Pain in neonates and current practice of analgesia and sedation in

Pain in neonates
and current practice of
analgesia and sedation in NICU
Federica Ferrero
TERAPIA INTENSIVA NEONATALE E PEDIATRICA
Aou Maggiore della Carità
Novara
Padova, 13 novembre 2014
Growing interest for the topic “PAIN AND NEWBORN”
Growing interest for the topic “PAIN AND NEWBORN”
Definition of Pain
“…an unpleasant sensory and
emotional experience
associated with actual or
potential tissue damage, or
described in terms of such
damage”
In 2006, the American Academy of Pediatrics and the Canadian
Pediatric Society (AAP/CPS) published new guidelines recommending
that each healthcare facility that treats neonates establish a neonatal
pain control program
These recommendations include:
●Routine
assessments for the detection of pain
●Reduce the number of painful procedures
Background:
NO COMPLAIN DOES NOT MEAN NO PAIN
Background:
NO COMPLAIN DOES NOT MEAN NO PAIN
Bellieni CV, The AAPS Journal 2012
Background:
FACTS ABOUT PAIN IN NEONATES
- Infants, regardless of age, feel pain.
- The youngest premature infant has the anatomic and physiologic
components to perceive pain and demonstrates a severe stress response
to painful stimuli.
Biochemical changes in response to pain:
→ stress hormones: corticosterone
adrenaline, noradrenaline
glucagon
aldosterone
→ metabolites: glucose
lactate
pyruvate
Background:
FACTS ABOUT PAIN IN NEONATES
- Nociceptive nerve endings in cutaneous and mucous
surfaces by 20 weeks of gestation
-Complete myelination of pain pathways to brainstem
and thalamus by 30 weeks gestation; thalamus to cortex
by 37 weeks
- Complete myelination of nerve pathways not
required for pain transmission
- C-fibers are unmyelinated and A-delta fibers are thinly
myelinated
- Incomplete myelination results in slower
conduction velocity but offset by shorter distances
Background:
FACTS ABOUT PAIN IN NEONATES
Descending pathways that play a role in the inhibition of
incoming pain impulses do not mature until the last trimester,
which increases the preterm infant’s sensitivity to pain
Unrelieved pain can permanently change their nervous
system and may “prime” them for having chronic pain
PERIPHERAL NERVOUS SYSTEM
CHANGES IN
CENTRAL NERVOUS SYSTEM
Walker SM, Pediatric Anesthesia 2014
Changes in PERIPHERAL Nervous System
Sensitization:
↑ sensitivity of receptor (nociceptor)
↑ frequency of firing of receptor
Neuronal sprouting:
↑ receptor field
When sensitized, receptors respond to new
forms of stimulation (hyperalgesia, allodynia)
Walker SM, Pediatric Anesthesia 2014
Changes in CENTRAL Nervous System
- Central sensitization:
formation of spontaneous impulses
- Wind-up:
↑ in magnitude of response to C fiber activity by dorsal horn
neurons
- Long-term potentiation:
cellular “memory” for pain may lead to ↑ responses to
nociceptor stimuli
- Facilitation:
↓ impulse threshold and ↑ intensity of response
- Neuronal sprouting
↑ nerve endings into adjacent laminae
Long-term consequences of untreated pain
Reduce acute behavioral responses to neonatal pain,
but also
Protect from persistent sensitization of pain pathways and
potential damaging effects
Increased exposure to procedural pain has been associated
with poorer cognitive and motor scores, impairments of
growth , reduced white matter and subcortical gray matter
maturation, and altered corticospinal tract structure
Long-term consequences of untreated pain
NICU-preterms: red
NICU-fullterms: blue
Controls: green
The
preterms
showed
significantly higher activations
than
controls
in
primary
somatosensory cortex, anterior
cingulate cortex, and insula.
This
exaggerated
brain
response was pain-specific and
was not observed during nonpainful warmth stimulation.
Hohmeister, Pain 2010
It is mandatory to implement an effective
pain-prevention program that includes:
 minimizing the number of painful
procedures
 strategies for routinely assessing pain
 using pharmacologic and nonpharmacologic therapies
 preventing and treating pain associated
with surgery and other major procedures.
