UMC location VU Medical Center, Amsterdam, The Netherlands
| | - Irwin K.M. Reiss
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | | | | | - Sinno H.P. Simons
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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15
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Han YS, Kim HH, Kim HS, Yang MS, Ahn SY, Sung SI, Chang YS, Park WS. Sedation for Brain Magnetic Resonance Imaging in Preterm Infants: Using Propofol under Anesthesiologist Supervision. NEONATAL MEDICINE 2020. [DOI: 10.5385/nm.2020.27.3.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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16
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Tesoro S, Marchesini V, Fratini G, Engelhardt T, De Robertis E. Drugs for anesthesia and analgesia in the preterm infant. Minerva Anestesiol 2020; 86:742-755. [DOI: 10.23736/s0375-9393.20.14073-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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17
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Truong L, Kim JH, Katheria AC, Finer NN, Marc-Aurele K. Haemodynamic effects of premedication for neonatal intubation: an observational study. Arch Dis Child Fetal Neonatal Ed 2020; 105:123-127. [PMID: 31036701 DOI: 10.1136/archdischild-2018-316235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine changes in blood pressure (BP), cardiac output (CO) and cerebral regional oxygen saturation (rScO2) with administration of premedication for neonatal intubation. DESIGN Pilot, prospective, observational study. Oxygen saturation, heart rate, CO, rScO2 and BP data were collected. Monitoring began 5 min prior to premedication and continued until spontaneous movement. SETTING Single-centre, level 3 neonatal intensive care unit PATIENTS: 35 infants, all gestational ages. 81 eligible infants: 66 consented, 15 refused. INTERVENTIONS Intravenous atropine, fentanyl or morphine, ±cisatracurium MAIN OUTCOME MEASURES: BP, CO, rScO2 RESULTS: n=37 intubations. Mean gestational age and median birth weight were 31 4/7 weeks and 1511 g. After premedication, 10 episodes resulted in a BP increase from baseline and 27 in a BP decrease. Of those whose BP decreased, 17 had <20% decrease and 10 had ≥20% decrease. Those with <20% BP decrease took an average of 2.5 min to return to baseline while those with a ≥20% BP decline took an average of 15.2 min. Three did not return to baseline by 35 min. Following intubation, further declines in BP (21%-51%) were observed in eight additional cases. One infant required a bolus for persistently low BPs. CO and rScO2 changes were statistically similar between the two groups. CONCLUSION About 30% of infants dropped their BP by ≥20% after premedication for elective intubation. These BP changes were not associated with any significant change in rScO2 or CO. More data are needed to better characterise the immediate haemodynamic changes and clinical outcomes associated with premedication.
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Affiliation(s)
- Linda Truong
- Department of Pediatrics, Division of Neonatal-Developmental Medicine, Stanford University, Palo Alto, California, USA
| | - Jae H Kim
- Department of Pediatrics, Division of Neonatology, University of California San Diego Health System, San Diego, California, USA.,Department of Pediatrics, Division of Neonatology, Rady Children's Hospital of San Diego, San Diego, California, USA
| | | | - Neil N Finer
- Department of Pediatrics, Division of Neonatology, University of California San Diego Health System, San Diego, California, USA
| | - Krishelle Marc-Aurele
- Department of Pediatrics, Division of Neonatology, University of California San Diego Health System, San Diego, California, USA.,Department of Pediatrics, Division of Neonatology, Rady Children's Hospital of San Diego, San Diego, California, USA
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18
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Massolo AC, Sgrò S, Piersigilli F, Allegaert K, Capolupo I, Rechichi J, Landolfo F, Calzolari F, Toscano A, Picardo S, Patel N. Propofol Formulation Affects Myocardial Function in Newborn Infants. Pediatr Cardiol 2019; 40:1536-1542. [PMID: 31414158 DOI: 10.1007/s00246-019-02182-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022]
Abstract
This study aimed to evaluate the effects of propofol in diluted and undiluted formulations on cardiac function in infants. Infants > 30 days received propofol sedation for central line insertion. Cases were divided into two groups: those who received undiluted 1% propofol (P1%); and those who received a diluted formulation (Pd) of equal volumes propofol 1% and 0.9% NaCl. Echocardiograms were performed pre (t0)-, immediately post (t1)-, and 1-h post (t2) propofol administration. Myocardial deformation was assessed with tissue Doppler imaging (TDI) analysis and peak longitudinal strain (LS). 18 cases were included: nine (50%) P1% and nine (50%) Pd. In the P1% group, TDI velocities and LS were significantly reduced at t1 and t2. In the Pd Group, only TDI velocities in the left ventricle were reduced at t1, but not at t2. Dilution of propofol may minimize myocardial dysfunction while maintaining adequate sedation in infants. Further comparative studies are needed to investigate the safety and efficacy of this approach.
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Affiliation(s)
- Anna Claudia Massolo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazzale Sant'Onofrio 4, 00165, Rome, Italy.
