Neonatal Pain management in low resource setting.pptx

Neonatal pain management

1. Neonatal Pain management Presented by Ahmed Ismail Moderated by Dr H. Ashiru

2. Synopsis Introduction Types of pain Effects of pain Causes of pain Assesment of pain Guidelines for pain management Modalities of pain management Conclusion

3. Introduction The International Association for the study of pain has defined pain as ‘ an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage' From 24 weeks post- conceptional age, all neurotransmitters and receptors associated with pain modulation are present and responsive Sick newborn infants are subjected to many invasive procedures as part of their ongoing care and management

4. Types of pain Nociceptive vs neuropathic Based on duration

5. Effects of pain Infants exhibit predictable pain response patterns with respect to stress hormone levels , changes in heart rate, blood pressure, and oxygen saturation. Although the fetus is capable of mounting a stress response at approximately 23 weeks’ gestation, physiologic parameters are nonspecific and are not reliable indicators of pain, particularly among critically ill neonates

6. Premature infants tend to show a less robust response to pain Physiologic responses to painful stimuli include release of circulating catecholamines , heart rate acceleration, blood pressure increase, and a rise in intracranial pressure .

7. Physiologic effects: Tachycardia Blood pressure changes (↑ or ↓) Increase O2 consumption Hypoxemia Decrease cerebrovascular autoregulation Increase intracranial pressure Temperature changes Pallor , flushing, sweating

8. Physiologic effects Reduced tidal volume Increase in mean airway pressure Increase in muscle tone Abnormal respirations (shallow breathing , tachypnea, apnea) Prolonged catabolism Pupillary dilatation

9. Long term effects Neurodevelopmental outcomes There is evidence that infants have the ability to form implicit memory of pain and that there are negative behavioral consequences of untreated pain. Preterm infants who experience numerous painful procedures and noxious stimuli are less responsive to painful stimuli at corrected age of 18 months. Neonatal males who were circumcised with little or no analgesia showed significantly increased pain responses when immunized at 2, 4, and 6 months of age compared to infant males who were not circumcised or who received adequate analgesia.

10. Neonatal response to pain Behavioral Change: Change in facial expression- grimace , brow bulge, eye squeeze, deepening nasolabial furrow, nasal flaring, tongue curving or quivering Crying Whimpering ‘ Silent’ cry (intubated babies) Decreased sleep Heightened responses

11. Body Movement Fisting T remulousness Thrashing limbs Limb withdrawal Writhing Arching back Head banging Finger splaying Cycling

12. Causes of pain - procedure Mild Pain Moderate Pain Severe Pain IV line insertion Bronchoscopy Heel prick Laparoscopic surgeries Local stoma reversal/closure Ventricular shunt insertion Laser eye surgery IM/SC injections lumbar puncture Urinary catheter insertion NG Tube insertion   Chest drain insertion Abdominal drain insertion Tracheostomy/critical airway procedure Uncomplicated Gastroschisis repair Gastroschisis silo formation Inguinal hernia repair   Congenital diaphragmatic hernia (CDH) repair Oesophageal atresia and or/ tracheoesophageal repair Thoracotomy Laparotomy Operative Necrotising Enterocolitis Gastroschisis or omphalocele closure under tension   

13. Causes of pain NEC Caput succadeneum Fractures Trauma Birth injuries Intestinal obstructions

14. Pain Assessment Babies are unable to report pain. Appropriate and accurate assessment of pain is necessary and routine element in deciding the need for effective management of the infants pain A number of validated and reliable scales of pain assessment are available . These use physiologic parameters and/or behavioral responses to pain

15. Changes in facial activity and heart rate are the most sensitive measures of pain observed in term and preterm infants.

16. Pain should be assessed within one hour of admission and reassessed daily once per shift or according to each infant needs Post operatively pain should be assessed hourly for first 8 hr , then 4-hrly until 48 hr. Should be assessed prior to starting and after commencement of painful procedure

