NEWBORN POSTOPERATIVE PAIN CONTROL
Category: Pediatric Surgery
Abstract : Perioperative Pain Management in Newborns - neonatal analgesia, newborn postoperative pain control POSTOPERATIVE PAIN CONTROL: NONNARCOTIC AND NONPHARMACOLOGIC MODALITIES Nonnarcotic analgesics Nonnarcotic pain management modalities are important in pain management of the postoperative neonate. Acetaminophen is useful either as a sole analgesic for mild discomfort or as an adjuvant medica
Perioperative Pain Management in Newborns - neonatal analgesia, newborn postoperative pain control
POSTOPERATIVE PAIN CONTROL:
NONNARCOTIC AND NONPHARMACOLOGIC MODALITIES
Nonnarcotic analgesics Nonnarcotic pain management modalities are important in pain management of the postoperative neonate.
Acetaminophen is useful either as a sole analgesic for mild discomfort or as an adjuvant medication for moderate-to-severe pain when narcotic or regional analgesia is employed. Either oral or rectal administration may be employed. Rectal administration is associated with lower plasma levels and a longer elimination half-life. While 15 mg/kg may be administered orally, this dose is associated with subtherapeutic plasma levels when administered rectally to neonates.
An initial dose of 20-35 mg/kg is recommended for the initial preincision dose or the immediate postoperative dose administered per rectum. Ketorolac is not approved by the Food and Drug Administration (FDA) for use in neonates, and reports of its use in this patient population are absent from the literature. Moreover, ketorolac may be no more effective than high-dose rectal acetaminophen in some older patients.
Nonpharmacologic interventions
A discussion of nonnarcotic pain modalities would be incomplete without a discussion of nonpharmacologic interventions. While these modalities, in some fashion, may be employed with older patients, they are considered central to the pain management of neonates. These modalities include bundling, holding, and rocking the neonate, provision of a pacifier to alleviate distress, and minimization of environmental stimuli such as extraneous noise and unnecessary light.
POSTOPERATIVE PAIN CONTROL: REGIONAL ANALGESIA
Regional pain control techniques are increasingly employed to manage postoperative pain in neonates. Regional techniques may include single-dose administration of local anesthetics into the caudal space, plexus blockade of the upper or lower extremity, extrapleural catheter placement, or neuraxial catheter placement for continuous pain control postoperatively. The most common regional techniques in neonates include single-dose caudal administration and placement of epidural catheters for prolonged pain management.
Caudal anesthesia is a highly effective simple technique associated with a high success rate and a low complication rate. Caudal anesthesia is neuraxial anesthesia and thus is associated with some of the risks inherent to neuraxial access. However, because the neuraxial space is accessed at its most caudad entry point, the risk of neural injury or even inadvertent dural puncture is reduced. Sterile technique is required and may be accomplished by wearing sterile gloves or palpating the caudal space anatomy through an alcohol swab (ie, no-touch technique) before instilling a single dose of medication into the caudal space.
Use a short beveled needle to minimize the likelihood of inadvertent intravascular or intramedullary injection of the local anesthetic medication. A caudal anesthetic can be successfully administered in 96% of pediatric patients. Once the sacrococcygeal ligament has been penetrated with the regional anesthetic needle, lower the angle of the needle, advance the needle no more than 3-5 mm, aspirate the syringe to ensure the absence of cerebral spinal fluid or heme, and administer the local anesthetic. Most commonly, bupivacaine is administered for single-dose caudal blocks. Effective concentrations range from 0.125-0.25% bupivacaine. Volumes of 0.75-1 mL/kg are administered. Supplemental analgesics may not be required for up to 12 hours postoperatively when the caudal is effective.
Placement of a caudal, lumbar, or even thoracic catheter for continuous postoperative pain management has also been proven safe and effective in neonates. An epidural catheter may be successfully placed via the caudal approach and advanced cephalad to the lumbar or thoracic level. Using superficial anatomic landmarks as a guide, the level of the catheter may be accurately predicted. This catheter may then be used for postoperative infusion of narcotics or local anesthetic infusions. Epidural catheters have been successfully used for postoperative management of many major neonatal surgical procedures that require laparotomy or thoracotomy, including hepatic resection, abdominal wall defects (gastroschisis and omphalocele), tracheoesophageal fistula, congenital diaphragmatic hernia, and coarctation of the aorta. After successful placement and an initial bolus dose of the epidural catheter, pain management may be maintained with a continuous infusion of analgesic medications. Epidural infusions provide an acceptable alternative to the intermittent top-up technique.
Epidural infusions are both safe and effective in term and preterm neonates. Postoperative epidural bupivacaine infusions result in significantly less sedation, less depression of the respiratory rate, and improvement in oxygenation without supplemental oxygen administration, while providing similar analgesia and similar complication and hemodynamic profiles to a morphine infusion.
In 1992, Berde reported recommendations to facilitate safe use of epidural analgesia in pediatric patients after analysis of more than 20,000 pediatric regional anesthetic procedures in 15 institutions. Berde recommended bolus dosing of epidural bupivacaine not to exceed 2-2.5 mg/kg. Infusion rates of 0.2-0.25 mg/kg/h were recommended for neonates. This paper cautioned that children are probably not more resistant to local anesthetic toxicity than adults, as had been previously thought. Neonates, in particular, may be at risk for local anesthetic toxicity because of diminished plasma alpha1-acid glycoprotein levels, which could result in a higher free fraction and slower clearance of bupivacaine. Premonitory symptoms or signs of local anesthetic toxicity may be absent in neonates. Reduce infusion rates for patients at risk for seizures.
When the epidural catheter level is too low to provide adequate analgesia at the incision site for a neonatal patient, increasing the rate of the epidural infusion cannot safely overcome this low catheter level. In one study, plasma bupivacaine levels continued to increase over a 48-hour infusion period, reaching the upper limits of the safe range before the end of this 48-hour period. In addition, plasma levels of bupivacaine were higher in neonates who were at higher risk for increased abdominal pressure postoperatively. Furthermore, as with all drugs administered during the neonatal period, interindividual variability in plasma bupivacaine levels were considerable in neonates receiving epidural infusions. While plasma clearance is lower in neonates than in adults receiving epidural infusions, this difference is even more dramatic in preterm neonates.
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