Gabapentin Use in the Neonatal Intensive Care Unit

Gabapentin was used for the treatment of term and preterm infants with suspected visceral hyperalgesia caused by a variety of neurologic and gastrointestinal morbidities. Improved feeding tolerance and decreased irritability were seen, as well as decreased usage of opioids and benzodiazepines. Adverse events occurred with abrupt discontinuation of this medication.

Treating dyspnea with morphine sulfate in nonverbal children with neurological impairment

Children with severe neurological impairment (NI) are at risk for recurrent respiratory illness with risk for associated distressing respiratory symptoms as respiratory exacerbations become more frequent. Evidence for treating dyspnea in adults with severe pulmonary disease offers interventions for consideration, including morphine sulfate. This case series of four individuals with severe NI reviews the benefit from morphine for respiratory distress. Information includes descriptors of distress, starting dose, and dose increases. This is the first report to review the use of morphine for the treatment of dyspnea in nonverbal children with severe impairment of the central nervous system.

Gabapentin for management of recurrent pain in 22 nonverbal children with severe neurological impairment: a retrospective analysis

BACKGROUND

Children with severe impairment of the central nervous system (CNS) have a high incidence of distressing symptoms, with many experiencing frequent recurrent pain episodes.

OBJECTIVE

The study objective was to describe presenting pain behaviors, daily dose, and response to gabapentin for the management of frequent recurrent pain in this population.

METHODS

A retrospective analysis was performed with data from 22 children with severe impairment of the CNS residing at a long-term care facility, treated with gabapentin for recurrent pain behaviors. Response was considered significant if the frequency and severity of symptoms decreased by more than 50% as assessed by nursing staff.

RESULTS

Pain behaviors commonly reported included facial grimacing, crying, or moaning. Intermittent increase in muscle tone was identified in 86% (n=19). Gastrointestinal (GI) symptoms occurred in 64% (n=14), including pain localized to the GI tract and vomiting. All were assessed for nociceptive pain sources, many with repeated testing. Most were on medications for spasticity (n=20, 91%) and gastroesophageal reflux disease (GERD) (n=22, 100%) prior to gabapentin use. Of the 22 treated with gabapentin, 21 (91%) had a significant decrease in symptoms. No serious adverse events occurred. The mean gabapentin dose for children five years of age or less (n=11) was 50 mg/kg/day (95% CI 45-56) compared to children older than 11 years (n=11) with a mean dose of 36 mg/kg/day (95% CI 34-38).

CONCLUSIONS

Gabapentin appears to be an effective treatment for children with severe impairment of the CNS and recurrent pain behaviors, including intermittent changes in muscle tone. Dosing information can guide treatment trials and future prospective studies.

Central hypothermia as a cause of acute pancreatitis in children with neurodevelopmental impairment

Children with severe neurodevelopmental impairment are at risk for recurrent hypothermia, defined as a temperature of less than 35 degrees C, as a result of hypothalamic dysfunction. Acute pancreatitis following hypothermia from environmental exposure or induced as medical therapy has been reported in adults. In this case series of 10 children (six males, four females) with severe neurodevelopmental impairment and associated hypothermia, five had an episode of acute pancreatitis. These five patients had documented hypothermia, an elevated lipase of greater than 1000U/L, and presenting symptoms of irritability or lethargy along with gastrointestinal symptoms such as feeding intolerance. Four of these five children had no other explanation for pancreatitis; the fifth had multiple gallstones. This case series identifies the risk of acute pancreatitis in children with central hypothermia. Monitoring for resolution upon establishment of euthermia can minimize unnecessary testing and cost.

Gabapentin successfully manages chronic unexplained irritability in children with severe neurologic impairment

Neurologically impaired children have an increased frequency of recurrent pain and irritability that persist in some despite comprehensive evaluation and management of possible pain sources. We hypothesized that visceral hyperalgesia was a source of chronic unexplained irritability and report the outcome of gabapentin treatment in 9 severely neurologically impaired children. Caregivers reported marked improvement after treatment ranging from 3 months to 3 years. Nystagmus in 1 child was the only noted adverse effect. Visceral hyperalgesia may be a source of unexplained irritability in the neurologically impaired child. Symptoms may improve with gabapentin treatment.

Intergovernmental preparedness and response to potential catastrophic biological terrorism

The 20th century is replete with examples of the use of biological weapons in times of war. Today, it is only a matter of time before terrorists find a way to develop and deploy biological weapons as well. Because of the narrow window of opportunity in which treatment and prophylaxis can positively affect the outcome of those exposed to and infected by biological weapons, aggressive public health surveillance is the best early defense. A casualty management and mass prophylaxis campaign will require coordination at all levels of government involving many agencies.