| | - Stefania Sgrò
- Department of Anesthesiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fiammetta Piersigilli
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazzale Sant'Onofrio 4, 00165, Rome, Italy
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazzale Sant'Onofrio 4, 00165, Rome, Italy
| | - Jole Rechichi
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazzale Sant'Onofrio 4, 00165, Rome, Italy
| | - Francesca Landolfo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazzale Sant'Onofrio 4, 00165, Rome, Italy
| | - Flaminia Calzolari
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazzale Sant'Onofrio 4, 00165, Rome, Italy
| | - Alessandra Toscano
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazzale Sant'Onofrio 4, 00165, Rome, Italy
| | - Sergio Picardo
- Department of Anesthesiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
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19
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Walter-Nicolet E, Courtois E, Milesi C, Ancel PY, Beuchée A, Tourneux P, Benhammou V, Carbajal R, Durrmeyer X. Premedication practices for delivery room intubations in premature infants in France: Results from the EPIPAGE 2 cohort study. PLoS One 2019; 14:e0215150. [PMID: 30970001 PMCID: PMC6457540 DOI: 10.1371/journal.pone.0215150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/27/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives To assess premedication practices before tracheal intubation of premature newborns in the delivery room (DR). Study design From the national population-based prospective EPIPAGE 2 cohort in 2011, we extracted all live born preterms intubated in the DR in level-3 centers, without subsequent circulatory resuscitation. Studied outcomes included the rate and type of premedication, infants’ and maternities’ characteristics and survival and major neonatal morbidities at discharge from hospital. Univariate and multivariate analysis were performed and a generalized estimating equation was used to identify factors associated with premedication use. Results Out of 1494 included neonates born in 65 maternities, 76 (5.1%) received a premedication. Midazolam was the most used drug accounting for 49% of the nine drugs regimens observed. Premedicated, as compared to non premedicated neonates, had a higher median [IQR] gestational age (30 [28–31] vs 28 [27–30] weeks, p<10−3), median birth weight (1391 [1037–1767] vs 1074 [840–1440] g, p<10−3) and median 1-minute Apgar score (8 [6–9] vs 6 [3–8], p<10−3). Using univariate analyses, premedication was significantly less frequent after maternal general anesthesia and during nighttime and survival without major morbidity was significantly higher among premedicated neonates (56/73 (81.4%) vs 870/1341 (69.3%), p = 0.028). Only 10 centers used premedication at least once and had characteristics comparable to the 55 other centers. In these 10 centers, premedication rates varied from 2% to 75%, and multivariate analysis identified gestational age and 1-minute Apgar score as independent factors associated with premedication use. Conclusion Premedication rate before tracheal intubation was only 5.1% in the DR of level-3 maternities for premature neonates below 34 weeks of gestation in France in 2011 and seemed to be mainly associated with centers’ local policies.
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Affiliation(s)
| | - Emilie Courtois
- Paediatric Emergency Department. Trousseau Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Christophe Milesi
- Paediatric and Neonatal Intensive Care Unit, University Hospital Arnaud de Villeneuve, Montpellier, France
| | - Pierre-Yves Ancel
- INSERM, U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Paris Descartes University France, Paris, France
- URC - CIC P1419, Cochin Hotel-Dieu Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Alain Beuchée
- Division of Neonatology and CIC-1414, Department of Pediatrics, University Hospital, Rennes, France
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
| | - Pierre Tourneux
- Neonatal and Paediatric Intensive Care Unit, University hospital, Amiens, France
- PériTox - UMI 01, Medicine University, Picardie Jules Verne University, Amiens, France
| | - Valérie Benhammou
- INSERM, U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Paris Descartes University France, Paris, France
| | - Ricardo Carbajal
- Paediatric Emergency Department. Trousseau Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
- INSERM, U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Paris Descartes University France, Paris, France
- Paediatric and Neonatal Intensive Care Unit, Trousseau Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Xavier Durrmeyer
- INSERM, U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, University Paris Est Créteil, Créteil, France
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20
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Ancora G, Lago P, Garetti E, Merazzi D, Savant Levet P, Bellieni CV, Pieragostini L, Pirelli A. Evidence-based clinical guidelines on analgesia and sedation in newborn infants undergoing assisted ventilation and endotracheal intubation. Acta Paediatr 2019; 108:208-217. [PMID: 30290021 DOI: 10.1111/apa.14606] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/31/2018] [Accepted: 10/01/2018] [Indexed: 02/02/2023]
Abstract
AIM This review informed pain control guidelines for clinicians performing mechanical ventilation, nasal continuous positive airway pressure and endotracheal intubation on term and preterm newborn infants. METHODS We reviewed literature published between 1986 and June 2017 on analgesia and sedation during assisted ventilation and before endotracheal intubation in newborn infants admitted to neonatal intensive care units. The subsequent guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Our review produced five strong standard of care recommendations. One, reduce neonatal stress and use nonpharmacological analgesia during invasive ventilation. Two, favour intermittent boluses of opioids, administered after pain scores and before invasive procedures, during short expected periods of mechanical ventilation, mainly in preterm infants affected by respiratory distress syndrome. Three, do not use morphine infusion in preterm infants under 27 gestational weeks. Four, always use algometric scores to titrate analgesic drugs doses. Five, use premedication before endotracheal intubation for a more rapid, less painful, less traumatic and safer manoeuvre. We also developed 30 conditional recommendations on therapeutic options. CONCLUSION Our review produced 35 recommendations on standard care and therapeutic options relating to the analgesia and sedation of newborn infants during ventilation and before endotracheal intubation.
