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Franklin AD, Tsao K, Barq R, Kelley-Quon LI, Veneziano G, Aldrink JH. Updates From the Other Side of the Drape: Recent Advances in Multimodal Pain Management and Opioid Reduction Among Pediatric Surgical Patients. J Pediatr Surg 2024; 59:1297-1303. [PMID: 38614947 DOI: 10.1016/j.jpedsurg.2024.03.027] [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] [Received: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
As the management of acute pain for children undergoing surgical procedures as well as recognition of the short and long term risks of exposure to opioids has evolved, multimodal and multidisciplinary approaches using organized pathways has resulted in improved perioperative outcomes and patient satisfaction. In this 2023 symposium held at the American Academy of Pediatrics on Surgery meeting, a multidisciplinary discussion on current enhanced recovery after surgery pathways, alternate methods of effective pain control and education and advocacy efforts for opioid reduction were discussed, and highlights are included in this article.
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Affiliation(s)
- Andrew D Franklin
- Division of Pediatric Anesthesia, Department of Anesthesia, Vanderbilt University Medical Center, Nashville, TN, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Rabab Barq
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
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2
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Hannan KE, Bourque SL, Ross E, Wymore EM, Kinsella JP, Mandell EW, Houin SS. Successful and Rapid Reduction in Neurosedative and Analgesic Medications in Complex Infants with Severe Bronchopulmonary Dysplasia After Tracheostomy Placement: Experience with 24-hour Propofol Infusions. J Pediatr 2024; 270:114040. [PMID: 38554746 DOI: 10.1016/j.jpeds.2024.114040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
Infants with severe bronchopulmonary dysplasia may require high doses of neurosedative medications to ensure pain control and stability following tracheostomy placement. Subsequent weaning of these medications safely and rapidly is a challenge. We describe a 24-hour propofol infusion to reduce neurosedative medications in 3 high-risk infants following tracheostomy placement.
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Affiliation(s)
- Kathleen E Hannan
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Stephanie L Bourque
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Emma Ross
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Erica M Wymore
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Erica W Mandell
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Satya S Houin
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Selvanathan T, Miller SP. Brain health in preterm infants: importance of early-life pain and analgesia exposure. Pediatr Res 2024:10.1038/s41390-024-03245-w. [PMID: 38806664 DOI: 10.1038/s41390-024-03245-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/23/2024] [Indexed: 05/30/2024]
Abstract
"Everyday" exposures in the neonatal period, such as pain, may impact brain health in preterm infants. Specifically, greater exposure to painful procedures in the initial weeks after birth have been related to abnormalities in brain maturation and growth and poorer neurodevelopmental outcomes in preterm infants. Despite an increasing focus on the importance of treating pain in preterm infants, there is a lack of consensus of optimal approaches to managing pain in this population. This may be due to recent findings suggesting that commonly used analgesic and sedative medications in preterm infants may also have adverse effects of brain maturation and neurodevelopmental outcomes. This review provides an overview of potential impacts of pain and analgesia exposure on preterm brain health while highlighting research areas in need of additional investigations for the development of optimal pain management strategies in this population.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven P Miller
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
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Selvanathan T, Ufkes S, Guo T, Chau V, Branson HM, Ibrahim GM, Ly LG, Kelly EN, Grunau RE, Miller SP. Pain Exposure and Brain Connectivity in Preterm Infants. JAMA Netw Open 2024; 7:e242551. [PMID: 38488791 PMCID: PMC10943417 DOI: 10.1001/jamanetworkopen.2024.2551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/24/2024] [Indexed: 03/18/2024] Open
Abstract
Importance Early-life exposure to painful procedures has been associated with altered brain maturation and neurodevelopmental outcomes in preterm infants, although sex-specific differences are largely unknown. Objective To examine sex-specific associations among early-life pain exposure, alterations in neonatal structural connectivity, and 18-month neurodevelopment in preterm infants. Design, Setting, and Participants This prospective cohort study recruited 193 very preterm infants from April 1, 2015, to April 1, 2019, across 2 tertiary neonatal intensive care units in Toronto, Canada. Structural connectivity data were available for 150 infants; neurodevelopmental outcomes were available for 123 infants. Data were analyzed from January 1, 2022, to December 31, 2023. Exposure Pain was quantified in the initial weeks after birth as the total number of invasive procedures. Main Outcome and Measure Infants underwent early-life and/or term-equivalent-age magnetic resonance imaging with diffusion tensor imaging to quantify structural connectivity using graph theory measures and regional connection strength. Eighteen-month neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition. Stratifying by sex, generalized estimating equations were used to assess whether pain exposure modified the maturation of structural connectivity using an interaction term (early-life pain exposure × postmenstrual age [PMA] at scan). Generalized estimating equations were used to assess associations between structural connectivity and neurodevelopmental outcomes, adjusting for extreme prematurity and maternal education. Results A total of 150 infants (80 [53%] male; median [IQR] gestational age at birth, 27.1 [25.4-29.0] weeks) with structural connectivity data were analyzed. Sex-specific associations were found between early-life pain and neonatal brain connectivity in female infants only, with greater early-life pain exposure associated with slower maturation in global efficiency (pain × PMA at scan interaction P = .002) and local efficiency (pain × PMA at scan interaction P = .005). In the full cohort, greater pain exposure was associated with lower global efficiency (coefficient, -0.46; 95% CI, -0.78, to -0.15; P = .004) and local efficiency (coefficient, -0.57; 95% CI, -1.04 to -0.10; P = .02) and regional connection strength. Local efficiency (coefficient, 0.003; 95% CI, 0.001-0.004; P = .005) and regional connection strength in the striatum were associated with cognitive outcomes. Conclusions and Relevance In this cohort study of very preterm infants, greater exposure to early-life pain was associated with altered maturation of neonatal structural connectivity, particularly in female infants. Alterations in structural connectivity were associated with neurodevelopmental outcomes, with potential regional specificities.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Steven Ufkes
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Computational Medicine, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ting Guo
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Vann Chau
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Helen M. Branson
