Impact of dexmedetomidine in conjunction with a weaning protocol on post-surgical opioid use in a neonatal intensive care unit.

STUDY OBJECTIVE: To describe the impact of protocol-driven dexmedetomidine (and clonidine) use on opioid exposure in post-surgical neonates. DESIGN: Retrospective chart review. SETTING: A Level III, surgical NICU. PATIENTS: Surgical neonates who received clonidine or dexmedetomidine concomitantly with an opioid for sedation and/or analgesia post-operatively. INTERVENTION: Implementation of a standardized sedation/analgesia weaning protocol. MEASUREMENTS AND MAIN RESULTS: There were clinically, although not statistically, significant reductions in opioid wean duration (240 vs. 227 h, p = 0.82), total opioid duration (604 vs. 435 h, p = 0.23), and total opioid exposure (91 vs. 51 mg ME/kg, p = 0.13), and limited impact on NICU outcomes or pain/withdrawal scores with use of the protocol. Increases in use of medications in alignment with the protocol (e.g., scheduled acetaminophen and opioids weaned first) were noted. CONCLUSIONS: We have been unable to demonstrate a reduction in opioid exposure with use of alpha-2 agonists alone; addition of a weaning protocol showed a reduction in opioid duration and exposure (although not statistically significant). At this point, dexmedetomidine and clonidine should not be introduced outside standardized protocols with scheduled acetaminophen post-operatively.

Dexmedetomidine Use in a Tertiary Care NICU: A Descriptive Study.

BACKGROUND: Continuous infusions of dexmedetomidine are increasingly used for sedation in critically ill pediatric patients. Emerging data suggest potential benefits when used for sedation in neonates, including reduced sedative requirements and earlier enteral feeds. OBJECTIVE: To describe the use, adverse effects, and signs of withdrawal in a cohort of neonates receiving dexmedetomidine, the majority of whom were receiving concomitant opioids. METHODS: This was a retrospective, descriptive review of 38 neonates receiving dexmedetomidine in a medical surgical neonatal intensive care unit, including data on duration of use, dose, adverse effects, weaning, and signs of withdrawal. RESULTS: Dexmedetomidine was used for a median of 183 hours, at a median maximum dose of 0.5 µg/kg/h. Premature infants were started on dexmedetomidine at a later chronological age than term infants (41 vs 9 days, P = 0.004). Of 18 patients receiving an opioid infusion at the time of dexmedetomidine initiation, 67% had a dose reduction in opioids by 24 hours. The majority (89%) of neonates had at least 1 potentially related adverse effect during the dexmedetomidine infusion, though no discontinuations were needed as a result. In all, 80% of patients had their dexmedetomidine gradually weaned off, and 71% had at least 1 sign of withdrawal. CONCLUSIONS AND RELEVANCE: In this cohort, dexmedetomidine was often used in a postsurgical setting, with concomitant opioids, over prolonged periods. These factors appear to affect and likely confound the rates of adverse effects and withdrawal signs from dexmedetomidine. Clinicians considering the use of dexmedetomidine in a similar population can draw guidance from our data.

Probiotics supplementation and length of hospital stay in neonates with gastrointestinal surgery.

Any manipulation on open bowel causes interventional impact on gut microbiome, and surgical stress triggers bacterial translocation; thus, it will be fundamental to determine gut microbiome after surgery. Monitoring dynamic changes in microbiome of post-surgical infants who received probiotics and placebo could provide with important information about gut colonization and potential bacterial overgrowth. The purpose of this study is to assess the effect of probiotics supplementation on length of hospital stay, duration of parenteral nutrition, and feed tolerance in neonates after gastrointestinal surgery.

Comparison of pain responses in infants of different gestational ages.

BACKGROUND: There is a plethora of infant pain measures; however, none of them have been validated for extremely low for gestational age (ELGA) infants (<27 weeks' gestation). To date, clinicians, researchers and parents use information gleaned from more mature infants to make inferences about pain in ELGA infants. Using physiological or behavioral pain indicators derived from more mature infants may lead to inaccurate assessments and management. OBJECTIVES: To compare physiological (heart rate, oxygen saturation) and behavioral (9 facial activities, cry) pain indicators of ELGA infants with infants of varying more mature gestational ages (GAs). METHODS: The aim was to determine the effects of GA on pain response. GA was categorized into four mutually exclusive strata: <27 6/7 weeks, 28-31 6/7 weeks, 32-35 6/7 weeks and >36 weeks. Physiological data during four phases of a routine heel lance were collected by placing disposable ECG electrodes and pulse oximetry probes on the infant's chest. Behavioral data were collected by videotaping facial activities, and cry data were collected by audio recording. RESULTS: Four facial activities (brow bulge, eye squeeze, nasolabial furrow, vertical mouth stretch) in response to acute pain were present in ELGA infants. Facial activities increased following painful procedures and the magnitude of responses was proportional to GA with the youngest infants (<27 6/7 weeks GA) showing the least amount of change. Decreased oxygen saturation and increased heart rate were associated with the most invasive phase of the heel lance; however, the differences were neither clinically or statistically significant across age groups. Cry was not a sensitive pain indicator in ELGA infants, due to the presence of endotracheal tubes in this high-risk population. DISCUSSION: ELGA infants have similar pain responses to older infants, but the responses are dampened. Other factors such as severity of illness, frequency of painful procedures or medication use should be examined, as they may influence the pain responses in ELGA infants.

Procedural pain in newborns at risk for neurologic impairment.

In the past decade, our knowledge of pain in newborn infants has advanced considerably. However, infants at significant risk for neurologic impairment (NI) have been systematically excluded from almost all research on pain in neonates. The objectives of this study were to compare: (a). the nature, frequency and prevalence of painful procedures, (b). analgesics and sedatives administered, and (c). the relationship between painful procedures and analgesia for neonates at risk for NI. One hundred and ninety-four infants at high (cohort A, n=67), moderate (cohort B, n=59) and low (cohort C, n=68) risk for NI from two tertiary level Neonatal Intensive Care Unit's in Canada were included in a retrospective cohort study on the first 7 days of life. Data were collected from medical records and analyzed using chi-square, ANOVA and regression approaches. All cohorts had a mean of >10 painful procedures per day during the first 2 days of life. There was an interaction effect between cohort group and day of life (F(5,188)=2.13, P<0.06) with cohort A having significantly more painful procedures on day 1 (F(2,191)=4.79, P<0.009). There was no statistical difference in the number of infants who received continuous infusion (F(2,20)=1.9, P=0.13) or bolus (F(2,20)=1.3, P=0.25) opioids or sedatives (F(2,20)=0.45, P=0.84) by cohort over the 7 day period. There was a statistical difference in bolus opioid administration for days 1 (P<0.05) and 2 (P<0.001) with less than 10% of infants in cohort A receiving bolus opioids compared with approximately 22-33% of infants in cohorts B and C. There was a statistically significant correlation between painful procedures and analgesic use (r=0.29, P<0.001), although significant associations existed for cohorts B and C only. The number of painful procedures and study site primarily accounted for the variance (61% in cohort B and 35% in cohort C) in analgesic use, while in cohort A, only study site contributed to the variance (16%). Neonates at the highest risk for NI had the greatest number of painful procedures and the least amount of opioids administered during the first day of life. There was no relationship between painful procedures and analgesic use in this group. As these infants are vulnerable to pain and its consequences, the rational underlying health professional strategies regarding painful procedures and analgesic use for procedural pain in this population urgently awaits exploration.