Analgesia for preterm ventilated Infants

[Skysurfer]

Dear Colleagues,

i am currently concerned to see a new hype in managing preterm infants who are intubated and ventilated with no form of analgesia...

For the last 5 years i can rememder we used to manage theese infants with morphine and midazolam by continuous infusion pumps (Morphine with 10micr/KG/h). We have had no problems with delayed extubations or children with respiratory depressions.
Nowadays our children have to undergo all medical & nursing interventions without Morphine or Midazolam. Midazolam is no longer in use because of it`s effects on brain development. Althought i believe that we would get similar results for any other medication which makes our children sleepy... If the brain doesnt get enough stimuli, it simply cannot develop neuronal links. But thats my theory.
The rational for not giving morphine is (said by our MD`s) that we could wean our children off the ventilators, sooner...

Anyway. I am concerned about this kind of development in our field of work and i am wondering what you folks are doing regarding that matter. I think the detrimental effects of pain and stress are well documented in the literature and we should do something about it. I am quite sure, and the current literature supports my theory,that pain and distress leads to alterations in the brain. I am not quite sure which way is better. Not to give proper medications because we dont want to have the negative effects of midazolam on the brain development, accepting the fact, that the brain development is altered by pain and stress, or to give such medications and to accept the fact that the brain development is altered by the medication itself?!?
Regarding the pain situation. Some of our MD`s believe that Morphine can cause or worsen NEC, by altering the intestinal motility. The fact that stress and pain for their part are major causes of NEC seems to play a secondary role...
So children with NEC are often treatet without any pain medication. One simply cannot give glucose orally, because of the NEC, but we are also often not allowed to give Morphine or are ordered to give 0,1mg /KG no more than every 4 Hours... what a mess. Is this matter an issue in your institutions? How do you/would you handle the situation?

Personally i dont think that this fashion, if it can establish, will not be seen as a glorious era of medical care in future times. But this is only my opinion.

Cheers Norbert

[chandas]

The reason for the decline in use of routine morphine analgesia is the outcome of the NEOPAIN trial. Whilst providing sedation and analgesia for ventilated preterm infants seems intuitive, the trails suggest that we may be causing more harm than good. It could be that we do not have the correct agent, or do not yet know how best to target the opiates appropriately whilst minimising harm.

[JoannieO]

Interestingly enough, in our unit we have not routinely used sedation for ventilated preterm infants for several year, and when we did use sedation we used Fentanyl infusions at 2 - 5 mcg/kg/hr. However, recently one of our neonatologists returned from a conference very keen to introduce routine sedation, and we are now using low dose Morphine. We have not been doing this long enough to see any differences in outcomes yet, but I will be interested to see how it pans out. Incidentally, we use Midazolam only on term or near term babies who need sedation as well as pain relief. I would be interested to hear what others are doing, it is always instructive to catch up with colleagues and compare treatment modalities.

Joan O'Sullivan
Clinical Support Nurse
Neonatal Intensive Care Unit
Waikato Hospital
Hamilton
New Zealand

[goosman]

In support of the remark by "Chandas" Simons showed that morphine does not seem to have analgesic effect in the ventilated preterm infant (JAMA. 2003 Nov 12;290(18):2419-27.).
However we do see some preemies with loads of stress on the ventilator. Most of the time this can be corrected by adjusting ventilator settings, but sometimes this is not effective. So we also experience difficulty in these infants.

With regards to NEC: in NEC > stage 1 we do use morphine as routine analgesic, in NEC stage 1 we use paracetamol intravenously (in preterms > 32 weeks postmenstrual age). Our belief is that the pain associated with NEC must be managed, because the pain itself has its shortterm and longterm effects. I'm not sure however if this is the right choice. Is pain associated with NEC acute pain? Or is it prolonged, needing perhaps other analgesics.....We know it is very hard to assess pain in infants with NEC. Often they show no behavioral signs, and changes in heartrate, bloodpressure and oxygen saturation may reflect pain or circulatory/respiratory instabillity.

Best regards,

CJ