The use of methohexital during chest tube removal in neonates

Propofol Dose-Finding to Reach Optimal Effect for (Semi-)Elective Intubation in Neonates

OBJECTIVE

To define the effective dose for 50% of patients (ED₅₀) of propofol for successful intubation and to determine the rate of successful extubation in those patients with planned intubation, surfactant administration, and immediate extubation (INSURE procedure). In addition, pharmacodynamic effects were assessed.

STUDY DESIGN

Neonates (n = 50) treated with propofol for (semi-)elective endotracheal intubation were stratified in 8 strata by postmenstrual and postnatal age. The first patient in each stratum received an intravenous bolus of 1 mg/kg propofol. Dosing for the next patient was determined using the up-and-down method. A propofol ED₅₀ dose was calculated in each stratum with an effective sample size of at least 6, via the Dixon-Masey method, with simultaneous assessment of clinical scores and continuous vital sign monitoring.

RESULTS

Propofol ED₅₀ values for preterm neonates <10 days of age varied between 0.713 and 1.350 mg/kg. Clinical recovery was not attained at the end of the 21-minute scoring period. Mean arterial blood pressure showed a median decrease between 28.5% and 39.1% from baseline with a brief decrease in peripheral and regional cerebral oxygen saturation. Variability in mean arterial blood pressure area under the curve could not be explained by weight or age.

CONCLUSIONS

Low propofol doses were sufficient to sedate neonates for intubation. Clinical recovery was accompanied by permissive hypotension (no clinical shock and no treatment). The propofol ED₅₀ doses can be administered at induction, with subsequent up-titration if needed, while monitoring blood pressure. They can be used for further dosing optimalization and validation studies.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01621373; EudraCT: 2012-002648-26.

The effect of cold application on pain due to chest tube removal

AIM AND OBJECTIVES

The aim of the research is to determine the effect of cold application on the pain owing to chest tube removal for patients with single pleural chest tube.

BACKGROUND

Removal of chest tubes causes patients to feel pain and interventions used for reducing the pain owing to the removal of chest tubes are not sufficient.

DESIGN

Controlled clinical trial with repeated measures.

METHODS

This study was conducted with 140 patients, of whom 70 patients were in the experimental group and 70 patients were in the control group, in a thoracic hospital in Turkey. Data were collected using a data collection form consisting of patients' demographic and health history and Visual Analogue Scale. Cold was applied to patients in the experimental group prior to chest tube removal. In the experimental group, skin temperature and pain intensity was measured for each patient at four time points. In the control group, pain intensity was evaluated for each patient at three time points. Data were evaluated using Chi-square and Repeated Measurements two-way anova tests.

RESULTS

The Visual Analogue Scale score was measured immediately after the chest tube removal in the experimental group was 3·85, compared with 5·60 in the control group. There were significant differences on pain with cold application between the two groups prior and after the intervention. Age, gender, the number of days the chest tube was inserted and the chest tube insertion indication had no effect on the pain owing to chest tube removal.

CONCLUSION

Cold application is effective in reducing the pain owing to chest tube removal.

RELEVANCE TO CLINICAL PRACTICE

Cold application was recommended prior to chest tube removal to reduce the pain owing to removal of chest tube.

Maturational pharmacokinetics of single intravenous bolus of propofol

BACKGROUND

Our aim was to document propofol pharmacokinetics in preterm and term neonates following a single intravenous bolus and compare these estimates with pharmacokinetics findings in toddlers and young children.

METHODS

Newly collected observations following intravenous bolus administration of propofol in preterm and term neonates (n = 9) were compared with earlier reported pharmacokinetic estimates in toddlers and young children. Data are reported by median and range. Mann-Whitney U-test or correlation was used to analyze differences in pharmacokinetic findings between neonates, toddlers and young children.

RESULTS

Concentration-time profiles obtained were interpreted by two-stage analysis as a three compartment open model in nine neonates with a median weight of 2.51 (range 0.91-3.8) kg and a median postmenstrual age (PMA) of 36 (range 27-43) weeks. Median clearance (CL) was 13.6 (range 3.7-78.2) ml.min(-1).kg(-1) and median apparent volume of distribution at steady state (V(ss)) was 3.7 (1.33-7.96) l.kg(-1). Following allometric scaling and standardization to 70 kg, median CL was 442 (range 97-2184) ml.min(-1).70 kg(-1). Compared with earlier reported observations in toddlers and children, median clearance (kg.min(-1)) was significantly lower in neonates (P < 0.01) and these differences remained significant after allometric scaling (70 kg.min(-1)) while V(ss) (l.kg(-1)) was significantly lower in neonates (P < 0.01).

CONCLUSIONS

Propofol disposition is significantly different in neonates compared with toddlers and young children, reflecting both ontogeny and differences in body composition. Based on the reduced clearance of propofol, a longer recovery time is more likely to occur in neonates.

Prevention and management of pain in the neonate. An update

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Prevention and management of pain in the neonate: an update

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Chest drain removal pain and its management: a literature review

AIMS AND OBJECTIVES

The purpose of this review was to analyse critically the published research on chest drain removal pain and its management. The findings of descriptive and non-pharmacological intervention studies were summarized and studies of analgesic efficacy were critiqued in depth.

BACKGROUND

The removal of a chest drain is a painful and frightening experience, particularly for children. However, there is limited research regarding the amount of pain experienced or effectiveness of analgesia for this procedure.

RESULTS

Fourteen studies were reviewed, including five descriptive studies; three studies of non-pharmacological interventions; and six randomized controlled trials of morphine, local anaesthetics and Entonox. The search revealed only two paediatric studies. Many of the studies had design limitations or were poorly reported. The majority of studies indicated that patients experienced moderate to severe pain during chest drain removal, even when morphine or local anaesthetics were given.

CONCLUSIONS

Morphine alone does not provide satisfactory analgesia for chest drain removal pain. Non-steroidal anti-inflammatory drugs, local anaesthetics and inhalation agents may have a role to play in providing more effective analgesia for this procedure.

RELEVANCE TO CLINICAL PRACTICE

Analgesic protocols for the management of painful procedures such as chest drain removal are unsatisfactory and practice in this area should be revised. More research is needed to determine the efficacy of drugs other than morphine, particularly Entonox and to investigate multi-modal techniques of management further.