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - George M. Ibrahim
- Department of Surgery, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Linh G. Ly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Edmond N. Kelly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ruth E. Grunau
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven P. Miller
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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5
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Keane OA, Ourshalimian S, Lakshmanan A, Lee HC, Hintz SR, Nguyen N, Ing MC, Gong CL, Kaplan C, Kelley-Quon LI. Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US. JAMA Netw Open 2024; 7:e240555. [PMID: 38470421 PMCID: PMC10936113 DOI: 10.1001/jamanetworkopen.2024.0555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/04/2024] [Indexed: 03/13/2024] Open
Abstract
Importance High-risk infants, defined as newborns with substantial neonatal-perinatal morbidities, often undergo multiple procedures and require prolonged intubation, resulting in extended opioid exposure that is associated with poor outcomes. Understanding variation in opioid prescribing can inform quality improvement and best-practice initiatives. Objective To examine regional and institutional variation in opioid prescribing, including short- and long-acting agents, in high-risk hospitalized infants. Design, Setting, and Participants This retrospective cohort study assessed high-risk infants younger than 1 year from January 1, 2016, to December 31, 2022, at 47 children's hospitals participating in the Pediatric Health Information System (PHIS). The cohort was stratified by US Census region (Northeast, South, Midwest, and West). Variation in cumulative days of opioid exposure and methadone treatment was examined among institutions using a hierarchical generalized linear model. High-risk infants were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and other abdominal surgery. Infants with neonatal opioid withdrawal syndrome, in utero substance exposure, or malignant tumors were excluded. Exposure Any opioid exposure and methadone treatment. Main Outcomes and Measures Regional and institutional variations in opioid exposure. Results Overall, 132 658 high-risk infants were identified (median [IQR] gestational age, 34 [28-38] weeks; 54.5% male). Prematurity occurred in 30.3%, and 55.3% underwent surgery. During hospitalization, 76.5% of high-risk infants were exposed to opioids and 7.9% received methadone. Median (IQR) length of any opioid exposure was 5 (2-12) cumulative days, and median (IQR) length of methadone treatment was 19 (7-46) cumulative days. There was significant hospital-level variation in opioid and methadone exposure and cumulative days of exposure within each US region. The computed intraclass correlation coefficient estimated that 16% of the variability in overall opioid prescribing and 20% of the variability in methadone treatment was attributed to the individual hospital. Conclusions and Relevance In this retrospective cohort study of high-risk hospitalized infants, institution-level variation in overall opioid exposure and methadone treatment persisted across the US. These findings highlight the need for standardization of opioid prescribing in this vulnerable population.
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Affiliation(s)
- Olivia A. Keane
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, California
| | - Henry C. Lee
- Division of Neonatology, University of California San Diego, La Jolla
| | - Susan R. Hintz
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatology, Palo Alto, California
| | - Nam Nguyen
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Division of Pediatric Surgery, Memorial Care Miller Children’s & Women’s Hospital, Long Beach, California
| | - Madeleine C. Ing
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Cynthia L. Gong
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Cameron Kaplan
- USC Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles
| | - Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
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van Haren JS, Delbressine FLM, Schoberer M, te Pas AB, van Laar JOEH, Oei SG, van der Hout-van der Jagt MB. Transferring an extremely premature infant to an extra-uterine life support system: a prospective view on the obstetric procedure. Front Pediatr 2024; 12:1360111. [PMID: 38425664 PMCID: PMC10902175 DOI: 10.3389/fped.2024.1360111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
To improve care for extremely premature infants, the development of an extrauterine environment for newborn development is being researched, known as Artificial Placenta and Artificial Womb (APAW) technology. APAW facilitates extended development in a liquid-filled incubator with oxygen and nutrient supply through an oxygenator connected to the umbilical vessels. This setup is intended to provide the optimal environment for further development, allowing further lung maturation by delaying gas exposure to oxygen. This innovative treatment necessitates interventions in obstetric procedures to transfer an infant from the native to an artificial womb, while preventing fetal-to-neonatal transition. In this narrative review we analyze relevant fetal physiology literature, provide an overview of insights from APAW studies, and identify considerations for the obstetric procedure from the native uterus to an APAW system. Lastly, this review provides suggestions to improve sterility, fetal and maternal well-being, and the prevention of neonatal transition.
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Affiliation(s)
- Juliette S. van Haren
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, Netherlands
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
| | | | - Mark Schoberer
- Institute for Applied Medical Engineering and Clinic for Neonatology, University Hospital Aachen, Aachen, Germany
| | - Arjan B. te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Judith O. E. H. van Laar
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - S. Guid Oei
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - M. Beatrijs van der Hout-van der Jagt
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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Oschman A, Rao K. Challenges in management of refractory pain and sedation in infants. Front Pharmacol 2024; 14:1259064. [PMID: 38235119 PMCID: PMC10791862 DOI: 10.3389/fphar.2023.1259064] [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: 07/15/2023] [Accepted: 12/08/2023] [Indexed: 01/19/2024] Open
Abstract
The survival of preterm infants continues to improve, along with an increased in neonatal intensive care unit (NICU) management of chronic infants who are medically complex infants who have prolonged hospital stays, sometimes up until 2 years of age. Despite advances in neonatal and infant care, the management of pain and sedation in chronic NICU patients continues to be a challenge. Challenges such as development of appropriate pain, sedation, and withdrawal scales along with unfamiliarity of the NICU care team with pediatric disease states and pharmacotherapy complicate management of these patients. Opioid induced hyperalgesia (OIH) and delirium may play a large role in these refractory cases, yet are often not considered in the NICU population. Drug therapy interventions such as gabapentin, ketamine, risperidone, and others have limited data for safety and efficacy in this population. This article summarizes the available literature regarding the evidence for diagnosis and management of infants with refractory pain and sedation along with the challenges that clinicians face when managing these patients.
