Atlas of Procedures in Neonatology, 4th Edition
Preparation and Support
Analgesia and Sedation in the Newborn
Nicholas J. Marsh
Pain management is an integral part of compassionate neonatal medical care. Historically, barriers to adequate pain management in neonates have been related to the question of pain perception in the newborn. This question is no longer debated, and the use of analgesics for these patients is well established (1,2,3,4 and 5). However, pain management and sedation practices continue to vary among practitioners (6,7). Safe care requires careful choice and dosing of medications, appropriate monitoring, and preparedness to manage complications (4,8). This chapter offers general guidelines for the management of analgesia and sedation in newborn infants.
- Analgesia: A condition in which nociceptive stimuli are perceived but are not interpreted as pain; usually accompanied by sedation without loss of consciousness (9)
- Conscious sedation: A medically controlled state of depressed consciousness that allows protective reflexes to be maintained, retains the ability to maintain a patent airway independently and continuously, and permits appropriate responses by the patient (8)
- Deep sedation: A medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. It may be accompanied by a partial or complete loss of protective reflexes and includes the inability to maintain a patent airway independently and respond purposefully to stimulation (8).
- Tolerance: The ability to resist the action of a drug or the requirement for increasing doses of a drug, with time, to achieve a desired effect (10)
- Withdrawal: The development of a substance-specific syndrome that follows the cessation of, or reduction in, intake of a psychoactive substance previously used or administered regularly (11)
- Neonatal abstinence syndrome: Onset of withdrawal symptoms in neonates upon cessation of an agent associated with physical dependence (11)
- General Indications
- Any condition or procedure known to be painful (4,12) (see E)
- Physiologic indications consistent with perception of pain (1,13)
- Elevated blood pressure (with secondary increase in intracranial pressure)
- Decreased arterial oxygen saturation
- Hyperglycemia secondary to hormonal and metabolic stress responses
- Behavioral indications consistent with perception of pain (4,5,13,14,16)
- Simple motor responses (i.e., withdrawal of an extremity from a noxious stimulus)
- Facial expressions (i.e., grimace)
- Altered cry (primary method of communicating painful stimuli in infancy)
- Specific Indications
In general, the potency of analgesic treatment selected should be related directly to the anticipated or assessed level of pain (1).
- Mild pain
- Nonpharmacologic approaches (see H)
- Local and/or topical anesthesia
- Nonopioid analgesics (e.g., acetaminophen)
- Moderate and severe pain
- Intravenous opioid analgesics (see E)
- Local and/or topical anesthesia
- Benzodiazepines (in combination with D2a; see E)
Sedatives may be co-administered with analgesics to enhance the anticipated benefits. Because of the escalated risks associated with deep sedation, conscious sedation should be the usual clinical endpoint.
- Benzodiazepines (see E)
- Chloral hydrate (see E)
- Nonpharmacologic approaches (see H)
- Be aware, when assessing patients, that:
- The clinical assessment of pain in the newborn is imprecise.
- Physiologic and behavioral indicators of pain are nonspecific and may be related to many other factors.
- Intubated neonates receiving muscle relaxants may have altered physiologic indicators and completely ablated behavioral indicators.
- A high index of suspicion is required to identify newborn infants in pain (13).
- Be aware, when medicating patients, that:
- There are numerous potential complications associated with analgesic and sedative agents (Table 5.1) (17,18).
- Large inter- and intraindividual variations in response may occur (19).
- Medications must always be titrated slowly (4).
- Co-administration of opioids, benzodiazepines, and other sedatives may result in greatly exaggerated respiratory depressant effects, including apnea (20,21).
- Resuscitation equipment and medications should be immediately available. Be prepared to support ventilation and perform tracheal intubation if needed; respiratory depression is a common side effect of a number of analgesic agents.
- Be aware that:
- Newborn infants who have developed tolerance to a sedative or analgesic agent, by either direct or in utero exposure, may exhibit symptoms of the neonatal abstinence syndrome upon abrupt cessation or reversal of the administered agent (20,21). For example, naloxone administered to opioid-dependent neonates may precipitate acute, severe withdrawal symptoms (11).
- Chronic analgesic therapy with agents known to induce tolerance should be weaned gradually, with close monitoring for evidence of withdrawal symptoms (4,20,21).
- When using analgesics for a painful procedure:
- Consider both the duration and the anticipated pain when selecting medications and methods. For example, short procedures with mild to moderate discomfort, such as lumbar puncture, may be best managed with topical and local anesthetics (22,23 and 24).
- Minimize the number of painful episodes. Multiple procedures performed at the same time may avoid the need for repeated administration of analgesics (2,15).
- Ensure that oxygen, suction, airway, resuscitation equipment, and reversal agents are readily available.
- Follow nothing-by-mouth (NPO) guidelines for ambulatory surgery.
- Have a nurse, or other professional not involved in the procedure, constantly monitor respirations, pulse oximetry, heart rate, and level of consciousness.
- Chloral hydrate, previously regarded as a highly safe sedative, should be used with caution in neonates (particularly premature neonates) owing to the risk of hyperbilirubinemia and accumulation of toxic metabolites (25,26 and 27). For these reasons, a single dose only is recommended.
- Advantages and Disadvantages of Commonly Used Agents in the Newborn
See Table 5.1.
See Table 5.1.
- Nonpharmacologic Approaches
- Swaddling during heel-stick procedures has been shown to reduce behavioral pain responses (28).
- Non-nutritive sucking has been demonstrated to significantly reduce crying in response to painful stimuli (29,30).
- Infants who drank 2 mL of a 12% sucrose solution prior to blood collection via heel stick cried 50% less than control infants during the same procedure (30).
- Infants who received sucrose on a pacifier prior to and during circumcision cried significantly less than control infants (30).
- 2 mL of 12% to 50% sucrose administered orally 2 minutes prior to the procedure is an effective neonatal analgesic with few adverse effects (31,32).
- There are no absolute contraindications to using analgesia and/or sedation when deemed clinically appropriate.
- Be aware of the potential side effects associated with the specific agent selected and take the proper precautions.
TABLE 5.1 Sedative and Analgesic Agents Commonly Used in the Newborn
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