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Affiliation(s)
- Gina Ancora
- NICU; Azienda Sanitaria Romagna; Infermi Hospital Rimini; Rimini Italy
| | - Paola Lago
- NICU; Azienda ULSS 2 MarcaTrevigiana; CàFoncello Hospital; Treviso Italy
| | - Elisabetta Garetti
- NICU; Women's and Children's Health Department; Azienda Ospedaliera; University of Modena; Modena Italy
| | - Daniele Merazzi
- NICU; Mother's and Infant's Department; Valduce Hospital; Como Italy
| | - Patrizia Savant Levet
- NICU; Maria Vittoria Hospital; Mother's and Infant's Department; ASL Città di Torino Italy
| | | | | | - Anna Pirelli
- NICU; Rho Hospital; ASST Rhodense; Garbagnate Milanese; Milano Italy
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21
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Vedrenne-Cloquet M, Breinig S, Dechartres A, Jung C, Renolleau S, Marchand-Martin L, Durrmeyer X. Cerebral Oxygenation During Neonatal Intubation-Ancillary Study of the Prettineo-Study. Front Pediatr 2019; 7:40. [PMID: 30881948 PMCID: PMC6407664 DOI: 10.3389/fped.2019.00040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/30/2019] [Indexed: 01/25/2023] Open
Abstract
Purpose: This study aimed to describe cerebral Near InfraRed Spectroscopy (NIRS) profiles during neonatal intubation using two different premedication regimens. Methods: Neonates requiring non-emergency intubation were enrolled in an ancillary study, conducted in two French Neonatal Intensive Care Units participating in a larger on-going multicenter, double blind, randomized, controlled trial. Patients were randomly assigned to the "atropine-propofol" (Prop) group or the "atropine-atracurium-sufentanil" (SufTrac) group. Regional cerebral oxygen saturation (rScO2), pulse oxymetry (SpO2), mean arterial blood pressure (MABP), and transcutaneous partial pressure of carbon dioxide (TcPCO2) were collected at 9 predefined time points from 1 min before to 60 min after the first drug injection. The two primary outcomes were a decrease in rScO2 value >20% from baseline and a decrease in fractional cerebral tissue oxygen extraction (FTOE) value >10% from baseline, at any time point. Secondary outcomes included physiological parameters changes over time and correlations between mean arterial blood pressure, and FTOE at different time points. Descriptive results were obtained and exploratory statistical analyses were performed for 24 included patients. Results: rScO2 decreased in 5/11 (46%) infants from the Prop group and 10/13 (77%) from the SufTrac group (p = 0.11); FTOE decreased in 10/11 (91%) infants from the Prop group, and 12/13 (92%) from the SufTrac group (p = 0.90). rScO2 values decreased over time in both groups, whereas FTOE's pattern appeared more stable. SpO2 and transcutaneous TcPCO2 seemed more preserved in the Prop group while MABP seemed more preserved in the SufTrac group. No important correlation was observed between MABP and FTOE (r = 0.08 to 0.12 across the time points). Conclusion: Our results suggest a frequent decrease in cerebral oxygenation without obvious impairment in cerebral autoregulation during neonatal intubation with premedication. This study confirms the feasibility and the informative value of cerebral NIRS monitoring in this setting. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02700893.
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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,Pediatric Intensive Care Unit, Necker University Hospital, Paris, France
| | - Sophie Breinig
- Neonatal and Pediatric Intensive Care Unit, Toulouse University Hospital, Toulouse, France
| | - Agnes Dechartres
- Inserm U1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département Biostatistique santé publique, information médicale-Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, Paris, France
| | - Camille Jung
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit, Necker University Hospital, Paris, France
| | - Laetitia Marchand-Martin
- INSERM, UMR1153, Obstetrical, Perinatal and Paediatric Epidemiology (Epopé) Team, Epidemiology and Biostatistics Sorbonne, Paris Descartes University, Paris, France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,Faculté de Médecine de Créteil, IMRB, GRC CARMAS, Université Paris Est Créteil, Créteil, France
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22
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Sgrò S, Morini F, Bozza P, Piersigilli F, Bagolan P, Picardo S. Intravenous Propofol Allows Fast Intubation in Neonates and Young Infants Undergoing Major Surgery. Front Pediatr 2019; 7:321. [PMID: 31475123 PMCID: PMC6702265 DOI: 10.3389/fped.2019.00321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 07/16/2019] [Indexed: 11/18/2022] Open
Abstract
Aim of the study: In selected surgical neonates and infants, the rapidity of induction and intubation may represent an important factor for their safety. Propofol is an anesthetic characterized by a rapid onset and fast recovery time that may reduce time of anesthetic induction and improve post-anesthetic outcome. The aim of this study was to evaluate the safety and efficacy of anesthesia induction in full-term neonates and young infants after propofol bolus administration. Methods: A retrospective case-control study including infants below 6 months of age, undergoing general anesthesia between 2011 and 2013, was carried out. Patients that received intravenous propofol bolus to induce anesthesia were compared to patients who received inhaled sevoflurane. Time to reach successful orotracheal intubation (OTI) was measured in seconds. The quality of OTI was defined as "excellent," "good," and "poor," based on established classification and was reported. Hemodynamic parameters as systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), heart rate (HR), and oxygen saturation (SaO2) were collected before OTI (t0), at OTI (t1), and at spontaneous breathing recovery (t2). Main adverse effects were recorded for both groups. Results are median (IQ range) or prevalence; p < 0.05 was considered significant. Results: 160 infants were enrolled in the study, 80 received propofol and 80 inhaled sevoflurane. Major surgery (involving organs in the thoracic, abdominal, or pelvic cavities) was performed in 64 and 54% of patients in the propofol and sevoflurane group, respectively (p = 0.07). Patients in the propofol group showed a shorter time for OTI [11.5 (4.0-65) vs. 360.0 (228.0-720.0) seconds, (p < 0.0001)]. No difference was found in the quality of OTI between the two groups. No significant complications were recorded in either group. Conclusions: Propofol is a safe and effective anesthetic in neonates and infants permitting rapid induction of anesthesia and rapid intubation, without negative impact on the quality of intubation and haemodynamic compromise.
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Affiliation(s)
- Stefania Sgrò
- Department of Anesthesia and Critical Care, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Francesco Morini
- Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Patrizia Bozza
- Department of Anesthesia and Critical Care, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Fiammetta Piersigilli
- Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Sergio Picardo
- Department of Anesthesia and Critical Care, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
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23
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Abstract
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.
