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[Analgesia and sedation in neonatal-pediatric intensive care]
C Schlünder1, F Houben, S Hartwig
1Kinderklinik, Universität Köln.
Insights
Fentanyl effectively manages pain and sedation in newborns and premature infants, reducing the need for other analgesics. Careful administration and supportive care are crucial for optimal outcomes in pediatric intensive care.
Area of Science:
- Neonatal intensive care
- Pediatric critical care medicine
- Pharmacology in pediatrics
Context:
- Analgesia and sedation are critical in pediatric intensive care units (ICUs) for newborns and premature infants.
- The distinction between analgesia and sedation is often unclear, leading to potential under-recognition of pain management needs.
- Fentanyl and midazolam are commonly used agents in neonatal and pediatric ICUs.
Purpose:
- To evaluate the efficacy and safety of fentanyl for analgesia and sedation in newborns and premature infants with respiratory problems.
- To assess the impact of fentanyl on the requirement for other sedatives and analgesics.
- To investigate the pharmacokinetics and efficacy of midazolam, alone and in combination with fentanyl, in specific pediatric populations.
Summary:
- Fentanyl monotherapy was sufficient for analgesia and sedation in newborns and prematures with severe respiratory issues, significantly reducing the need for additional sedatives and analgesics compared to a historical control group.
- Cardiopulmonary tolerance to fentanyl was satisfactory. While bilirubin levels peaked slightly earlier and higher, oral nutrition was initiated sooner in the fentanyl group.
- In infants undergoing cardiac surgery, midazolam was used, with serum levels correlating to sedation depth initially. Concomitant fentanyl administration reduced the required midazolam dose for adequate sedation.
Impact:
- Fentanyl administration can lead to reduced overall sedative and analgesic requirements in critically ill neonates and premature infants.
- Optimized pain and sedation management, including the judicious use of fentanyl and midazolam, can improve clinical outcomes and potentially shorten the time to oral feeding.
- Recommendations include ensuring hemodynamic stability before administration, slow drug infusion, and environmental modifications (reduced stimuli, parental contact) to support critically ill pediatric patients.
Abstract:
In pediatric intensive care, analgesia and sedation has become increasingly important for newborns as well as prematures in recent years. However, its importance is frequently not well recognized and sedation is confounded with analgesia. In our intensive-care unit (ICU), fentanyl and midazolam have proved to be useful. In newborn and premature infants, fentanyl alone has been sufficient because of its analgesic and sedative action. In a study on 20 newborns and prematures suffering from severe respiratory problems as compared with a historical group that did not receive fentanyl, we could show that in subjects receiving fentanyl, considerably less treatment with sedatives and other analgesics was necessary. Cardiopulmonary tolerance was satisfactory. The highest bilirubin values were reached about 1 day earlier and were slightly higher than those measured in the control group, but oral nutrition could be initiated sooner. In small infants, additional midazolam was given after cardiac surgery. During the first 72 h, we found a correlation between serum levels of midazolam and the depth of sedation; however, after 72 h of medication, the dose had to be raised because of an increase in metabolic clearance. During the concomitant administration of midazolam and fentanyl, significantly less midazolam was needed to achieve appropriate analog-sedation. Prior to the administration of analgesics and sedatives, care should be taken to ensure that circulatory conditions are stable and that there is no hypovolemia, and the drugs must be given slowly during several minutes. Especially in a pediatric ICU, light and noise should be diminished and contact between the parents and the child should be encouraged, even when the child is undergoing mechanical ventilation.