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Affiliation(s)
- Alexandra Oschman
- Department of Pharmacy, Children’s Mercy Hospital, Kansas City, MO, United States
| | - Karishma Rao
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
- University of Missouri Kansas City School of Medicine, Kansas City, MO, United States
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Hardin BG, McCarter A, Hamrick SEG. A Delirium Prevention and Management Initiative: Implementing a Best Practice Recommendation for the NICU. Neonatal Netw 2024; 43:19-34. [PMID: 38267090 DOI: 10.1891/nn-2023-0041] [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] [Indexed: 01/26/2024]
Abstract
Medically complex infants experiencing NICU stays can be difficult to manage, exhibiting refractory agitation, disengagement, or both-all signs of delirium, which can present in a hypoactive, hyperactive, or mixed form. Though documented in other settings, delirium is under-recognized in NICUs. Pediatric studies show that a high percentage of patients with delirium are under the age of 12 months. Delirium is associated with increased ventilation days, hospital days, and costs. It negatively affects neurodevelopment and social interaction. Studies show that pediatric nurses are unprepared to recognize delirium. Our nurse-led multidisciplinary group created a best practice recommendation (BPR) focused on detecting delirium and minimizing risk through thoughtful sedation management, promotion of sleep hygiene and mobility, and facilitation of meaningful caregiver presence. Occasionally, medications, including melatonin and risperidone, are helpful. In 2019, we introduced this BPR to reduce delirium risk in our NICU. Practice changes tied to this initiative correlate with a significant reduction in delirium scores and risk including exposure to deliriogenic medications. A multidisciplinary care bundle correlates with decreased delirium screening scores in NICU patients.
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Archer VA, Samiee-Zafarghandy S, Farrokyhar F, Briatico D, Braga LH, Walton JM. Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP). PLoS One 2023; 18:e0294519. [PMID: 37983228 PMCID: PMC10659208 DOI: 10.1371/journal.pone.0294519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05678244, Registered December 6, 2022.
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Affiliation(s)
- Victoria Anne Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | | | - Daniel Briatico
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Luis H. Braga
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - J. Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Curtis S, Kilpatrick R, Billimoria ZC, Zimmerman K, Tolia V, Clark R, Greenberg RG, Puia-Dumitrescu M. Use of Dexmedetomidine and Opioids in Hospitalized Preterm Infants. JAMA Netw Open 2023; 6:e2341033. [PMID: 37921767 PMCID: PMC10625033 DOI: 10.1001/jamanetworkopen.2023.41033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
Importance Dexmedetomidine, an α2-adrenergic agonist, is not approved by the Food and Drug Administration for use in premature infants. However, the off-label use of dexmedetomidine in premature infants has increased 50-fold in the past decade. Currently, there are no large studies characterizing dexmedetomidine use in US neonatal intensive care units (NICUs) or comparing the use of dexmedetomidine vs opioids in infants. Objectives To describe dexmedetomidine use patterns in the NICU and examine the association between dexmedetomidine and opioid use in premature infants. Design, Setting, and Participants A multicenter, observational cohort study was conducted from November 11, 2022, to April 4, 2023. Participants were inborn infants born between 22 weeks, 0 days, and 36 weeks, 6 days, of gestation at 1 of 383 Pediatrix Medical Group NICUs across the US between calendar years 2010 and 2020. Main Outcome and Measure Exposure to medications of interest defined as total days of exposure, timing of use, and changes over time. Results A total of 395 122 infants were included in the analysis. Median gestational age was 34 (IQR, 32-35) weeks, and median birth weight was 2040 (IQR, 1606-2440) g. There were 384 infants (0.1% of total; 58.9% male) who received dexmedetomidine. Infants who received dexmedetomidine were born more immature, had lower birth weight, longer length of hospitalization, more opioid exposure, and more days of mechanical ventilation. Dexmedetomidine use increased from 0.003% in 2010 to 0.185% in 2020 (P < .001 for trend), while overall opioid exposure decreased from 8.5% in 2010 to 7.2% in 2020 (P < .001 for trend). The median postmenstrual age at first dexmedetomidine exposure was 31 (IQR, 27-36) weeks, and the median postnatal age at first dexmedetomidine exposure was 3 (IQR, 1-35) days. The median duration of dexmedetomidine receipt was 6 (IQR, 2-14) days. Conclusion and Relevance The findings of this multicenter cohort study of premature infants suggest that dexmedetomidine use increased significantly between 2010 and 2020, while overall opioid exposure decreased. Future studies are required to further examine the short- and long-term effects of dexmedetomidine in premature and critically ill infants.