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Affiliation(s)
- Şule Yiğit
- Division of Neonatology, Department of Pediatrics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Ayşe Ecevit
- Division of Neonatology, Department of Pediatrics, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Özge Altun Köroğlu
- Division of Neonatology, Department of Pediatrics, Ege University, Faculty of Medicine, İzmir, Turkey
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24
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Thewissen L, Caicedo A, Dereymaeker A, Van Huffel S, Naulaers G, Allegaert K, Smits A. Cerebral autoregulation and activity after propofol for endotracheal intubation in preterm neonates. Pediatr Res 2018; 84:719-725. [PMID: 30201953 DOI: 10.1038/s41390-018-0160-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/12/2018] [Accepted: 08/10/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite increasing use of propofol in neonates, observations on cerebral effects are limited. AIM To investigate cerebral autoregulation (CAR) and activity after propofol for endotracheal intubation in preterm neonates. METHODS Twenty-two neonates received propofol before intubation as part of a published dose-finding study. Mean arterial blood pressure (MABP), near-infrared spectroscopy-derived cerebral oxygenation (rScO2), and amplitude-integrated electroencephalography (aEEG) were analyzed until 180 min after propofol. CAR was expressed as transfer function (TF) gain, indicating % change in rScO2 per 1 mmHg change in MABP. Values exceeding mean TF gain + 2 standard deviations (SD) defined impaired CAR. RESULTS After intubation with a median propofol dose of 1 (0.5-4.5) mg/kg, rScO2 remained stable during decreasing MABP. Mean (±SD) TF gain was 0.8 (±0.3)%/mmHg. Impaired CAR was identified in 1 and 5 patient(s) during drug-related hypotension and normal to raised MABP, respectively. Suppressed aEEG was observed up to 60 min after propofol. CONCLUSIONS Drug-related hypotension and decreased cerebral activity after intubation with low propofol doses in preterm neonates were observed, without evidence of cerebral ischemic hypoxia. CAR remained intact during drug-related hypotension in 95.5% of patients. Cerebral monitoring including CAR clarifies the cerebral impact of MABP fluctuations.
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Affiliation(s)
- Liesbeth Thewissen
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.
| | - Alexander Caicedo
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium
| | | | - Sabine Van Huffel
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Anne Smits
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
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25
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Abstract
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.
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26
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Milési C, Baleine J, Mura T, Benito-Castro F, Ferragu F, Thiriez G, Thévenot P, Combes C, Carbajal R, Cambonie G. Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial. Arch Dis Child Fetal Neonatal Ed 2018; 103:F221-F226. [PMID: 28818854 DOI: 10.1136/archdischild-2017-312808] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/23/2017] [Accepted: 06/27/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the effectiveness of sedation by intranasal administration of midazolam (nMDZ) or ketamine (nKTM) for neonatal intubation. DESIGN A multicentre, prospective, randomised, double-blind study. SETTING Delivery rooms at four tertiary perinatal centres in France. PATIENTS Preterm neonates with respiratory distress requiring non-emergent endotracheal intubation for surfactant instillation. INTERVENTIONS Treatment was randomly allocated, with each neonate receiving a bolus of 0.1 mL/kg in each nostril, corresponding to 0.2 mg/kg for nMDZ and 2 mg/kg for nKTM. The drug was repeated once 7 min later at the same dose if adequate sedation was not obtained. MAIN OUTCOME MEASURES Success was defined by adequate sedation before intubation and adequate comfort during the procedure. Intubation features, respiratory and cardiovascular events were recorded. RESULTS Sixty newborns, with mean (SD) gestational age and birth weight of 28 (3) weeks and 1100 (350) g, were included within the first 20 min of life. nMDZ was associated with a higher success rate (89% vs 58%; RR: 1.54, 95% CI 1.12 to 2.12, p<0.01) and shorter delays between the first dose and intubation (10 (6) vs 16 (8) min, p<0.01).Number of attempts, time to intubation, mean arterial blood pressure measures over the first 12 hours after birth and length of invasive ventilation were not different. CONCLUSIONS nMDZ was more efficient than nKTM to adequately sedate neonates requiring intubation in the delivery room. The haemodynamic and respiratory effects of both drugs were comparable. CLINICAL TRIAL This clinical trial was recorded on the National Library of Medicine registry (NCT01517828).
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Affiliation(s)
- Christophe Milési
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
| | - Julien Baleine
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
| | - Thibault Mura
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier University Hospital, Montpellier, France
| | - Fernando Benito-Castro
- Department of Neonatal Medicine, Carémeau Hospital, Nîmes University Hospital, Nimes, France
| | - Félicie Ferragu
- Department of Neonatal Medicine, Carémeau Hospital, Nîmes University Hospital, Nimes, France
| | - Gérard Thiriez
- Department of Neonatal Medicine, Jean Minjoz Hospital, Besançon University Hospital, Besancon, France
| | - Pierre Thévenot
- Department of Neonatal Medicine, St Jean Hospital, Perpignan General Hospital, Perpignan, France
| | - Clémentine Combes
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
| | - Ricardo Carbajal
- Paediatric Emergency Unit, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Pierre and Marie Curie University, Paris, France
| | - Gilles Cambonie
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
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27
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Durrmeyer X, Breinig S, Claris O, Tourneux P, Alexandre C, Saliba E, Beuchée A, Jung C, Levy C, Marchand-Martin L, Marcoux MO, Dechartres A, Danan C. Effect of Atropine With Propofol vs Atropine With Atracurium and Sufentanil on Oxygen Desaturation in Neonates Requiring Nonemergency Intubation: A Randomized Clinical Trial. JAMA 2018; 319:1790-1801. [PMID: 29715354 PMCID: PMC6583687 DOI: 10.1001/jama.2018.3708] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, CHI Créteil, CRETEIL, France
- INSERM, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris Descartes University, France
| | - Sophie Breinig
- Pediatric and Neonatal Intensive Care Unit, CHU Toulouse, Toulouse, France
| | - Olivier Claris
- Neonatal Intensive Care Unit, Hospices civils de Lyon, Lyon, France
| | | | | | - Elie Saliba
- Neonatal Intensive Care Unit, CHU Tours, Tours, France
| | - Alain Beuchée
- Neonatal Intensive Care Unit, CHU Rennes, Rennes, France
| | - Camille Jung
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Corinne Levy
- ACTIV, St Maur, France
- IMRB- GRC GEMINI, Université Paris Est, Créteil, France
| | - Laetitia Marchand-Martin
- INSERM, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris Descartes University, France
| | | | - Agnes Dechartres
- INSERM, U1153, METHODS Team, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Paris Descartes University, Hotel-Dieu Hospital (AP-HP), France
| | - Claude Danan
- Neonatal Intensive Care Unit, CHI Créteil, CRETEIL, France
- Clinical Research Center, CHI Créteil, Créteil, France
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28
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A different perspective: anesthesia for extreme premature infants: is there an age limitation or how low should we go? Curr Opin Anaesthesiol 2018; 31:308-312. [PMID: 29474212 DOI: 10.1097/aco.0000000000000581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To put in perspective, the various challenges that faces pediatric anesthesiologists because of the recently lowered limits with regards to the viability of a fetus. Both medical and ethical considerations will be highlighted. RECENT FINDINGS Issues related to: who should anesthetize these tiny babies; can we provide adequate and legal monitoring during the anesthetic; does these immature babies need hypnosis and amnesia and the moral/ethical implications associated with being involved with care of doubtful long-term outcome are reviewed. SUMMARY There does currently not exist sufficient research data to provide any evidence-based guidelines for the anesthetic handling of extreme premature infants. Current practice relies on extrapolations from other patient groups and from attempting to preserve normal physiology. Thus, focused research initiatives within this specific field of anesthesia should be a priority. Furthermore, in-depth multiprofessional ethical discussions regarding long-term outcome of aggressive care of extremely premature babies are urgently needed, including the new concepts of disability-free survival and number-need-to-suffer.
