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dos Santos IN, Peano CTG, Soares ES, Cimarosti HI. Iatrogenic Withdrawal Syndrome in Critically Ill Neonates: A Review of Mechanisms, Assessment, Management, and Prevention. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
AbstractConsidering that neonatal pain is a relevant matter given its implications and consequences, many neonates, particularly those undergoing critical care, are subjected to analgo-sedation therapies, which commonly includes treatment with opioids and benzodiazepines. These drugs, however, can induce tolerance and dependency, leading to the development of the so-called iatrogenic withdrawal syndrome (IWS) which is observed following discontinuation of these therapeutic agents particularly when utilized for a prolonged period of time (≥5 days). IWS consists of signs and symptoms manifested especially in young children, such as term and premature newborns in the neonatal intensive care unit, who are less capable of metabolizing and eliminating these drugs, compared with older patients. In this study, we review assessment tools that were developed to identify, evaluate, and manage children affected by IWS. The studies reviewed demonstrate that optimal management of IWS includes consideration of alternate routes of drug administration, the need for adequate time for drug tapering, and also the presence of planned rescue therapy when encountering cases refractory to ongoing management. Equally important is prevention of IWS which can be accomplished with the implementation of drug rotation protocols and, adherence to evidenced-based guidelines which facilitate an overall decline in the use and duration of opioids and benzodiazepines. Finally, our review strongly supports the need for more research on IWS in neonates given their increased susceptibility and sparse published data for this age group.
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Affiliation(s)
- Isaque Nilton dos Santos
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
| | - Carolina Teixeira Goulart Peano
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
| | - Ericks Sousa Soares
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
| | - Helena Iturvides Cimarosti
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
- Postgraduate Program in Neuroscience, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
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Tauzin M, Gouyon B, Hirt D, Carbajal R, Gouyon JB, Brunet AC, Ortala M, Goro S, Jung C, Durrmeyer X. Frequencies, Modalities, Doses and Duration of Computerized Prescriptions for Sedative, Analgesic, Anesthetic and Paralytic Drugs in Neonates Requiring Intensive Care: A Prospective Pharmacoepidemiologic Cohort Study in 30 French NICUs From 2014 to 2020. Front Pharmacol 2022; 13:939869. [PMID: 35924063 PMCID: PMC9341520 DOI: 10.3389/fphar.2022.939869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: No consensus exists about the doses of analgesics, sedatives, anesthetics, and paralytics used in critically ill neonates. Large-scale, detailed pharmacoepidemiologic studies of prescription practices are a prerequisite to future research. This study aimed to describe the detailed prescriptions of these drug classes in neonates hospitalized in neonatal intensive care units (NICU) from computerized prescription records and to compare prescriptions by gestational age. Materials and Methods: We included all neonates requiring intensive care in 30 French level III units from 2014 through 2020 with a computerized prescription for an analgesic, sedative, anesthetic, or paralytic agent. We described frequencies of prescription, methods of administration, concomitant drug prescriptions, and dosing regimen, and compared them across gestational ages. Results: Among 65,555 neonates, 29,340 (44.8%) were prescribed at least one analgesic (acetaminophen in 37.2% and opioids in 17.8%), sedative (9.8%), anesthetic (8.5%), and/or paralytic agent (1%). Among preterm infants born before 28 weeks, 3,771/4,283 (88.0%) were prescribed at least one of these agents: 69.7% opioids, 41.2% sedatives, 32.5% anesthetics, and 5.8% paralytics. The most frequently prescribed agents were sufentanil (in 10.3% of neonates) and morphine (in 8.0% of neonates) for opioids, midazolam (9.3%) for sedatives, ketamine (5.7%) and propofol (3.3%) for anesthetics. In most neonates, opioids and sedatives were prescribed as continuous infusion, whereas anesthetics were prescribed as single doses. Opioids, sedatives and paralytics were mostly prescribed in association with another agent. Doses varied significantly by gestational age but within a limited range. Gestational age was inversely related to the frequency, cumulative dose and duration of prescriptions. For example, morphine prescriptions showed median (IQR) cumulative doses of 2601 (848-6750) vs. 934 (434-2679) µg/kg and median (IQR) durations of 7 (3-15) vs. 3 (2-5) days in infants born <28 vs. ≥ 37 weeks of gestation, respectively (p-value<0.001). Conclusion: The prescriptions of analgesic, sedative, anesthetic, or paralytic agent were frequent and often combined in the NICU. Lower gestational age was associated with higher frequencies, longer durations and higher cumulative doses of these prescriptions. Dose-finding studies to determine individualized dosing regimens and studies on long-term neurodevelopmental outcome according to received cumulative doses are required.