Use of the Heimlich valve in a compact autotransfusion device

A compact device which evacuates blood from a hemothorax and facilitates rapid autotransfusion was evaluated in dogs. Experimental hemothorax was established surgically by incising the internal mammary artery through a thoracotomy with the animals under general anesthesia. Postoperatively the blood was drained by one of two methods. In the Heimlich valve group (n = 5), blood was drained by a chest tube through a one-way flutter valve into a collapsible plastic bag. In the Sorenson group (n = 5), blood was drained by a chest tube into the Sorenson Autotransfusion System. Blood from these two groups was then autotransfused. In the control group (n = 5), the drained blood was not autotransfused. Results showed no statistical difference between the two autotransfusion groups in the volume of blood collected, circulating fibrinogen levels, platelet counts, stroma-free hemoglobin levels, prothrombin time, or 51Cr-labeled RBC survival. There was a significant drop in the circulating platelet count, which returned to normal by 24 hours, in both groups of dogs which were autotransfused. We conclude that autotransfusion of blood collected by a compact device which utilizes a Heimlich valve and requires no suction is similar to using the Sorenson Autotransfusion System. It may be safe to use the Heimlich valve to collect blood for autotransfusion in clinical situations, where its qualities of simplicity, portability and a minimum requirement for storage space are desirable.

Controversies in autotransfusion

Although techniques for autotransfusion have been available for many years, recently the various methods of collecting and reinfusing a patient's own blood have become popular once again. There are many advantages in using a patient's own blood for transfusion, but there are many issues that remain unanswered or controversial. In an effort to clarify and, therefore, reduce many of the concerns often experienced about using autotransfused blood, we have outlined the current state-of-the-art in autotransfusion practice, primarily addressing these issues and concerns.

A comparison of preclotting techniques for prosthetic aortic replacement

Bleeding through graft interstices after replacement of the ascending aorta can occur despite the use of low-porosity, woven graft material and standard preclotting methods. To avoid this complication, improved techniques of preclotting by autoclaving the graft after immersion to either blood or plasma have been developed. We used a quantitative method to compare graft permeability in vitro. The control leak rate (LR) was 111 +/- 7 ml/cm2/min. Standard preclotting reduced this to 23 +/- 4 ml/cm2/min (p less than 0.01). Grafts were autoclaved after immersion in heparinized whole blood (LR 3 +/- 4 ml/cm2/min), 5% albumin (LR 5 +/- 2 ml/cm2/min), plasma alone (LR 4 +/- 0.3 ml/cm2/min) and plasma with thrombin added (LR 2 +/- 0.2 ml/cm2/min). All autoclaved grafts were less permeable than those preclotted by the standard method (p less than 0.01). Scanning electron microscopy showed that the interstices of autoclaved grafts were more uniformly filled than those of grafts prepared by standard preclotting. Perfusion with fibrinolysins significantly (p less than 0.01) increased leak rates of grafts with standard preclotting but did not affect autoclaved grafts. We conclude that autoclaving grafts after immersion in blood, plasma or albumin decreases graft permeability and that autoclaved grafts are resistant to fibrinolysis.

Autotransfusion of shed mediastinal blood after cardiac surgery: a prospective study

In a randomized prospective study of patients having cardiac surgery, autologous blood collected from mediastinal tubes was autotransfused preferentially in 63 patients (ATS), whereas 51 patients received bank blood for transfusion (control). Comparison of the two groups showed no significant difference in regard to age, sex, operations performed, or total postoperative bleeding (ATS 813 +/- 121 ml. per square meter versus control 711 +/- 93 ml. per square meter; N.S.) Although mean postoperative blood replacement was similar in the two groups (ATS 4.3 +/- 0.6 units per patient versus control 4.8 +/- 0.6 units per patient), requirements for transfusion of stored bank blood were reduced by 50 percent in the ATS group (ATS 2.4 +/- 0.3 units per patient versus control 4.8 +/- 0.6 units per patient; p less than 0.005). Coagulation studies demonstrated that this blood was defibrinogenated; yet it contains significantly more platelets and clotting factors than does bank blood. In this study, autotransfusion of shed mediastinal blood was safe and simple. It significantly reduced bank blood requirements and resulted in substantial financial savings for the patients and the hospital.