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29
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de Kort EHM, Halbmeijer NM, Reiss IKM, Simons SHP. Assessment of sedation level prior to neonatal intubation: A systematic review. Paediatr Anaesth 2018; 28:28-36. [PMID: 29159860 DOI: 10.1111/pan.13285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Adequate premedication before neonatal endotracheal intubation reduces pain, stress, and adverse physiological responses, diminishes duration and number of attempts at intubation, and prevents traumatic airway injury. Therefore, intubation should not be started until an adequate level of sedation is reached. It is not clear how this should be measured in the clinical situation. OBJECTIVES The aim of this study is to provide a systematic review of the usability and validity of scoring systems or other objective parameters to evaluate the level of sedation before intubation in neonates. Secondary aims were to describe parameters that are used to determine the level of sedation and criteria on which the decision to proceed with intubation is based. METHODS Literature was searched (January 2017) in the following electronic databases: Embase, Medline, Web of Science, Cochrane Central Registrar of Controlled Trials, Pubmed Publisher, and Google Scholar. RESULTS From 1653 hits, 20 studies were finally included in the systematic review. In 7 studies, intubation was started after a predefined time period; in 1 study, preoxygenation was the criterion to start with intubation; and in 12 studies, intubation was started in case of adequate sedation and/or relaxation. Only 4 studies described the use of 3 different objective scoring system, all in the neonatal intensive care unit, which are not validated. CONCLUSION No validated scoring systems to assess the level of sedation prior to intubation in newborns are available in the literature. Three objective sedation assessment tools seem promising but need further validation before they can be implemented in research and clinical settings.
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Affiliation(s)
- Ellen H M de Kort
- Department of Pediatrics and Neonatology, Máxima Medical Center, Veldhoven, The Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke M Halbmeijer
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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30
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Piersigilli F, Di Pede A, Catena G, Lozzi S, Auriti C, Bersani I, Capolupo I, Lipreri A, Di Ciommo V, Dotta A, Sgrò S. Propofol and fentanyl sedation for laser treatment of retinopathy of prematurity to avoid intubation. J Matern Fetal Neonatal Med 2017; 32:517-521. [DOI: 10.1080/14767058.2017.1383379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Fiammetta Piersigilli
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Alessandra Di Pede
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Gino Catena
- Department of Ophthalmology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Simona Lozzi
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Cinzia Auriti
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Iliana Bersani
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Anna Lipreri
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Vincenzo Di Ciommo
- Unit of Clinical Epidemiology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Andrea Dotta
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Stefania Sgrò
- Department of Anesthesiology, Bambino Gesù Children’s Hospital, Rome, Italy
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van Hasselt TJ. Question 1 What is the best sedative to give as premedication for neonatal intubation? Arch Dis Child 2017; 102:780-783. [PMID: 28724706 DOI: 10.1136/archdischild-2017-313107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Tim J van Hasselt
- Birmingham Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Romantsik O, Bruschettini M, Calevo MG, Banzi R, Ley D. Pharmacological pain and sedation interventions for the prevention of intraventricular hemorrhage in preterm infants on assisted ventilation - an overview of systematic reviews. Hippokratia 2017. [DOI: 10.1002/14651858.cd012706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Olga Romantsik
- Lund University, Skåne University Hospital; Department of Paediatrics; Lund Sweden
| | - Matteo Bruschettini
- Lund University, Skåne University Hospital; Department of Paediatrics; Lund Sweden
- Skåne University Hospital; Research & Development, Section for HTA Analysis; Wigerthuset, Remissgatan 4, first floor room 11-221 Lund Sweden 22185
| | - Maria Grazia Calevo
- Istituto Giannina Gaslini; Epidemiology, Biostatistics and Committees Unit; Genoa Italy 16147
| | - Rita Banzi
- IRCCS - Mario Negri Institute for Pharmacological Research; Laboratory of Regulatory Policies; via G La Masa 19 Milan Italy 20156
| | - David Ley
- Lund University, Skåne University Hospital; Department of Paediatrics; Lund Sweden
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Klotz D, Porcaro U, Fleck T, Fuchs H. European perspective on less invasive surfactant administration-a survey. Eur J Pediatr 2017; 176:147-154. [PMID: 27942865 DOI: 10.1007/s00431-016-2812-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/12/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Abstract
UNLABELLED Less invasive surfactant administration or minimally invasive surfactant therapy (LISA/MIST) has been proposed for the administration of surfactant in preterm infants without intubation. The aim of our survey was to assess the rate of utilization, premedication as well as technique and equipment used for LISA/MIST. Furthermore, attitudes and experiences in regard to indications, side effects, and efficacy should be assessed. An online-based survey was sent to 324 neonatologists from different centers within 37 European countries between December 2015 and March 2016. Of those 165 who responded (response rate 51%), 86 (52%) were using LISA/MIST. It is regarded the standard procedure for surfactant administration by 41%, with a wide variation in personal views on patient selection in terms of indication, appropriate gestational and postnatal age. Policies concerning premedication, devices, and technique of LISA/MIST differed widely. Side effects like surfactant reflux, bradycardia, and hypoxia were observed by 77% of neonatologists. Of neonatologists inexperienced in LISA/MIST, 89% would consider utilizing it in the future. Perceived efficacy of LISA/MIST was high (52%) to medium (33%). CONCLUSION The use of LISA/MIST within Europe is widespread. There is a wide variation concerning all aspects of LISA in daily clinical routine and different views on when and how LISA should be performed. What is Known: • Noninvasive surfactant administration has been the subject of randomized controlled trials and has found its way into clinical routine. What is New: • Noninvasive surfactant administration techniques are widely applied in European neonatal units. • There is a wide variety of equipment used and techniques applied for less invasive surfactant delivery as well as different views on the indications and perceived efficacy of this intervention.