17. Pain Assessment Tool Gestational Age/Post conceptional Age Physiologic Components Behavioral Components Type of Pain Adjusts for Prematurity Scale Metric PIPP (Premature In fant Pain Profile)* 28–40 weeks Heart rate, oxygen saturation Alertness, brow bulge, eye squeeze, nasolabial furrow Procedural and Postoperative Yes 0–21 CRIES (Cries, Requires Oxygen, Increased Viral Signs, Expression, Sleeplessness) † 32–56 weeks Blood pressure, heart rate, oxygen saturation Cry, expression, sleeplessness Postoperative No 0–10 NIPS (Neonatal In fant Pain Scale) ‡ 28–38 weeks Breathing pattern Facial expression, cry, arms, legs , alertness Procedural No 0–7 COMFORT (and COMFORTneo ) 0–3 years (COM FORTneo: 24–42 weeks) Respiratory response, blood pressure, heart rate Alertness, agitation, physical movements , muscle tone, facial tension Postoperative (COM FORTneo: prolonged) No 8–40 NFCS (Neonatal Facial Coding System)** 25 weeks to term None Brow bulge, eye squeeze , nasolabial furrow, open lips, stretched mouth (vertical and horizontal), lip purse, taut tongue, chin quiver Procedural No 0–10

18. EDIN (Échelle de la Douleur Inconfort Noveau-Né — Neonatal Pain and Discomfort Scale ) 25–36 weeks None Facial activity, body movements , quality of sleep, quality of contact with nurses, consolability Prolonged No 0–15 BPSN (Bernese Pain Scale for Neo nates ) 27–41 weeks Respiratory pattern, heart rate, oxygen saturation Alertness, duration of cry, time to calm, skin color, brow bulge with eye squeeze, posture Procedural No 0–27 EVANDOL ( Evaluation enfant douleur ) 0–7 years Vocal or verbal expression, facial expression, movements Postures, Interaction with the environment Acute pain and procedural pain no - 15 N-PASS ( Neonatal Pain , Agitation, and Sedation Scale ) 0–100 days Heart rate, respiratory rate, blood pressure , oxygen saturation Crying/irritability , behavior state, facial expression, extremities/tone Acute and prolonged pain Also assesses sedation Yes Pain: 0–10 Sedation –10 to

19. NIPS

20. CRIES

21. PIPP-R

22. EDIN

23. Posture/Tone Normal/Relaxed Extended 1 Flexed and/or Tense 2 Sleep Pattern Relaxed Easily Woken 1 Agitated or Withdrawn 2 Expression Normal/Relaxed Frown 1 Grimace 2 Cry No Yes, Consolable 1 Yes 2 Colour Pink/Normal Occasionally mottled/pale 1 Pale/Dusky/Flushed 2 Respirations Normal baseline rate Tachypnoea 1 Apnoea/Splinting 2 Heart Rate        Normal baseline rate Tachycardia 1 Fluctuating 2 Oxygen Saturation Normal Fleeting desaturation 1 Desaturating 2 Blood Pressure Normal Fluctuates with Handling 1 Hypotensive/Hypertensive 2 Nurses Perception No Pain Pain with Handling 1 Yes Pain 2

24. Guidelines for pain management Prevention Reduce number of needle punctures by drawing blood tests at one time if feasible. Use indwelling venous or arterial catheters when appropriate . Avoid invasive monitoring when possible. Select most competent staff to perform invasive procedures. Use minimal amount of tape and remove tape gently.

25. Ensure proper premedication before invasive procedures Use appropriate equipment (smallest gauge needle) Decrease environmental stimuli (light, noise, abrupt movements )

26. Treatment Assess each infant on an individual basis. Choose the appropriate pain assessment tool to determine a pain score Institute an appropriate intervention in keeping with the severity

27. Modalities of pain management Non- pharmacoloical Pharmacological

28. Non-pharmacological Swaddling combined with positioning, facilitated tucking Skin-to-skin care (SSC ) Breastfeeding or EBM Sensorial stimulation (SS ) - a method of gently stimulating the tactile, gustatory, auditory, and visual systems simultaneously. Non-nutritive sucking Stimuli reduction (light and sound)

29. Non-pharmacological modalities Swaddling Skin-to-skin care

30. Non-nutritive sucking

31. Pharmacological Oral sucrose or Glucose Opiods Paracetamol Sedatives Topical anasthetics Epidural anasthesia

32. Oral Sucrose or Glucose Oral sucrose is commonly used to provide analgesia to infants during mild to moderately painful procedures. sucrose should only be used in infants of 32 weeks gestational age (actual /corrected) or above. An oral dose of 0.1 to 1 mL of 24% sucrose to be administered at least 2 minutes before the invasive procedure. Do not administer for longer than 8 minutes before the procedure as the sucrose will become ineffective . 20 % to 30% glucose could be used as an alternative to sucrose solutions Sucrose/glucose should be used with other non pharmacological method .

