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NICU
https://t.me/medicina_free
Infant
• GA
• Illness severity
• Mechanical ventilation
• Pain exposure
Early Pain Management
• Analgesia
• Sedation
• Sucrose
• Comfort
Parent/Caregiver
• History
• Beliefs
• Tr aits
• Interaction with child
NICU Reactivity and Arousal
• Sleep/waking states
• Pain
• Handling
Pain Infancy/Childhood
• Reactivity
• Dampening
• Somatization
Prenatal/Perinatal/Postnatal
• Prenatal stress infection
• Intraventricular hemorrhage
• Periventricular leukomalacia
CHAPTER 12 Pain and Pain Relief
Parent and Family Context
• Stress
• Coping
• Support network
• Poverty
• Education
Neurodevelopment
Infancy/Childhood
Cognition
• Language
• Visual-motor
• Motor
Behavior
• Temperament
• Arousal
• Attention
• Self-regulation
319
Major sensorineural impairments
• Blindness
• Nonambulatory cerebral palsy
• Sensorineural hearing loss
FIGURE 12.8 Model of long-term effects of pain showing complex, interactive, bidirectional relationships among multiple biologic and
environmental factors. GA, Gestational age; NICU, neonatal intensive care unit. (From Grunau R. Early pain in preterm infants: a model of long-term effects. Clin Perinatol. 2002;29:376.)
neonates should be carefully calculated, and lower doses should be administered. Benzodiazepines or phenobarbital can be used to treat refractive seizures; cardiopulmonary resuscitation (CPR) and defibril­lation may be necessary to treat cardiovascular complications. Administration of intralipids 20%
in a dose of 1 to 2 mg/kg/day is a specific anti­dote for cardiac toxicity from local anesthetics. Patients who are receiving epidural analgesia for postoperative pain control should be mon­itored for signs of potential CNS toxicity (e.g.,
irritability, jitteriness, twitching, myoclonic jerking). If an opioid is being administered with the local anesthetic infusion, then respiratory depression is also a possibility, and patients should be monitored as described. Clonidine in the epidural infusion can lead to hypotension and decreased heart rate. Other
extremely rare complications of epidurals are nerve injury and/or paralysis.
Hematoma formation can occur (1.2%) with the placement of a dorsal penile nerve block. Using a ring block usually avoids this problem.
Epinephrine-containing solutions must never be used, because this can lead to compromise of the blood supply to the penis and severe tissue damage.
Tolerance and Withdrawal
Tolerance is the need for escalating doses of drug to achieve the same effect. Tolerance (1)
occurs sooner with the use of synthetic opioids (e.g., fentanyl) than with naturally occurring opi­oids (e.g., morphine); (2) is related to the duration
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of use—the longer the use (>5 days),25 the more likely tolerance is to develop (use for less than 72 hours usually is not associated with tolerance); (3) develops more rapidly with continuous infusions versus intermittent therapy; (4) may develop more rapidly in preterm neonates than in term neo­nates; and (5) occurs more often in males than in females.
24,383,384,405
Physical dependence is the state in which con-
tinued drug is needed to prevent the signs of withdrawal.
405
Withdrawal arises when discontin­uing the drug causes symptoms such as irritability, diarrhea, tachycardia, hypertension, insomnia, rest­lessness, diaphoresis, or palmar sweating and muscle twitches. Addiction occurs when there is psycho-
logical and physical dependence and is associated
with active drug-seeking behavior and use (abuse) of the drugs for nonmedical conditions. Infants are
incapable of this level of cognition and there­fore cannot become addicted to analgesics and sedatives.
160,373
Tolerance, dependence, and with-
drawal can occur with opioids and benzodiazepines.
Medications should not be restricted because of fear of addiction. Family members should be made aware of this.
Critically ill infants sometimes need long-
term infusions of opioids or benzodiazepines to provide analgesia and sedation. ECMO and
prolonged mechanical ventilation are two examples of this situation. Use of fentanyl for more than 5 to 7 days can lead to tolerance and withdrawal (also known as opioid abstinence syndrome; see Chapter 11).
Tapering doses to wean neonates from opioids will depend on the duration of the medication’s use and the infant’s response to the changes.
For short-term use, decrease opioid dose by 25% to 50% of the drug dose per day, so that the drug is discontinued within 2 to 3 days. For longer opi­oid use, decrease doses by no more than 10% to 20% every 1 to 3 days. Infusion regimens can be changed to intermittent administration before the drug is discontinued.
384
Oral forms of opioids
should be used whenever possible. Shorter-
acting medications such as fentanyl and midazolam can be switched to methadone and lorazepam, which have the advantage of being longer acting and being available in an oral form. Addition of
oral clonidine 1.5 to 3 mcg/kg twice daily can help alleviate withdrawal symptoms. The dose of clonidine can be titrated up to 5 to 10 mcg/ kg twice daily as tolerated. The side effects of
clonidine include bradycardia, hypotension, and sedation. In addition, minimal handling and a quiet, darkened environment help decrease external stim­uli. A pacifier, swaddling, and holding are effective comfort measures.
PARENT TEACHING
Mothers of neonates in the NICU report dissatisfaction with pain management, worry about their infant’s pain and pain management, and a desire to participate in comforting their distressed infants.
tional study is the first to provide a comprehensive description of parental concerns, distress, infor­mation needs, and involvement in care of their infant in pain. NICUs participated in completing questionnaires: (1) both parents reported a moderate degree of stress; (2) stress responses were slightly higher for mothers; (3) mothers’ stress was related to the sights and sounds of the NICU and their inability to per­form their maternal role; and (4) mothers reported higher anxiety levels. Specific parental concerns about pain included (1) effects of pain on the infant, (2) immediate medical problems caused by pain, and (3) long-term effects of pain. Parents reported few worries about the effects of pain medications. Parents rated their infant’s worst pain as moderate to severe and had expected there to be less pain and that their infant would receive a high degree of pain relief.