INSTRUMENTS FOR SCORING PHYSIOLOGICAL AND
BEHAVIORAL CUES OF PAIN, NON-PAIN RELATED
DISTRESS, AND ADEQUACY OF ANALGESIA
Neonatal Facial Action Coding System
Grunau R, Craig K –Pain 1987
RESPONSES OF INFANTS TO PAIN
Neonatal pain assessment tools
for procedural and post operative pain
for sedation and agitation in ventilated patients
Giordano V et all Acta Paediatr. 2014
Observational scales recommended for pain assessment in newborns
are:
PIPP
CRIES
N-PASS
EDIN
Sedation must be regularly assessed and documented using
adequate monitoring scales
COMFORT scale, validated also for the neonatal age, is the
most utilised tool
Minerva Anestesiol. 2014
Pain assessment tools: PIPP
(Premature Infant Pain Profile)
Reliability >0,93
Stevens B, Clin J Pain, 1996
Pain assessment tools: CRIES
Reliability >0,72
Krechel SM, Paediatr Anaesth 1995
Pain assessment tools: N-PASS
(Neonatal Pain, Agitation and Sedation Scale)
Hummel P, J Perinatol 2008
Pain assessment tools: EDIN
(Échelle Douleur Inconfort Nouveau-Né)
Debillon T, Arch Dis Child Fetal Neonatal Ed 2001
COMFORT scale
8-16 deep sedation
17-26 optimal sedation
27-40 inadequate sedation
Ambuel B, J Pediatr Psychol 1992
What's new? PIPP-R
Stevens J, Clin J Pain 2014
What's new? NIAPAS
(Neonatal Infant Acute Pain Assessment Scale)
Pollki T, Int J Nurs Stud. 2014
What's new? ALPS-NEO
(Astrid Lindgren Children’s Hospital Pain
Assessment Scale for term neonates)
Lunqvist P, Acta Paediatr 2014
Treating pain step by step
Whit Hall R, Clin Perinatol. 2012
Non-pharmacological techniques
neonates could benefice of non pharmacological
interventions (NPIs) to relieve mild to moderate pain,
anxiety and discomfort from minor invasive procedures.
Non-pharmacological intervention for neonatal pain control
Lago P, Italian Journal of Pediatrics 2014
Non-pharmacological techniques
2013
- Sucrose is safe and effective for
reducing procedural pain from single
events.
- An optimal dose could not be
identified.
-Further investigation on repeated
administration of sucrose in neonates
and the use of sucrose in combination
with other non-pharmacological and
pharmacological
interventions
is
needed.
- Sucrose use in extremely preterm,
unstable, ventilated (or a combination
of these) neonates needs to be
addressed.
- Additional research is needed to
determine the minimally effective dose
of sucrose
Non-pharmacological techniques
SSC appears to be effective and safe
for a single painful procedure such as a
heel lance. .
- There was more heterogeneity in the
studies with behavioural or composite
outcomes.
There
is
a
need
for
replication studies that use similar,
clearly defined outcomes.
-
New
duration
2014
studies
of
examining
SSC,
optimal
gestational
age
groups, repeated use, and long-term
effects of SSC are needed.
Sucrose (oral) for procedural pain
blood tests by means of heel pricks, venipuncture or arterial stabs
intravenous catheter insertion
lumbar puncture
suture removal
dressings
urinary catheter insertion
intramuscular or subcutaneous injections
eye examination
adhesive tape removal
nasogastric insertion
Patient group
Nil Orally
<1500 grams
Babies 0-1mths
Infants 1-18 mths
Recommended
maximum for a
particular
procedure
0.2 mls
0.2-0.5 mls
0.2-1 ml
1-2 mls
Recommended
maximum in 24
hrs
1 ml
2.5 mls
5 mls
5 ml/s
“heel-lances” in preterm newborns
three different treatment: administration of fentanyl (FE, 1–2
μg/kg), facilitated tucking (FT), sensorial saturation (SS).
CRIES score was used to evaluate the procedural pain.
The results showed that the reduction in the pain score was
greater in FE and SS groups than FT group.
Repeated invasive procedures occur routinely
 Heel lancing
- pacifier with sucrose (concentration 12% - 24%) given 2 minutes
before the procedure OR
- breast feeding OR
- multisensory stimulation (+/- skin contact)
Venepuncture is the preferred method for blood sampling in term
newborns as it is less painful, more efficient and requires less
resampling.
Topical anaesthesia with EMLA cream ( eutectic mixture of
lidocaine and prilocaine hydrochloride in an emulsion base) or
amethocaine gel or 5% lignocaine ointment, acetaminophen, and
warming the heel are ineffective for heel lancing; squeezing for
blood collection is the most painful part of the procedure.