33. Oral sucrose of glucose Use with caution in Infants at high risk of developing necrotising enterocolitis (NEC ), hyperglycaemia , Infants who are intubated, Newborn infants of opiate-dependent mothers. Do not use in Infants less than 32 weeks of gestation at the time of proposed administration, Infants with known fructose or sucrose intolerance, infants with teeth as sucrose/glucose can bind to the enamel and cause tooth decay Infants who are muscle relaxed

34. Opiods Opioids are the mainstay for postoperative analgesia after moderate/major surgery, if regional anesthesia is not feasible . Preferrably as a regular dose or continuous infusion rather than on-demand basis Elimination of opioids may be influenced by enterohepatic recirculation and elevated plasma concentrations; therefore, monitoring for side effects should be maintained for several hours after opioids are discontinued.

35. Opiods fentanyl or morphine to be used for persistent pain Respiratory depression and/or arrest may occur with opioid agents as well as with benzodiazepine particularly given in combination. Careful and appropriate monitoring of infants receiving these agents is essential, especially when the patients are not receiving mechanical ventilation.

36. Morphine and fentanyl provide a similar degree of analgesia. Morphine has a greater sedative effect and less risk of chest wall rigidity. Tolerance on long use is less common. Morphine is associated with a greater risk of hypotension. Fentanyl has a faster onset, and shorter duration of action. Effect on gastrointestinal (GI) motility, hemodynamics, and urinary retention are less common.

37. Medication Ventilated Self-ventilating Morphine 25 - 100mcg/kg 10 - 25mcg/kg Fentanyl 1 - 5 mcg/kg 1 - 2mcg/kg Hydromorphone 5 - 10 mcg/kg  

38. Opioid tolerance. Prolonged opioid administration may lead to tolerance; pain recurs, sleep is disrupted, and an infant may exhibit a high-pitched cry or tremors during handling. In this case, there is a need to increase the dose, typically in increments of 10% to 20%, to relieve symptoms. Opioid and sedative weaning. Prolonged use of opioids can result in iatrogenic physical dependence. Neonates exposed to continuous or higher doses of opioids for >5 days are at an increased risk for opioid withdrawal; therefore, weaning rather than abrupt discontinuation is recommended. Opioid withdrawal is more prevalent and may occur earlier in infants receiving fentanyl compared to morphine . Opioids are weaned slowly with a goal to avoid unsafe symptoms of withdrawal

39. Weaning patient of Opiods Duration of opioid use Wean rate Less than 1 day for non-postoperative babies Reduce rate by 50%  of highest dose  and cease when clinically appropriate. Less than 1 day for postoperative babies Do not wean for first 12 hours post-operatively unless medically indicated and following discussion with treating medical team (weaning may be appropriate for some surgical procedures). After this time, reduce rate by 10–20%  of the highest dose  every 4–6 hours 1–4 days Reduce rate by 10–20%  of the highest dose  every 4–6 hours Equal to or greater than 5 days Reduce rate by 10–20% per day  of the highest dose  until ceased or changed to enteral therapy as per consultant.

40. Paracetamol Can be given via IV, IM, rectal and Oral routes Relatively safe with no risk of dependence or tolerance Can be used for mild to moderate pain Dose- 10 -15mg/kg/dose 6-8 hrly

41. Sedatives Mainly used as adjuncts to other forms of analgesia May also be required in certain procedural pain management

42. Sedatives Sedatives are often given in conjunction with pain medication . Sedatives do not provide analgesia but may be given to manage agitation, example during mechanical ventilation. Sedatives postoperatively can be administered to reduce opioid requirements

43. Benzodiapines Commonly used are midazolam (short acting) and lorazepam (intermediate acting) Midazolam dose – 50 – 100 mcg bolus Infusion maintained at 0.5mcg/kg/min Lorazepam dose – 0.05mg/kg/dose 4-8hrly Diazepam is not recommended

44. Clonidine Centrally acting antihypertensive but found to have sedative effect in neonates Used as an adjuncts with opioids Clonidine dose – 0.5mcg/kg/ hr Can be increased 2.0mcg/kg/ hr infusion Bolus dose – 1-3mcg/kg every 4- 6 hrs

45. Dexmedetomidine The sedative and anxiolytic effects in adults have been found to be beneficial— easy arousal without respiratory depression , less frequent hypertension and tachycardia, and shorter duration of mechanical ventilation. Although off-label use in neonatal care units is becoming increasingly common, its effectiveness and safety profile as a sedative and analgesic in neonates has not been systematically reviewed .