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Affiliation(s)
- Daniel Klotz
- Center for Pediatrics, Department of Neonatology, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany. .,Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Ugo Porcaro
- Department of Woman, Child and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Thilo Fleck
- Center for Pediatrics, Department of Pediatric Cardiology, Heart Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hans Fuchs
- Center for Pediatrics, Department of Neonatology, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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The basic principles of anesthesia for the neonate☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201701000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Smits A, Thewissen L, Caicedo A, Naulaers G, Allegaert K. Propofol Dose-Finding to Reach Optimal Effect for (Semi-)Elective Intubation in Neonates. J Pediatr 2016; 179:54-60.e9. [PMID: 27597733 DOI: 10.1016/j.jpeds.2016.07.049] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/05/2016] [Accepted: 07/28/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To define the effective dose for 50% of patients (ED50) of propofol for successful intubation and to determine the rate of successful extubation in those patients with planned intubation, surfactant administration, and immediate extubation (INSURE procedure). In addition, pharmacodynamic effects were assessed. STUDY DESIGN Neonates (n = 50) treated with propofol for (semi-)elective endotracheal intubation were stratified in 8 strata by postmenstrual and postnatal age. The first patient in each stratum received an intravenous bolus of 1 mg/kg propofol. Dosing for the next patient was determined using the up-and-down method. A propofol ED50 dose was calculated in each stratum with an effective sample size of at least 6, via the Dixon-Masey method, with simultaneous assessment of clinical scores and continuous vital sign monitoring. RESULTS Propofol ED50 values for preterm neonates <10 days of age varied between 0.713 and 1.350 mg/kg. Clinical recovery was not attained at the end of the 21-minute scoring period. Mean arterial blood pressure showed a median decrease between 28.5% and 39.1% from baseline with a brief decrease in peripheral and regional cerebral oxygen saturation. Variability in mean arterial blood pressure area under the curve could not be explained by weight or age. CONCLUSIONS Low propofol doses were sufficient to sedate neonates for intubation. Clinical recovery was accompanied by permissive hypotension (no clinical shock and no treatment). The propofol ED50 doses can be administered at induction, with subsequent up-titration if needed, while monitoring blood pressure. They can be used for further dosing optimalization and validation studies. TRIAL REGISTRATION ClinicalTrials.gov: NCT01621373; EudraCT: 2012-002648-26.
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Affiliation(s)
- Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.
| | - Liesbeth Thewissen
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Electrical Engineering (ESAT), STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Neonatal pain management: still in search for the Holy Grail. Int J Clin Pharmacol Ther 2016; 54:514-23. [PMID: 27087155 PMCID: PMC5012190 DOI: 10.5414/cp202561] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 12/31/2022] Open
Abstract
Inadequate pain management but also inappropriate use of analgesics in early infancy has negative effects on neurodevelopmental outcome. As a consequence, neonatal pain management is still in search for the Holy Grail. At best, effective pain management is based on prevention, assessment, and treatment followed by a re-assessment of the pain to determine if additional treatment is still necessary. Unfortunately, epidemiological observations suggest that neonates are undergoing painful procedures very frequently, unveiling the need for effective preventive, non-pharmacological strategies. In addition, assessment is still based on validated, multimodal, but subjective pain assessment tools. Finally, in neonatal intensive care units, there is a shift in clinical practices (e.g., shorter intubation and ventilation), and this necessitates the development and validation of new pharmacological treatment modalities. To illustrate this, a shift in the use of opioids to paracetamol has occurred and short-acting agents (remifentanil, propofol) are more commonly administered to neonates. In addition to these new modalities and as part of a more advanced approach of the developmental pharmacology of analgesics, pharmacogenetics also emerged as a tool for precision medicine in neonates. To assure further improvement of neonatal pain management the integration of pharmacogenetics with the usual covariates like weight, age and/or disease characteristics is needed.
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Weber F, Honing GHM, Scoones GP. Arterial blood pressure in anesthetized neonates and infants: a retrospective analysis of 1091 cases. Paediatr Anaesth 2016; 26:815-22. [PMID: 27218872 DOI: 10.1111/pan.12924] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hypotension during general anesthesia in neonates and infants is considered to contribute to poor neurological outcome. AIM The aim of this retrospective analysis was to determine the incidence of hypotension after induction of anesthesia and sustained hypotension (>10 min) during the anesthesia, and to determine factors contributing to the development of (sustained) hypotension. METHOD We performed a retrospective analysis of 1091 electronic anesthesia records from children <1 year. Patients were stratified for age (group 1: <1 month, group 2: 1-3 months, group 3: 4-6 months, group 4: >6 months). Hypotension was defined as a mean arterial pressure (MAP) <35 mmHg in patients ≤6 months and <43 mmHg in patients >6 months. RESULTS The incidence of hypotension after induction was highest in group 1 (25.5%) [P = 0.009 vs group 2 (13.3%), P < 0.0001 vs groups 3 (3.4%) and 4 (1.0%)], in group 2, it was higher than in groups 3 and 4 (P < 0.0001), and in group 3, it was higher than in group 4 (P = 0.033). The incidence of sustained hypotension was highest in group 1 (43.6%) (P < 0.0001 vs groups 2-4), followed by group 2 (15.7%) [P < 0.0001 vs group 3 (3.4%) and P = 0.006 vs group 4 (8.8%)] and group 4 (P = 0.004 vs group 3). Hypotension after induction occurred more often in emergency procedures than in elective procedures in groups 1 (P = 0.002), 2 (P = 0.029), and 3 (P = 0.037). CONCLUSION Hypotension, both postinduction and sustained during surgery, is a common phenomenon in anesthetized children under 1 year, peaking in neonates. Generally accepted lower limits of MAP in anesthetized infants urgently need to be defined, enabling us to develop anesthesia strategies avoiding cerebral hypoperfusion.