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Affiliation(s)
- Samantha Curtis
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Ryan Kilpatrick
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Kanecia Zimmerman
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Veeral Tolia
- Pediatrix Medical Group, Baylor Scott and White Healthcare, Dallas, Texas
| | - Reese Clark
- MEDNAX Center for Research, Education, Quality and Safety, San Antonio, Texas
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
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11
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Szatkowski L, Sharkey D, Budge H, Ojha S. Association between opioid use during mechanical ventilation in preterm infants and evidence of brain injury: a propensity score-matched cohort study. EClinicalMedicine 2023; 65:102296. [PMID: 37954903 PMCID: PMC10632414 DOI: 10.1016/j.eclinm.2023.102296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Background Preterm infants often require mechanical ventilation (MV), which can be a painful experience. Opioids (such as morphine) are used to provide analgesia, despite conflicting evidence about their impact on the developing brain. We aimed to quantify the use of opioids during MV in infants born at <32 weeks' gestational age and to investigate the association between opioid use and evidence of brain injury. Methods In this retrospective propensity score-matched cohort study, we used routinely recorded data from the National Neonatal Research Database to study infants born at 22-31 weeks gestational age who were admitted to neonatal units in England and Wales (between Jan 1, 2012, and Dec 31, 2020) and who were mechanically ventilated on one or more days during their hospital stay. We used propensity score matching to identify pairs of infants (one who received opioids during MV and one who did not) with similar demographic and clinical characteristics. The pre-specified primary outcome was preterm brain injury assessed in all infants who received MV for more than two days and had evidence of preterm brain injury at or before discharge from neonatal care. Adjusted analyses accounted for differences in infants' characteristics, including illness severity and painful/surgical conditions. Findings Of 67,206 infants included, 45,193 (67%) were mechanically ventilated for one or more days and 26,201 (58% of 45,193) received an opioid whilst ventilated. Opioids were given for a median of 67% of ventilated days (IQR 43-92%) and the median exposure was 4 days (2-11). The percentage of mechanically ventilated infants who received opioids while ventilated increased from 52% in 2012 to 60% in 2020 (morphine, 51%-56%; fentanyl, 6%-18%). In the propensity score-matched cohort of 3608 pairs who were ventilated for >2 consecutive days, the odds of any preterm brain injury (adjusted odds ratio 1.22, 95% CI 1.10-1.35) were higher in those who received opioids compared with those who did not (received opioids, 990/3608 (27.4%) vs. did not receive opioids, 855/3608 (23.7%). The adjusted odds of these adverse outcomes increased with increasing number of days of opioid exposure. Interpretation Use of opioids during mechanical ventilation of preterm infants increased during the study period (2012-2020). Although causation cannot be determined, among those ventilated for >2 consecutive days, these data suggest that opioid use is associated with an increased risk of preterm brain injury and the risk increases with longer durations of exposure. Funding University of Nottingham Impact Fund.
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Affiliation(s)
- Lisa Szatkowski
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Helen Budge
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shalini Ojha
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Trust, Derby, UK
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12
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Selvanathan T, Zaki P, McLean MA, Au-Young SH, Chau CMY, Chau V, Synnes AR, Ly LG, Kelly E, Grunau RE, Miller SP. Early-life exposure to analgesia and 18-month neurodevelopmental outcomes in very preterm infants. Pediatr Res 2023:10.1038/s41390-023-02536-y. [PMID: 36859445 DOI: 10.1038/s41390-023-02536-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/28/2023] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND We assessed variability of analgesic use across three tertiary neonatal intensive care units (NICUs) accounting for early-life pain, quantified as number of invasive procedures. We also determined whether analgesia exposure modifies associations between early-life pain and neurodevelopment. METHODS Multicenter prospective study of 276 very preterm infants (born <24-32 weeks' gestational age [GA]). Detailed data of number of invasive procedures and duration of analgesia exposure were collected in initial weeks after birth. Eighteen-month neurodevelopmental assessments were completed in 215 children with Bayley Scales for Infant Development-Third edition. RESULTS Multivariable linear regressions revealed significant differences in morphine use across sites, for a given exposure to early-life pain (interaction p < 0.001). Associations between early-life pain and motor scores differed by duration of morphine exposure (interaction p = 0.01); greater early-life pain was associated with poorer motor scores in infants with no or long (>7 days) exposure, but not short exposure (≤7 days). CONCLUSIONS Striking cross-site differences in morphine exposure in very preterm infants are observed even when accounting for early-life pain. Negative associations between greater early-life pain and adverse motor outcomes were attenuated in infants with short morphine exposure. These findings emphasize the need for further studies of optimal analgesic approaches in preterm infants. IMPACT In very preterm neonates, both early-life exposure to pain and analgesia are associated with adverse neurodevelopment and altered brain maturation, with no clear guidelines for neonatal pain management in this population. We found significant cross-site variability in morphine use across three tertiary neonatal intensive care units in Canada. Morphine use modified associations between early-life pain and motor outcomes. In infants with no or long durations of morphine exposure, greater early-life pain was associated with lower motor scores, this relationship was attenuated in those with short morphine exposure. Further trials of optimal treatment approaches with morphine in preterm infants are warranted.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Pearl Zaki
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Mia A McLean
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Stephanie H Au-Young
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Cecil M Y Chau
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Vann Chau
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Anne R Synnes
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Linh G Ly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Edmond Kelly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada.,BC Women's Hospital, Vancouver, BC, Canada
| | - Steven P Miller
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada. .,Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada.