46. Dexmedetomidine Limit uses to 3-7days Loading dose 0.5 -1mcg over 15 mins then 0.1 -0.6mcg/her Not to be given as bolus

47. Topical anasthetics Eutectic Mixture of Local Anesthetics (EMLA) to be used during venipuncture, percutaneous central venous catheter insertion, peripheral arterial puncture and lumbar puncture

48. Epidural analgesia Epidural analgesia is the administration of analgesics and local anesthetic agents into the epidural space (as a single, intermittent bolus, or continuous infusion ). Used for surgical procuderes Advantage of epidural anesthesia is effective analgesia at lower doses of systemic opioids and earlier extubation . Monitoring include cardiorespiratory monitoring, sensory responses, pain assessment, and urine output.

49. Pain management recommendation based on condition Examples Recommended intevention Routine Procedures Position change, diaper change, weighing, abdominal girth, vitals recording such as temperature and BP Non-pharmacologic measures such as sucrose, breast milk, skin-to-skin contact, facilitated Tucking Acute Pain of Short Duration Heel prick, venepuncture , arterial puncture, intramuscular, subcutaneous injections, bladder catheterization, nasogastric tube insertion, ROP, chest Physiotherapy EMLA, oral sucrose ROP - fentanyl boluses or topical eye drops along with non-pharmacologic measures which have a synergistic Effect

50. Acute Pain of Long Duration Umbilical catheter insertion, tracheal suction, lumbar punctures, chest tube insertion, central line insertion and Circumcision Intravenous fentanyl, if term neonate and agitated, can consider midazolam to calm the neonate provided other causes of agitation and pain are excluded. Avoid taking sutures on the skin while umbilical vessel catheterizations Chronic pain Postoperative pain, congenital skin disorders such as epidermolysis Bullosa Paracetamol and morphine or Fentanyl. Fentanyl is reported to be better for postoperative Congenital diaphragmatic hernia and other congenital lung malformations with PPHN, since fentanyl has vascular stabilizing Properties

51. Intubation, Noninvasive and Invasive Mechanical Ventilation Delivery room intubation where IV line may not be present, Short intubation such as RDS, pneumothorax, prolonged ventilation, INSURE, CPAP and noninvasive ventilation, nonemergency, or elective Intubations For delivery room intubations, intranasal midazolam has been reported to be useful, but ensure to keep the bag and mask ready in case of failure of intubation in first attempt For noninvasive ventilation and CPAP, nonpharmacologic approach along with boluses of morphine or fentanyl at minimum doses should be considered On mechanical ventilation, routine sedation is not preferred. Midazolam should be given only for agitated term neonates (after excluding other causes for agitation) or in neonates with PPHN (for calming effect).

52. Procedural pain relief Mild pain moderate pain severe pain procedure Non-pharmacologic Oral glucose Topical analgesics Paracetamol Opioid bolus +/-Clonidine/benzodiazepines Opioid infusion Epidural analgesia +/- adjuncts

53. Post operative pain recommendation

54. Conclusion Pain in the neonates in under-recognized and under treated Preterms have a less robust response to pain Neonates including preterm maye experience more pain than adults Pain if left untreated may lead to significant physiologic changes which can affect morbidity in the short term and behavioral changes in the long term

55. It is important to accurately grade pain using the appropriate assessment tool in the neonate Appropriate interventions should be adequately instituted to reduce pain in the neonates

56. References Eric CE, Anne RH, Camilia RM, Ann RS, Naveen J. Cloherty and Stark’s Manual of Neonatal Care. South Asian edition. India; Wolters Kluwer Health; 2021 Bonnie JS, Sharyn G, Janet Y, Kimberley Di, Grace, Celeste J et al. The Premature Infant Pain Profile-Revised (PIPP-R) - Initial Validation and Feasibility. Clinical Journal of Pain Internet. March 2014; 30(3 ). G. Raffaeli, G. Cristofori, B. Befani, A. De Carli, G. Cavallaro,M. Fumagalli et al. EDIN Scale Implemented by Gestational Age for Pain Assessment in Preterms : A Prospective Study. Hindawi Publishing Corporation, BioMed Research International. 2017 . Article ID 9253710 http ://dx.doi.org/10.1155/2017/9253710

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