Pain management is a priority concern for parents. Seeing their babies in pain and being unable to protect them from pain is very stressful.
preterm infants are exposed to a greater number of invasive procedures, their mothers’ memories of their infant’s pain during these procedures is asso­ciated with increased PTSD symptomatology. Comparing maternal and paternal responses of their knowledge, self-efficacy, and satisfaction with their infant’s pain management in a single NICU resulted in findings of adequate knowledge by parents, moderate to high self-efficacy, and satis­faction with their infant’s pain management.
The majority of parents in this study preferred to receive written information about pain and wanted the opportunity to be present and comfort their infant during and after painful
141,145,392
141
Both mothers and fathers from 11
223
A recent study found that when
A multicenter interna-
409
406
CHAPTER 12 Pain and Pain Relief
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321
procedures.
406
Another study found that 97% of surveyed parents accessed the Internet daily, preferred the Internet for information rather than books or brochures, and wanted more information on how they could comfort their infant and more participation in comforting their infant during painful procedures.
308
An RCT to increase parental involvement in pain management for their NICU infants was con­ducted to evaluate reduction in parental stress and postdischarge parenting ability.
144
Although NICU­related stress was not reduced, parents who received information about pain and comforting techniques were better prepared to be active participants in their infant’s pain care and have more positive views about their parenting role after discharge.
144
Parents in two studies received primarily ver­bal information (i.e., 81% than any written (4%)
142
145
and 58%
information about pain
142
) rather
and pain relief. Nurses (41%), more commonly
than physicians (28%), provided information about pain to parents.
142
Although parents were usually satisfied with the pain information they received, 30% indicated that they wished they had received more information about infant pain.
142
Fifty per­cent of parents reported that they were shown how to recognize if their infant was in pain and how to provide comfort.
145
In the more recent study, 18% of parents were shown how to assess pain in their infant, and 55% were shown how to comfort the
142
infant.
In the multicenter study, 57% of parents reported that they would prefer to be with their infant during procedures.
145
Yet most parents had never (52%) or not often (24%) been asked about their preference. Parents who would have preferred to be absent during procedures reported higher stress levels, anxiety, and current worry about pain for their infant than did parents who preferred to be present. Eighty-seven percent of parents
stated that they wanted greater involvement in their infant’s pain care. Generally, the parents in
this survey reported a high level of satisfaction with their infant’s pain care.
142
Parental stress was related to (1) their estimation of infant pain, (2) their worries about infant pain, and (3) their degree of satisfaction about infor­mation about infant pain care.
142
The influence of these factors on the degree of parental stress were “strikingly consistent” among the diverse NICUs in the study. More research is needed to
determine whether (1) more parental information, involvement, and satisfaction with pain care reduces parental stress; (2) greater parental involvement in pain care improves parent-infant attachment, interaction, competence, and confidence after dis­charge; (3) culturally and socially diverse families respond similarly; and (4) barriers exist to providing more parental information and facilitating more involvement.
142
The lack of information (Box 12.8) and
passive involvement of parents in pain care for their infant
12,142,323,362
should be addressed
in the NICU. Parents are excellent observers
of their infant and often recognize when the infant is experiencing pain, even before the care provider does.
276
The health care provider loses credibility and parental trust when he or she does not acknowledge and effectively treat the infant’s
276
pain.
Listening to parents’ concerns about their
BOX
12.8
• The body that is in pain is “stressful” to the infant.
• The body that is in pain cannot grow, cannot heal, and may not
• Newborn infants, both full-term and preterm, feel pain in the NICU.
• Newborns in the NICU deserve to have their pain assessed, ade-
• Newborn infants, both full-term and preterm, do not become
• Comforting distressed infants and children is basic to the maternal/
• No research or reports have documented a newborn forming a
• Research shows that skin-to-skin contact with the mother before,
• Breastfeeding full-term and preterm newborns before, during, and
PARENT/CAREGIVER TEACHING
PAIN IN NEWBORNS
survive.
Remember that pain (and repeated pain) may have long-term consequences.
quately treated with medications and comfort measures, and re-eval­uated to determine whether the therapies have relieved their pain.
“addicted” to medications that are used for pain relief, although they may develop tolerance and withdrawal, which can be managed by the health care provider.
paternal role.
negative association with the mother/parent while she or he was providing comfort during a painful event.
during, and after a painful procedure decreases the pain response in preterm and full-term infants.
after a painful procedure markedly decreases their pain response (e.g., crying, grimacing, less tachycardia). cologic interventions that can be used by parents include NNS, oral sucrose, facilitated tucking, swaddling, and recorded music.
168,355
167,355
Other nonpharma-
122,323
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infant’s pain, including the parents’ report of their assessment, communicating the plan of care about analgesia or sedation, and offering the rationale behind the medication decision-making help the parents become active participants in the manage­ment of their infant’s pain.
Parents of medically fragile infants have iden­tified specific sources of stress in the NICU: (1) parental role alterations, especially inability to comfort the infant, and (2) infant appearance and behavior, especially pain and difficulty breathing.
The most common fear expressed by parents is that their infant will experience undue pain while being cared for in the NICU. Three years
after their infant’s NICU experience, mothers can still recall the pain and procedures that their infants endured.
417
The care provider’s sensitivity to the neonate’s pain and advocating for pain relief are comforting for parents.
141,276,415
Teaching parents to report their assessments and encouraging par­ents to comfort their infants will help them in the attachment process and foster a trusting relationship with the health care team. Comfort measures are
ideally provided by parents, who may then actively participate in their infant’s pain relief.
12,40,47,105,144,323
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