PREOPERATIVE PAIN MANAGEMENT NEWBORNS
Category: Pediatric Surgery
Abstract : preoperative pain management in newborns : The practice of medicine has become progressively more sophisticated. Physicians can now achieve the goal of facilitating the healing process while simultaneously minimizing or even eliminating the pain once thought necessary to achieve this goal. Adults were the first to benefit from these advances. Only within the last 2 decades has the sophisticated
preoperative pain management in newborns :
The practice of medicine has become progressively more sophisticated. Physicians can now achieve the goal of facilitating the healing process while simultaneously minimizing or even eliminating the pain once thought necessary to achieve this goal. Adults were the first to benefit from these advances.
Only within the last 2 decades has the sophisticated medical establishment realized that pediatric patients, including neonates, also feel pain and require medical intervention to alleviate unnecessary suffering.
Medical intervention to alleviate unnecessary suffering is significantly affected by the beliefs of the caregiver. Before the late 1980s and early 1990s, the belief remained commonplace that neonates experienced no pain or less pain than adults, children, or infants who underwent similar surgical procedures. A health care provider who believes that neonates feel less pain tends to observe fewer clinical signs of pain in neonates.
Furthermore, this group of practitioners tends to believe that narcotic administration is associated with increased risk in neonates. These practitioners may administer narcotic analgesics; however, less aggressive intervention and, frequently, subtherapeutic regimens are employed in preverbal patients as compared to adults.
The fear of respiratory depression most significantly limits the administration of narcotics postoperatively, especially in nonintubated neonates or neonates undergoing minor surgical procedures. While these concerns may have some pharmacologic basis, they should not prevent the appropriate administration of narcotic analgesics to neonates who have experienced significant surgery.
Furthermore, other therapeutic regimens formerly reserved for adults, adolescents, and older children may also be used safely to manage postoperative pain for the neonate. This article expressly and specifically considers the application of medical advances in pain management to the care of our youngest perioperative patients, neonatal surgical patients.
PREOPERATIVE ASSESSMENT AND PREPARATION
Suffering can be minimized during the preoperative visit when physicians avoid unnecessary laboratory studies, especially those that require phlebotomy. Furthermore, inappropriately long NPO (ie, nothing by mouth) periods can be eliminated, thereby avoiding unwarranted patient agitation.
Postoperative pain management should be discussed when the surgical neonate and family are seen preoperatively. Issues that may eventually affect decisions about postoperative pain management, and should therefore be addressed, include coexisting disease states, surgical site, postoperative disposition, and family consent for pain management techniques that are being considered.
Neonates who are unstable, septic, or likely to remain intubated postoperatively are frequently managed with narcotic administration intraoperatively and are continued on narcotics as needed postoperatively. Narcotic administration is pursued more cautiously in neonates who will be in a non-ICU setting postoperatively. Neonates undergoing outpatient surgery or surgery associated with minor postoperative pain are frequently managed postoperatively with acetaminophen with regional or local anesthetic infiltration.
Neonates who undergo lower extremity, abdominal, or thoracic surgery are excellent candidates for regional anesthesia, whether undergoing inpatient or outpatient surgery. As in adults, coexisting pulmonary disease in neonates may be an excellent reason to consider regional anesthesia for postoperative pain management. Finally, anxiety among family members concerning a pain control strategy should be thoroughly addressed and considered in postoperative pain management decision-making.
THE PAIN RESPONSE IN NEONATES
After extensive work in the 1980s and 1990s, the fact that neonates experience pain and mount a stress response has been established and appreciated. Metabolic and hormonal indicators of the degree of stress a surgical patient experiences have been monitored during and after surgery. These indicators are, in fact, elevated in neonates perioperatively.
Even premature neonates undergoing surgery are capable of mounting a significant stress response, as measured by hormonal and metabolic indicators. Stress indicators include plasma adrenaline, noradrenaline, glucagon, insulin, and cortisol as well as blood glucose, lactate, pyruvate, and alanine. The mounting of a surgical stress response results in catabolic responses, including glycogenolysis, gluconeogenesis, and lipolysis during the perioperative period. These catabolic responses, when unmodulated by medical intervention, may have a detrimental effect on the clinical course of a neonatal surgical patient.
Adverse circulatory and respiratory events are also more likely during the postoperative course of neonates who have had inadequate interventions to minimize stress response. Tachycardia, systemic hypertension, pulmonary hypertension, respiratory embarrassment, and intraventricular hemorrhage may be associated with inadequate pain control in neonates. Furthermore, inadequate treatment of pain in neonates may have implications that extend beyond the neonatal period, including hypersensitivity to noxious stimuli later in life.
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