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13
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Yieh L, Dukhovny D, Ho T. Understanding Variation in Care: Guidelines, Value, and Equity. Hosp Pediatr 2023; 13:e37-e39. [PMID: 36617987 DOI: 10.1542/hpeds.2022-007043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Leah Yieh
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine.,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California
| | - Dmitry Dukhovny
- Division of Neonatology, Department of Pediatrics, Oregon Health Sciences University, Portland, Oregon
| | - Timmy Ho
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachussetts
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14
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Juul SE, Wood TR, German K, Law JB, Kolnik SE, Puia-Dumitrescu M, Mietzsch U, Gogcu S, Comstock BA, Li S, Mayock DE, Heagerty PJ. Predicting 2-year neurodevelopmental outcomes in extremely preterm infants using graphical network and machine learning approaches. EClinicalMedicine 2023; 56:101782. [PMID: 36618896 PMCID: PMC9813758 DOI: 10.1016/j.eclinm.2022.101782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/27/2022] Open
Abstract
Background Infants born extremely preterm (<28 weeks' gestation) are at high risk of neurodevelopmental impairment (NDI) with 50% of survivors showing moderate or severe NDI when at 2 years of age. We sought to develop novel models by which to predict neurodevelopmental outcomes, hypothesizing that combining baseline characteristics at birth with medical care and environmental exposures would produce the most accurate model. Methods Using a prospective database of 692 infants from the Preterm Epo Neuroprotection (PENUT) Trial, which was carried out between December 2013 and September 2016, we developed three predictive algorithms of increasing complexity using a Bayesian Additive Regression Trees (BART) machine learning approach to predict both NDI and continuous Bayley Scales of Infant and Toddler Development 3rd ed subscales at 2 year follow-up using: 1) the 5 variables used in the National Institute of Child Health and Human Development (NICHD) Extremely Preterm Birth Outcomes Tool, 2) 21 variables associated with outcomes in extremely preterm (EP) infants, and 3) a hypothesis-free approach using 133 potential variables available for infants in the PENUT database. Findings The NICHD 5-variable model predicted 3-4% of the variance in the Bayley subscale scores, and predicted NDI with an area under the receiver operator curve (AUROC, 95% CI) of 0.62 (0.56-0.69). Accuracy increased to 12-20% of variance explained and an AUROC of 0.77 (0.72-0.83) when using the 21 pre-selected clinical variables. Hypothesis-free variable selection using BART resulted in models that explained 20-31% of Bayley subscale scores and AUROC of 0.87 (0.83-0.91) for severe NDI, with good calibration across the range of outcome predictions. However, even with the most accurate models, the average prediction error for the Bayley subscale predictions was around 14-15 points, leading to wide prediction intervals. Higher total transfusion volume was the most important predictor of severe NDI and lower Bayley scores across all subscales. Interpretation While the machine learning BART approach meaningfully improved predictive accuracy above a widely used prediction tool (NICHD) as well as a model utilizing NDI-associated clinical characteristics, the average error remained approximately 1 standard deviation on either side of the true value. Although dichotomous NDI prediction using BART was more accurate than has been previously reported, and certain clinical variables such as transfusion exposure were meaningfully predictive of outcomes, our results emphasize the fact that the field is still not able to accurately predict the results of complex long-term assessments such as Bayley subscales in infants born EP even when using rich datasets and advanced analytic methods. This highlights the ongoing need for long-term follow-up of all EP infants. Funding Supported by the National Institute of Neurological Disorders and StrokeU01NS077953 and U01NS077955.
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Affiliation(s)
- Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kendell German
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Janessa B. Law
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Sarah E. Kolnik
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, NC, USA
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Sijia Li
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
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15
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Perrone S, Grassi F, Caporilli C, Boscarino G, Carbone G, Petrolini C, Gambini LM, Di Peri A, Moretti S, Buonocore G, Esposito SMR. Brain Damage in Preterm and Full-Term Neonates: Serum Biomarkers for the Early Diagnosis and Intervention. Antioxidants (Basel) 2023; 12:antiox12020309. [PMID: 36829868 PMCID: PMC9952571 DOI: 10.3390/antiox12020309] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/14/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
The Brain is vulnerable to numerous insults that can act in the pre-, peri-, and post-natal period. There is growing evidence that demonstrate how oxidative stress (OS) could represent the final common pathway of all these insults. Fetuses and newborns are particularly vulnerable to OS due to their inability to active the antioxidant defenses. Specific molecules involved in OS could be measured in biologic fluids as early biomarkers of neonatal brain injury with an essential role in neuroprotection. Although S-100B seems to be the most studied biomarker, its use in clinical practice is limited by the complexity of brain damage etiopathogenesis and the time of blood sampling in relation to the brain injury. Reliable early specific serum markers are currently lacking in clinical practice. It is essential to determine if there are specific biomarkers that can help caregivers to monitor the progression of the disease in order to active an early neuroprotective strategy. We aimed to describe, in an educational review, the actual evidence on serum biomarkers for the early identification of newborns at a high risk of neurological diseases. To move the biomarkers from the bench to the bedside, the assays must be not only be of a high sensitivity but suitable for the very rapid processing and return of the results for the clinical practice to act on. For the best prognosis, more studies should focus on the association of these biomarkers to the type and severity of perinatal brain damage.