Umbilical Arterial & Venous Catheter Insertion
Consider the use of a pacifier with sucrose
Use containment by holding the infant
Avoid the placement of sutures or hemostat clamps on the skin around the
umbilicus
Periferal Arterial & Venous Punctures/Insertions
Use a pacifier with sucrose
Use swaddling or containment by holding the infant
Consider opioid dose(s), if intravenous access is available Consider
subcutaneous infiltration of lignocaine
Consider applying EMLA (0.5-1g) to the proposed site 60-90 minutes prior
to insertion (when nonurgent)
 Endotracheal Intubation
Tracheal intubation without the use of analgesia or sedation
should be performed only for resuscitation in the delivery room
or for other life-threatening situations associated with the
unavailability of intravenous access
Combination of drugs: the superior efficacy of any one technique is
not supported by current evidence
-Consider using a topical lignocaine spray, if available
 Endotracheal Suction
This is considered a stressful procedure
-pacifier, consider giving sucrose, swaddling or containment
Consider continuous intravenous infusion of opioids (morphine) or
slow injection o Intermittent opioid doses, although this may not be
indicated in preterm infants
Lumbar Puncture
Use a pacifier with sucrose
Consider subcutaneous infiltration of lignocaine
Consider applying EMLA (0.5-1g) the proposed site 60-90 minutes
beforehand
Chest Tube Insertion
Anticipate the need for intubation and ventilation in neonates
breathing spontaneously
Use a pacifier with sucrose
Use subcutaneous infiltration of lignocaine
Systemic analgesia with a rapidly acting opiate such as fentanyl..
.
a wide practice gap between what is known and
what occurs in practice.
in 2004 only 10% of units used sucrose prior to a heel lance,
.
Results: There was a 21% overall improvement in the number of infants
receiving breastfeeding or sucrose for procedural pain, however,
breastfeeding rates remain poorly utilised.
The use of a pain assessment tool increased from 14% to 22%
POSTOPERATIVE AND PROLONGED PAIN
CURRENT PRACTICE IN NICU
EUROPAIN Survey
6700 ventilated and
not ventilated neonates
MORFINA
FENTANYL
MIDAZOLAM
PARACET.
53%
30%
30%
4,2%
Carbajal, EAPS 2014
REDUCING PAIN FROM SURGERY
Paracetamol can be used after surgery as an adjunct to regional
anesthetics or opioids.
Inadequate data on pharmacokinetics at gestational ages less
than 28 weeks to permit calculation of appropriate dosages.
Opioids should be the basis for postoperative analgesia after major
surgery and can be given by continuous infusion or by regular
bolus.
Randomized trials do not show any substantial benefit of
continuous infusion of opioids over intermittent dosing,
AMERICAN ACADEMY OF PEDIATRICS
CANADIAN PAEDIATRIC SOCIETY
Pediatrics 2006
13 studies on 1505 infants
Some works underlined the paucity of scientific evidence defining
optimal drug regimens and describing adverse effects
Uncertainty remains about long-term effects of opioid use and
about which opioid is most effective and safe.
No significant difference in combined death and disability rates
between morphine and non-morphine groups
Insufficient evidence to recommend routine use of opioids in
mechanically ventilated newborns.
2013
2013
The lack of prolonged reduction in pain scores and the
greater side effects associated with continuous fentanyl
infusion do not support the routine use of this treatment
in mechanically ventilated preterm newborns.
Boluses of fentanyl before invasive procedures or on the
basis of pain scores have the same efficacy and are
safer than continuous infusion and can be
recommended in such cases.
The routine use of continuous infusions of morphine,
fentanyl, or midazolam in chronically ventilated
preterm neonates is not recommended because of
concern about short-term adverse effects and lack of
long-term outcome data.
Midazolam has been evaluated as a sedative in
mechanically ventilated preterm infants. A Cochrane
Database Systematic Review recently concluded that
there were insufficient data to promote use of midazolam
because of a lack of demonstrated benefit and concern
for an increased risk of poor neurologic outcome
What is recommended
Caregivers should be trained to assess neonates for pain using
multidimensional tools.
Neonates should be assessed for pain routinely and before and
after procedures.
The chosen pain scales should help guide caregivers in the
provision of effective pain relief.
Use of a combination of oral sucrose/glucose and
other nonpharmacologic pain-reduction methods should be used
for minor routine procedures.
Topical anesthetics can be used to reduce pain associated with
venipuncture, lumbar puncture, and intravenous catheter insertion
but are ineffective for heel-stick blood draws, and repeated use of
topical anesthetics should be limited.
What is under discussion
 Concern about adverse respiratory effects of continuous
opioid infusions in chronically ventilated preterm infants
 Routine morphine infusion in preterm ventilated newborns
has no measurable analgesic effect and no effect on poor
neurological outcome
 Midazolam in premature infants maybe associated with a
higher incidence of adverse neurological events and longer
NICU stay
 Multimodal analgesia: comparison of analgesic techniques
to delineate the relative safety and efficacy of different drugs
Optimal pain management
is the right of all patients
and the responsibility of all
health professionals

Download Report