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Affiliation(s)
- Manon Tauzin
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France
| | - Béatrice Gouyon
- Centre d’Etudes Périnatales de L’Océan Indien (CEPOI, EA7388), Université de La Réunion, Saint Pierre, France
| | - Déborah Hirt
- Pharmacology Department, Hôpital Cochin APHP, Paris, France
| | - Ricardo Carbajal
- Pediatric Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Armand Trousseau- Sorbonne Université, Paris, France
- Institut National de La Santé et de La Recherche Médicale UMR1153, Paris, France
| | - Jean-Bernard Gouyon
- Centre d’Etudes Périnatales de L’Océan Indien (CEPOI, EA7388), Université de La Réunion, Saint Pierre, France
| | | | | | - Seydou Goro
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Camille Jung
- Clinical Research Center, CHI Créteil, Créteil, 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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Donato J, Rao K, Lewis T. Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit. Clin Perinatol 2019; 46:673-692. [PMID: 31653302 DOI: 10.1016/j.clp.2019.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.
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Affiliation(s)
- Jamesia Donato
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Karishma Rao
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Tamorah Lewis
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Division of Pediatric Clinical Pharmacology, UMKC School of Medicine, Children's Mercy Hospital, Kansas City, MO, USA.
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Norman E, Kindblom JM, Rane A, Berg A, Schubert U, Hallberg B, Fellman V. Individual variations in fentanyl pharmacokinetics and pharmacodynamics in preterm infants. Acta Paediatr 2019; 108:1441-1446. [PMID: 30721546 DOI: 10.1111/apa.14744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/02/2018] [Accepted: 02/01/2019] [Indexed: 12/24/2022]
Abstract
AIM Fentanyl pharmacokinetics and pharmacodynamics are lacking in preterm infants. Our aim was to study these and their relation with a new formulation of fentanyl 5 μg/mL for procedural pain. METHODS Preterm infants were given 0.5 (n = 20, median gestational age 26.5; range 23.3-34.1 weeks) and 2 μg/kg (n = 8, 27.4; 25.3-30.7 weeks) fentanyl, respectively, before skin-breaking procedures or tracheal intubation. Blood samples were collected after ten minutes, two, four, eight and 24 hours. Physiologic parameters were monitored and pain scores assessed. RESULTS The median fentanyl concentrations were 0.18, 0.15, 0.15 and 0.57, 0.37, 0.35 ng/mL at 15-31 minutes, two and four hours and the half-lives were 1.6 to 20.5 or 4.1 to 32.6 hours for the low- and high-dose groups, respectively. A significant correlation was seen between weight at study inclusion and half-life (Spearman's r = -0.9, p < 0.001), volume of distribution (r = -0.8, p < 0.01) and clearance (r = -0.9, p < 0.01) in the low-dose group (n = 9). Pain assessment results were not correlated to pharmacokinetic variables. Fentanyl was well tolerated. CONCLUSION The inter-individual variation of fentanyl pharmacokinetics is large in preterm infants, and the dose of 0.5 μg/kg seems not effective for skin-breaking procedures.