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Affiliation(s)
- Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence:
| | - Federica Grassi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Chiara Caporilli
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Giovanni Boscarino
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Giulia Carbone
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Chiara Petrolini
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Lucia Maria Gambini
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Antonio Di Peri
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Sabrina Moretti
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giuseppe Buonocore
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
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16
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General Anesthesia and the Premature Baby: Identifying Risks for Poor Neurodevelopmental Outcomes. J Neurosurg Anesthesiol 2023; 35:130-132. [PMID: 36745176 DOI: 10.1097/ana.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 12/12/2022]
Abstract
Preterm birth affects 1 in every 10 infants born in the United States. Importantly, more preterm infants are surviving to discharge from hospital, including those born at the cusp of viability (eg, 22 to 24 wk gestation). Such improvements, however, come at a cost as those delivered at less than 28 weeks gestation have the highest rates of morbidity and mortality. To complicate matters, these extremely preterm infants often require multiple surgical procedures resulting in repeated and prolonged exposures to anesthetic, analgesic, and sedative agents both during procedures and in the neonatal intensive care unit. Consequently, all of these factors, including premature birth itself, correlate with a higher risk for neurodevelopmental disabilities. More studies are needed to address the effects of prematurity-related morbidities and drug exposures on this vulnerable population, with the goal of improving neurodevelopmental outcomes. This brief review will discuss risk factors that impact neurodevelopmental outcomes in premature infants, with a particular focus on anesthetic, analgesic, and sedative agents.
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17
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Lo E, Kalish BT. Neurodevelopmental outcomes after neonatal surgery. Pediatr Surg Int 2022; 39:22. [PMID: 36449183 DOI: 10.1007/s00383-022-05285-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 12/05/2022]
Abstract
Children who require surgery in the newborn period are at risk for long-term neurodevelopmental impairment (NDI). There is growing evidence that surgery during this critical window of neurodevelopment gives rise to an increased risk of brain injury, predisposing to neurodevelopmental challenges including motor delays, learning disabilities, executive function impairments, and behavioral disorders. These impairments can have a significant impact on the quality of life of these children and their families. This review explores the current literature surrounding the effect of neonatal surgery on neurodevelopment, as well as the spectrum of proposed mechanisms that may impact neurodevelopmental outcomes. The goal is to identify modifiable risk factors and patients who may benefit from close neurodevelopmental follow-up and early referral to therapy.
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Affiliation(s)
- Emily Lo
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian T Kalish
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Molecular Genetics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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18
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Intravenous acetaminophen for postoperative pain control after open abdominal and thoracic surgery in pediatric patients: a systematic review and meta-analysis. Pediatr Surg Int 2022; 39:7. [PMID: 36441255 DOI: 10.1007/s00383-022-05282-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2022] [Indexed: 11/29/2022]
Abstract
Pediatric opioid exposure increases short- and long-term adverse events (AE). The addition of intravenous acetaminophen (IVA) to pediatric pain regimes to may reduce opioids but is not well studied postoperatively. Our objective was to quantify the impact of IVA on postoperative pain, opioid use, and AEs in pediatric patients after major abdominal and thoracic surgery. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched systematically for randomized controlled trials (RCTs) comparing IVA to other modalities. Five RCTs enrolling 443 patients with an average age of 2.12 years (± 2.81) were included. Trials comparing IVA with opioids to opioids alone were meta-analyzed. Low to very low-quality evidence demonstrated equivalent pain scores between the groups (-0.23, 95% CI -0.88 to 0.40, p 0.47) and a reduction in opioid consumption (-1.95 morphine equivalents/kg/48 h, 95% CI -3.95 to 0.05, p 0.06) and minor AEs (relative risk 0.39, 95% CI 0.11 to 1.43, p 0.15). We conclude that the addition of IVA to opioid-based regimes in pediatric patients may reduce opioid use and minor AEs without increasing postoperative pain. Given the certainty of evidence, further research featuring patient-important outcomes and prolonged follow-up is necessary to confirm these findings.
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19
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Ang JL, Rath CP, Tan H, Patole S, Rao SC. Mortality and neurodevelopmental outcomes of infants with spontaneous intestinal perforation: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 108:256-266. [PMID: 36328412 DOI: 10.1136/archdischild-2022-324157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is limited information about the mortality and neurodevelopmental outcomes of very preterm infants (<32 weeks) with spontaneous intestinal perforation (SIP). OBJECTIVE To explore the association between SIP and neurodevelopmental outcomes and mortality in very preterm infants. DATA SOURCES Medline, EMBASE, Cochrane Library, EMCARE and MedNar. STUDY SELECTION Databases were searched until September 2021. Studies comparing outcomes of 'SIP' versus 'no SIP or necrotising enterocolitis (NEC)' were included. DATA EXTRACTION Neurodevelopmental outcomes at ≥1 year corrected age were extracted as the main outcome measure. Data were pooled separately for adjusted and unadjusted ORs using the random-effects model. The evidence level was assessed using the GRADE (Grading of Recommendations, Assessments, Development and Evaluations) framework. RESULTS Eighteen cohort studies (13 606 infants) were included. Meta-analysis of unadjusted ORs showed that SIP was significantly associated with increased odds of mortality, cerebral palsy, composite outcome of death or disability, visual impairment and hearing impairment. However, pooling of adjusted ORs (aOR) found significant associations only for mortality (aOR (95% CI) 2.27 (2.07 to 2.49); I2: 0%; four studies (n=10 695)), severe disability (aOR (95% CI) 2.06 (1.38 to 3.08); I2: 0%; two studies (n=321)) and composite outcome of 'death or disability' (aOR (95% CI) 2.18 (1.55 to 3.06); I2: 0%; two studies (n=321)). The level of evidence was 'low' or 'very low'. LIMITATIONS Lack of information on aORs from many studies. CONCLUSIONS SIP in very preterm infants is associated with higher odds of mortality, severe disability, and death or disability.