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Affiliation(s)
- Frank Weber
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gijsbert H M Honing
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gail P Scoones
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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Smits A, van den Anker JN, Allegaert K. Clinical pharmacology of analgosedatives in neonates: ways to improve their safe and effective use. ACTA ACUST UNITED AC 2016; 69:350-360. [PMID: 27364566 DOI: 10.1111/jphp.12599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/11/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To propose approaches tailored to the specific needs of neonates, such as structured product development programmes, with the ultimate goal to improve the safe and effective use of analgosedatives in these fragile patients. KEY FINDINGS The feasibility and relevance of a structured product development programme in neonates (optimal study design based on preliminary data; model development; internal, external and prospective evaluation; an individualized dosing regimen; long-term safety; pharmacogenetics) are illustrated for the use of morphine. Based on changes in clinical practices, similar development plans are in progress for short-acting analgosedatives such as propofol, but are in need of tailored pharmacodynamic tools to assess and quantify effects. Furthermore, for drugs like paracetamol where there is already sufficient clinical pharmacology knowledge, attention needs to be given to long-term safety aspects. Finally, new covariates such as pharmacogenetics might further improve neonatal pain management, but clearly need to be integrated with other well-established covariates like age or weight. SUMMARY Product development programmes for analgosedatives in neonates are needed. These programmes should be tailored to their specific needs (short-acting sedation, pain relief), should include long-term safety and should incorporate the exploration of newer covariates like pharmacogenetics.
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Affiliation(s)
- Anne Smits
- Neonatal Intensive Care Unit, VU Medical Center, Amsterdam, The Netherlands.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - John N van den Anker
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland.,Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA.,Departments of Pediatrics, Integrative Systems Biology, Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karel Allegaert
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Feasibility of monitoring stress using skin conduction measurements during intubation of newborns. Eur J Pediatr 2016; 175:237-43. [PMID: 26328787 PMCID: PMC4724365 DOI: 10.1007/s00431-015-2621-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/09/2015] [Accepted: 08/14/2015] [Indexed: 11/21/2022]
Abstract
UNLABELLED The objective of this study was to assess the feasibility of monitoring stress responses in newborns during naso-tracheal intubation after two different premedication regimens, using skin conductance measurements (SCM). Twenty-two newborns were randomised and premedicated with morphine + vecuronium or propofol. SCM (peaks/s) were collected prior to, during and after the procedure. Threshold for interpreting responses as stressful was 0.21 peaks/s. Intubation conditions and physiological parameters were registered. Intubation conditions were good in all newborns. Administration of morphine (range 1.4-10.3 min) before administration of vecuronium did not affect SCM when a stressful stimulus was applied. Within 1.6 min (range 0.8-3 min) after administration of vecuronium, SCM disappeared in 10 of 11 newborns. Propofol reduced SCM in 10 of 11 newborns at the first attempt. Further attempts were associated with increasing SCM, mostly above a threshold of 0.21 peaks/s. There were no significant changes in physiological parameters during the procedure for either premedication regimen. CONCLUSION The variation in SCM between individual newborns limits the usefulness of SCM as stress monitor during intubation. The use of neuromuscular blockers for premedication precludes monitoring of SCM completely in newborns. WHAT IS KNOWN Skin conductance measurements have been used successfully to monitor pain in awake newborn infants. WHAT IS NEW Premedicated newborns display significant interindividual variation in skin conductance measurements during an intubation procedure. Neuromuscular blockade causes skin conductance measurements to disappear completely.
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Dekker J, Lopriore E, Rijken M, Rijntjes-Jacobs E, Smits-Wintjens V, Te Pas A. Sedation during Minimal Invasive Surfactant Therapy in Preterm Infants. Neonatology 2016; 109:308-13. [PMID: 26907795 DOI: 10.1159/000443823] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/07/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is no data available whether sedation should be given during minimally invasive surfactant therapy (MIST). OBJECTIVE To compare the level of comfort of preterm infants receiving sedation versus no sedation for MIST. METHODS A retrospective study of preterm infants receiving MIST was performed in Leiden University Medical Center in 2014. Sedation (propofol 1 mg/kg) was optional and left to the discretion of the caregiver. Standardized COMFORTneo scores were compared, and COMFORTneo <14 was considered comfortable. Basic characteristics and complications were noted. RESULTS In 38 infants receiving MIST, 23 received propofol and 15 were not sedated. Mean (SD) gestational age [29 (2) vs. 29 (3) weeks] and birth weight [1,312 (483) vs. 1,469 (588) g] were not different. Median (IQR) COMFORTneo was not different between the groups before [11 (9-15) vs. 10 (8-12)] and after MIST [10 (8-12) vs. 9 (8-10)], but lower in the sedated group during MIST [12 (9-17) vs. 20 (15-23)] with more often COMFORTneo <14 (56 vs. 11%). Duration of MIST [2 (2-4) vs. 3 (2-7) min] and occurrence of bradycardia (13 vs. 33%) and hypotension (21 vs. 18%) were not different. Although not significant, intubation occurred more often in the sedated group (during MIST: 9 vs. 0%, <24 h after MIST: 26 vs. 13%). During MIST, oxygen saturation <80% lasted longer in the sedated group [3 (2-4) vs. 1 (0-2) min], and nasal intermittent positive pressure ventilation was applied more (100 vs. 33%). CONCLUSIONS Preterm infants receiving MIST were more comfortable when sedation was given, but needed ventilation more often. A randomized controlled trial is warranted to test whether the benefit of sedation outweighs the risks of complications.