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Affiliation(s)
- Elisabeth Norman
- Department of Clinical Sciences, Pediatrics, Lund Lund University Lund Sweden
- Neonatology Skåne University Hospital Lund Sweden
| | | | - Anders Rane
- Division of Clinical Pharmacology Karolinska University Hospital (Huddinge site) and Karolinska Institutet Stockholm Sweden
| | - Ann‐Cathrine Berg
- Department of Clinical Sciences, Pediatrics, Lund Lund University Lund Sweden
- Neonatology Skåne University Hospital Lund Sweden
| | - Ulf Schubert
- Department of Neonatology Karolinska University Hospital and Karolinska Institutet CLINTEC Stockholm Sweden
| | - Boubou Hallberg
- Department of Neonatology Karolinska University Hospital and Karolinska Institutet CLINTEC Stockholm Sweden
| | - Vineta Fellman
- Department of Clinical Sciences, Pediatrics, Lund Lund University Lund Sweden
- Neonatology Skåne University Hospital Lund Sweden
- Children′s Hospital University of Helsinki Helsinki Finland
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Pirlotte S, Beeckman K, Ooms I, Van Rompaey B, Cools F. Pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates. Hippokratia 2019. [DOI: 10.1002/14651858.cd013355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Katrien Beeckman
- Universiteit Antwerpen; Midwifery Research, Education and Policymaking; Brussel Belgium
| | - Isabel Ooms
- UZ Brussel; Physiotherapy and Neonatology; Jette Belgium
| | - Bart Van Rompaey
- University of Antwerp; Department of Nursing and Midwifery; Antwerp Belgium
| | - Filip Cools
- UZ Brussel; Department Neonatology; Laarbeeklaan Brussels Belgium
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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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Flint RB, van Beek F, Andriessen P, Zimmermann LJ, Liem KD, Reiss IKM, de Groot R, Tibboel D, Burger DM, Simons SHP. Large differences in neonatal drug use between NICUs are common practice: time for consensus? Br J Clin Pharmacol 2018; 84:1313-1323. [PMID: 29624207 PMCID: PMC5980600 DOI: 10.1111/bcp.13563] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/24/2018] [Accepted: 02/11/2018] [Indexed: 01/27/2023] Open
Abstract
Aims Evidence for drug use in newborns is sparse, which may cause large differences in drug prescriptions. We aimed to investigate the differences between neonatal intensive care units (NICUs) in the Netherlands in currently prescribed drugs. Methods This multicentre study included neonates admitted during 12 months to four different NICUs. Drugs were classified in accordance with the Anatomical Therapeutic Chemical (ATC) classification system and assessed for on/off‐label status in relation to neonatal age. The treatment protocols for four common indications for drug use were compared: pain, intubation, convulsions and hypotension. Results A total of 1491 neonates (GA range 23+6–42+2 weeks) were included with a total of 32 182 patient days, 181 different drugs and 10 895 prescriptions of which 23% was off‐label in relation to neonatal age. Overall, anti‐infective drugs were most frequently used with a total of 3161 prescriptions, of which 4% was off‐label in relation to neonatal age. Nervous system drugs included 2500 prescriptions of which 31% was off‐label in relation to neonatal age. Nervous system drugs, blood and blood forming organs, and cardiovascular drugs showed the largest differences between NICUs with ranges of 919–2278, 554–1465, and 238–952 total prescriptions per 1000 patients per ATC class, respectively. Conclusions We showed that drug use varies widely in neonatal clinical practice. The drug classes with the highest proportion of off‐label drugs in relation to neonatal age showed the largest differences between NICUs, i.e. cardiovascular and nervous system drugs. Drug research in neonates should receive high priority to guarantee safe and appropriate medicines and optimal treatment.
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Affiliation(s)
- Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Floor van Beek
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter Andriessen
- Department of Pediatrics, Division of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Luc J Zimmermann
- Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht, The Netherlands
| | - Kian D Liem
- Department of Pediatrics, Division of Neonatology, Radboudumc, Nijmegen, Nijmegen, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ronald de Groot
- Laboratory of Pediatric Infectious Diseases, Department of Pediatrics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Department of Pediatrics, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - David M Burger
- Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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Abstract
Purpose of review Pain management presents a major challenge in neonatal care. Newborn infants who require medical treatment can undergo frequent invasive procedures during a critical period of neurodevelopment. However, adequate analgesic provision is infrequently and inconsistently provided for acute noxious procedures because of limited and conflicting evidence regarding analgesic efficacy and safety of most commonly used pharmacological agents. Here, we review recent advances in the measurement of infant pain and discuss clinical trials that assess the efficacy of pharmacological analgesia in infants. Recent findings Recently developed measures of noxious-evoked brain activity are sensitive to analgesic modulation, providing an objective quantitative outcome measure that can be used in clinical trials of analgesics. Summary Noxious stimulation evokes changes in activity across all levels of the infant nervous system, including reflex activity, altered brain activity and behaviour, and long-lasting changes in infant physiological stability. A multimodal approach is needed if we are to identify efficacious and well tolerated analgesic treatments. Well designed clinical trials are urgently required to improve analgesic provision in the infant population.
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Smits A, Annaert P, Allegaert K. Biomarkers of propofol metabolism in neonates: the quest beyond ontogeny. Biomark Med 2017; 11:933-936. [PMID: 29057662 DOI: 10.2217/bmm-2017-0184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Anne Smits
- Neonatal intensive care unit, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery & Disposition, Department of Pharmaceutical & Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium.,Intensive Care & Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Propofol as an Adjunct for Neonatal Intubation: The Contribution of Clinical Pharmacology. J Pediatr 2016; 179:9-10. [PMID: 27726868 DOI: 10.1016/j.jpeds.2016.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 09/12/2016] [Indexed: 11/21/2022]
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