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Affiliation(s)
- Ju Li Ang
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia
| | - Chandra Prakash Rath
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia .,Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia
| | - Herr Tan
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia
| | - Sanjay Patole
- Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia.,Paediatrics, The University of Western Australia School of Medicine, Nedlands, Western Australia, Australia
| | - Shripada C Rao
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Paediatrics, The University of Western Australia School of Medicine, Nedlands, Western Australia, Australia
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20
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Neitmann J, Hanke K, Humberg A, Siller B, Spiegler J, Juhnke K, Gilmore J, Odendahl R, Herting E, Göpel W, Härtel C, Fortmann I. Sleep problems in infancy and early school age in very preterm infants. Early Hum Dev 2022; 173:105656. [PMID: 35987047 DOI: 10.1016/j.earlhumdev.2022.105656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Sleep plays an important role for psychological and physical health, especially in infants at high risk for long-term neurodevelopmental impairment such as preterm infants. OBJECTIVE Our study aimed at determining risk factors for long-term sleep impairment in very-preterm (VPT; <32 weeks of gestation) infants. METHODS Sleep problems were analyzed in an observational study in infants of the German Neonatal Network born between January 1st 2009 and December 31st 2014. Parental questionnaires of n = 2928 VPT children were evaluated regarding the child's sleep behavior at five years of age. Univariate and logistic regression analyses were used to identify risk factors for delayed sleep onset and hyperactivity/inattention (Strength and Difficulties Questionnaire). In a second cohort of n = 342 VPT infants, sleep habits were evaluated at toddlers age via the Infant Sleep Questionnaire. RESULTS In our cohorts, 424/2928 (14.5 %) preterm children were diagnosed with delayed sleep onset at early school age while 57/342 (16.7 %) had sleep impairment in early infancy. Gestational age was not independently associated with sleep problems (i.e., early school age: OR 0.97, 95 % CI 0.9-1.1, p = 0.15). Notably, in both our cohorts, neonatal exposure to analgesics and sedatives was associated with a higher risk for sleep problems, i.e., early school age: exposure to sedatives: OR 1.31, 95%CI 1.02-1.7, p = 0.03. Sleep problems and drug exposure were both associated with hyperactivity/inattention. CONCLUSION Sleep problems of VPT children are unrelated to gestational age which suggests rather individual risk factors. The significant neonatal exposure to analgesics and sedatives may contribute to long-term sleep impairment.
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Affiliation(s)
- Johanna Neitmann
- Department of Pediatrics, University of Luebeck, Luebeck, Germany
| | - Kathrin Hanke
- Department of Pediatrics, University of Luebeck, Luebeck, Germany.
| | | | - Bastian Siller
- Department of Pediatrics, University of Luebeck, Luebeck, Germany.
| | - Juliane Spiegler
- Department of Pediatrics, University Hospital of Wuerzburg, Wuerzburg, Germany.
| | - Karla Juhnke
- Department of Pediatrics, University of Luebeck, Luebeck, Germany
| | - Jessica Gilmore
- Department of Pediatrics, University of Luebeck, Luebeck, Germany.
| | - Rainer Odendahl
- Department of Pediatrics, University of Luebeck, Luebeck, Germany.
| | - Egbert Herting
- Department of Pediatrics, University of Luebeck, Luebeck, Germany.
| | - Wolfgang Göpel
- Department of Pediatrics, University of Luebeck, Luebeck, Germany.
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Wuerzburg, Wuerzburg, Germany.
| | - Ingmar Fortmann
- Department of Pediatrics, University of Luebeck, Luebeck, Germany.
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21
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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] [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
- *Correspondence: Manon Tauzin,
| | - 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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Dexmedetomidine - An emerging option for sedation in neonatal patients. J Perinatol 2022; 42:845-855. [PMID: 35197548 DOI: 10.1038/s41372-022-01351-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/26/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022]
Abstract
Dexmedetomidine is a sedative agent with limited dosing, safety, and efficacy information in the neonatal population. This comprehensive review describes the available evidence summarizing the use of dexmedetomidine in various neonatal populations. We identified 21 studies and 1 case report supporting the efficacy and short-term safety of DEX in neonates. Reported dosing ranges from 0.5-1.5 mcg/kg/h with or without loading doses. Clinically relevant adverse effects include bradycardia and hypotension. Future studies are needed to determine long-term safety and facilitate clinical applicability.
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Ojha S, Abramson J, Dorling J. Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice? BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001460. [PMID: 36053596 PMCID: PMC9092181 DOI: 10.1136/bmjpo-2022-001460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/22/2022] [Indexed: 01/09/2023] Open
Abstract
Mechanical ventilation is an uncomfortable and potentially painful intervention. Opioids, such as morphine and fentanyl, are used for analgesia and sedation but there is uncertainty whether they reduce pain in mechanically ventilated infants. Moreover, there may be short-term and long-term adverse consequences such as respiratory depression leading to prolonged mechanical ventilation and detrimental long-term neurodevelopmental effects. Despite this, opioids are widely used, possibly due to a lack of alternatives.Dexmedetomidine, a highly selective alpha-2-adrenergic agonist with analgesic and sedative effects, currently approved for adults, has come into use in newborn infants. It provides analgesia and simulates natural sleep with maintenance of spontaneous breathing and upper airway tone. Although data on pharmacokinetics-pharmacodynamics in preterm infants are scant, observational studies report that using dexmedetomidine in conjunction with opioids/benzodiazepines or on its own can reduce the cumulative exposure to opioids/benzodiazepines. As it does not cause respiratory depression, dexmedetomidine could enable quicker weaning and extubation. Dexmedetomidine has also been suggested as an adjunct to therapeutic hypothermia in hypoxic ischaemic encephalopathy and others have used it during painful procedures and surgery. Dexmedetomidine infusion can cause bradycardia and hypotension although most report clinically insignificant effects.The increasing number of publications of observational studies and clinical use demonstrates that dexmedetomidine is being used in newborn infants but data on safety and efficacy are scant and not of high quality. Importantly, there are no data on long-term neurodevelopmental impact on preterm or term-born infants. The acceptance of dexmedetomidine in routine clinical practice must be preceded by clinical evidence. We need adequately powered and well-designed randomised controlled trials investigating whether dexmedetomidine alone or with opioids/benzodiazepines in infants on mechanical ventilation reduces the need for opioids/benzodiazepine and improves neurodevelopment at 24 months and later as compared with the use of opioids/benzodiazepines alone.