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Affiliation(s)
- Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Kamata M, Cartabuke RS, Tobias JD. Perioperative care of infants with pyloric stenosis. Paediatr Anaesth 2015; 25:1193-206. [PMID: 26490352 DOI: 10.1111/pan.12792] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2015] [Indexed: 11/28/2022]
Abstract
Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.
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Affiliation(s)
- Mineto Kamata
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard S Cartabuke
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Abstract
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.
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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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Intubation in the delivery room: experience with nasal midazolam. Early Hum Dev 2014; 90:39-43. [PMID: 24331827 DOI: 10.1016/j.earlhumdev.2013.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/22/2013] [Accepted: 10/29/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AIMS To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. STUDY DESIGN Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SUBJECTS Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. OUTCOME MEASURES Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. RESULTS Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011). CONCLUSION nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.
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Abstract
Effective and safe drug administration in neonates should be based on integrated knowledge on the evolving physiological characteristics of the infant who will receive the drug and the pharmacokinetics (PK) and pharmacodynamics (PD) of a given drug. Consequently, clinical pharmacology in neonates is as dynamic and diverse as the neonates we admit to our units while covariates explaining the variability are at least as relevant as median estimates. The unique setting of neonatal clinical pharmacology will be highlighted based on the hazards of simple extrapolation of maturational drug clearance when only based on 'adult' metabolism (propofol, paracetamol). Second, maturational trends are not at the same pace for all maturational processes. This will be illustrated based on the differences between hepatic and renal maturation (tramadol, morphine, midazolam). Finally, pharmacogenetics should be tailored to neonates, not just mirror adult concepts. Because of this diversity, clinical research in the field of neonatal clinical pharmacology is urgently needed and facilitated through PK/PD modeling. In addition, irrespective of already available data to guide pharmacotherapy, pharmacovigilance is needed to recognize specific side effects. Consequently, pediatric anesthesiologists should consider to contribute to improved pharmacotherapy through clinical trial design and collaboration, as well as reporting on adverse effects of specific drugs.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, University Hospitals Leuven, Belgium,Neonatal Intensive Care Unit, University Hospitals Leuven, Belgium
| | - Marc van de Velde
- Department of Cardiovascular Sciences, KU Leuven, University Hospitals Leuven, Leuven, Belgium,Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - John van den Anker
- Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, USA,Departments of Pediatrics, Pharmacology, Physiology and Integrative Systems Biology, George Washington University School of Medicine and Health Sciences, Washington, USA,Intensive Care, Erasmus MC- Sophia Children's Hospital, Rotterdam, the Netherlands
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Sedation of newborn infants for the INSURE procedure, are we sure? BIOMED RESEARCH INTERNATIONAL 2013; 2013:892974. [PMID: 24455736 PMCID: PMC3885201 DOI: 10.1155/2013/892974] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 11/28/2013] [Indexed: 11/17/2022]
Abstract
Background. Neonatal intubation is a stressful procedure that requires premedication to improve intubation conditions and reduce stress and adverse physiological responses. Premedication used during the INSURE (INtubation, SURfactant therapy, Extubation) procedure should have a very short duration of action with restoration of spontaneous breathing within a few minutes. Aims. To determine the best sedative for intubation during the INSURE procedure by systematic review of the literature. Methods. We reviewed all relevant studies reporting on premedication, distress, and time to restoration of spontaneous breathing during the INSURE procedure. Results. This review included 12 studies: two relatively small studies explicitly evaluated the effect of premedication (propofol and remifentanil) during the INSURE procedure, both showing good intubation conditions and an average extubation time of about 20 minutes. Ten studies reporting on fentanyl or morphine provided insufficient information about these items. Conclusions. Too little is known in the literature to draw a solid conclusion on which premedication could be best used during the INSURE procedure. Both remifentanil and propofol are suitable candidates but dose-finding studies to detect effective nontoxic doses in newborns with different gestational ages are necessary.
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Use of analgesic and sedative drugs in VLBW infants in German NICUs from 2003-2010. Eur J Pediatr 2013; 172:1633-9. [PMID: 23877637 DOI: 10.1007/s00431-013-2095-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 07/04/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Very low birth weight (VLBW) infants frequently receive analgesia and/or sedation for painful procedures and mechanical ventilation to avoid negative stress. Yet, concerns remain regarding potential adverse long-term effects of these drugs on VLBW infants' neurocognitive outcome. Recent studies have shown that less invasive surfactant application (LISA) and early nasal CPAP treatment reduce the need for mechanical ventilation and painful procedures. Therefore, these measures might also reduce the application of analgesic and/or sedative drugs in VLBW infants. To evaluate this hypothesis and to identify potential changes in analgesic treatment concepts in recent years, we retrospectively analyzed data on analgesia and sedation, respiratory support, and the method of surfactant application in VLBW infants enrolled in the German Neonatal Network (GNN) trial between 2003 and 2009 (period 1) and compared it with data from infants participating in GNN in 2010 (period 2). In both periods, about one third of all infants were treated with analgesic and/or sedative drugs using a wide variety of substances. The administration of novel drugs such as propofol, sufentanil, or intravenous paracetamol was higher in 2010 (6.7 vs. 12.2 %). Infants who were treated with CPAP only received significantly less analgesic/sedative medication than infants who were mechanically ventilated (12 vs. 65 %, p=<0.001). Similarly, infants treated with LISA received less analgesic or sedative drugs as compared to infants who received surfactant via endotracheal intubation (36 vs. 63 %, p=0.001). CONCLUSION Although both avoidances of mechanical ventilation and less invasive surfactant application are associated with reduced analgesic or sedative treatment, the percentage of VLBW infants who received analgesia and/or sedation remained unchanged in Germany in recent years.
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