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Affiliation(s)
- Shalini Ojha
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK .,Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Janine Abramson
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon Dorling
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Standardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates. Pediatr Qual Saf 2022; 7:e562. [PMID: 35720868 PMCID: PMC9197367 DOI: 10.1097/pq9.0000000000000562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/02/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Pain impacts brain development for neonates, causing deleterious neurodevelopmental outcomes. Prescription opioids for analgesia or sedation are common; however, prolonged opioid exposure in neonates is associated with neurodevelopmental impairment. Balancing the impact of inadequate pain control against prolonged opioid exposure in neonates is a clinical paradox. Therefore, we sought to decrease the average days of opioids used for analgesia or sedation in critically ill neonates at a level IV Neonatal Intensive Care Unit by 10% within 1 year. Methods A multidisciplinary quality improvement team used the model for improvement, beginning with a Pareto analysis, and identified a lack of consistent approach to weaning opioids as a primary driver for prolonged exposure. The team utilized 2 main interventions: (1) a standardized withdrawal assessment tool-1 and (2) a risk-stratified opioid weaning guideline. Results We demonstrated a reduction in mean opioid duration from 34.3 to 14.1 days, an increase in nursing withdrawal assessment tool-1 documentation from 20% to 90%, and an increase in the documented rationale for daily opioid dose in provider notes from 20% to 70%. Benzodiazepine use did not change. Conclusion Standardized withdrawal assessments combined with risk-stratified weaning guidelines can decrease opioid use in critically ill neonates.
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Nguyen NM, Vellichirammal NN, Guda C, Pendyala G. Decoding the Synaptic Proteome with Long-Term Exposure to Midazolam during Early Development. Int J Mol Sci 2022; 23:ijms23084137. [PMID: 35456952 PMCID: PMC9027542 DOI: 10.3390/ijms23084137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 12/05/2022] Open
Abstract
The intensive use of anesthetic and sedative agents in the neonatal intensive care unit (NICU) has raised controversial concerns about the potential neurodevelopmental risks. This study focused on midazolam (MDZ), a common benzodiazepine regularly used as a sedative on neonates in the NICU. Mounting evidence suggests a single exposure to MDZ during the neonatal period leads to learning disturbances. However, a knowledge gap that remains is how long-term exposure to MDZ during very early stages of life impacts synaptic alterations. Using a preclinical rodent model system, we mimicked a dose-escalation regimen on postnatal day 3 (P3) pups until day 21. Next, purified synaptosomes from P21 control and MDZ animals were subjected to quantitative mass-spectrometry-based proteomics, to identify potential proteomic signatures. Further analysis by ClueGO identified enrichment of proteins associated with actin-binding and protein depolymerization process. One potential hit identified was alpha adducin (ADD1), belonging to the family of cytoskeleton proteins, which was upregulated in the MDZ group and whose expression was further validated by Western blot. In summary, this study sheds new information on the long-term exposure of MDZ during the early stages of development impacts synaptic function, which could subsequently perturb neurobehavioral outcomes at later stages of life.
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Affiliation(s)
- Nghi M. Nguyen
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA;
- Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198, USA; (N.N.V.); (C.G.)
| | - Neetha N. Vellichirammal
- Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198, USA; (N.N.V.); (C.G.)
| | - Chittibabu Guda
- Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198, USA; (N.N.V.); (C.G.)
| | - Gurudutt Pendyala
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA;
- Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198, USA; (N.N.V.); (C.G.)
- Child Health Research Institute, Omaha, NE 68198, USA
- Correspondence: ; Tel.: +1-402-559-8690
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Diffusion Tensor Imaging Changes Do Not Affect Long-Term Neurodevelopment following Early Erythropoietin among Extremely Preterm Infants in the Preterm Erythropoietin Neuroprotection Trial. Brain Sci 2021; 11:brainsci11101360. [PMID: 34679424 PMCID: PMC8533828 DOI: 10.3390/brainsci11101360] [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] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
We aimed to evaluate diffusion tensor imaging (DTI) in infants born extremely preterm, to determine the effect of erythropoietin (Epo) on DTI, and to correlate DTI with neurodevelopmental outcomes at 2 years of age for infants in the Preterm Erythropoietin Neuroprotection (PENUT) Trial. Infants who underwent MRI with DTI at 36 weeks postmenstrual age were included. Neurodevelopmental outcomes were evaluated by Bayley Scales of Infant and Toddler Development (BSID-III). Generalized linear models were used to assess the association between DTI parameters and treatment group, and then with neurodevelopmental outcomes. A total of 101 placebo- and 93 Epo-treated infants underwent MRI. DTI white matter mean diffusivity (MD) was lower in placebo- compared to Epo-treated infants in the cingulate and occipital regions, and occipital white matter fractional isotropy (FA) was lower in infants born at 24-25 weeks vs. 26-27 weeks. These values were not associated with lower BSID-III scores. Certain decreases in clustering coefficients tended to have lower BSID-III scores. Consistent with the PENUT Trial findings, there was no effect on long-term neurodevelopment in Epo-treated infants even in the presence of microstructural changes identified by DTI.
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