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Pain management in neonates

Jul 03, 2015

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Education

Pain management in neonates

  • 1. Dr. Lokanath Reddy

2. International Association for Study of Pain(IASP) An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (note that the inability to communicate verbally or nonverbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain relieving treatment) 3. YES Pain system is intact and functional in both preterm and term neonates. Acute pain is processed in the somatosensory cortex which suggests conscious perception Behavioral responses to pain are complex and you can observe self expression. Effective mechanisms of hyperalgesia, allodynia and referred pain occur in both preterm and term neonates. 4. Flexion and adduction of affected limb Distinct facial expressions Specific features of a pain cry that has unique spectrographic characteristics to distinguish it from other types of cry(pain cry vs hunger cry) 5. 8 weeks -1st cutaneous sensory receptors perioral area 20 weeks Sensory receptors present in all cutaneous and mucosal surfaces 6 weeks - Synapses between peripheral sensory afferents and dorsal horn neurons will appear 20 weeks Thalamocortical connections will form that allow painful stimuli to reach the somatosensory cortex. A current theory of pain postulates that pain perception occurs at the level of thalamus 6. NO Developmentally regulated processes and behavioral reflexes suggest that pain threshold increases progressively during late gestation and postnatal period. Preterm neonates have much greater sensitivity to pain than term neonates and they manifest prolonged hyperalgesia after tissue injury. 7. Acute pain: Heel sticks, venipunctures, tracheal suctioning,lumbar puncture, circumcision. Prolonged/chronic pain: NEC, meningitis, mechanical ventilation, birth trauma, chest tubes. Post-operative pain: Hernia repair, ligation of PDA, VP shunts, abscess drainage etc. Routine care : Diaper change, daily weights, removing adhesive tapes, burns from transcutaneous probes and cold light, rectal stimulation. 8. YES, but in a different manner. Although children may not directly recall painful experiences from their NICU stay, they may demonstrate altered behavioral states from painful experiences that were not well managed. Pain will lead to long term and permanent alterations in brain development depending on type, duration and severity of pain, the neurological maturity at which pain occurs and the use of analgesia. Pathophysiology: Tissue damage profound and long lasting dendritic sprouting of sensory nerve terminals hyper-innervation that continues in childhood and adolescents. 9. Repeated heel sticks Abnormal gait in childhood Perioral and nasal suctioning Oral aversion syndrome Gastric suctioning Irritable bowel syndrome Surgical sites increased pain sensitivity Nerve injury in neonates does not lead to neuropathic pain as in adults 10. PRIMARY HYPERALGESIA: Neonates exposed to acute short term pain at the areas where injury occurred SECONDARY HYPERALGESIA: Hyperalgesia at remote areas from the site of injury. Primary and Secondary hyperalgesia several months Visceral Hyperalgesia several months to years Signs of ADHD, impulsivity and socialisation problems during early school years. Chronic pain syndromes in adult life. 11. Similar to term babies have heightened pain reactivity to painful procedures like heel stick. Conversely, cumulative pain since birth was significantly correlated with dampened reactivity to heel stick and lower cortisol levels to stress at 32 weeks, less pain reactivity at 4 months, faster recovery at 8 months, decreased everyday pain behavior at 18 months, increased somatization at 4.5 years and increased affective responses to depicted pain at 8-10 years. 12. Acute procedural pain/post operative pain Intensity Many pain scales PIPP(Premature Infant Pain Profile) (27 wks term) NIPS(Neonatal Infant Pain Scale) (28-38 wks) NPASS(Neonatal Pain, Agitation and Sedation Scale) CRIES score (32-60 wks) Character, location, duration and rhythm cannot be measured Chronic pain No scales to assess. 13. Scale Variables Type of pain PIPP (Premature Infant Pain Profile) (27 wks term) HR, SpO2, Facial expression, takes state and GA into account Procedural, Postoperative (minor) NIPS(Neonatal Infant Pain Scale) (28-38 wks) Facial expression, crying, breathing pattern, arm and leg movements, state of arousal Procedural NFCS (Neonatal Facial Coding System) Facial actions Procedural N-PASS (Neonatal pain, Agitation, and Sedation Scale) Crying, irritability, behavioral state, facial expression, extremity tone, vital signs Postoperative, Procedural, Ventilated CRIES (Cry, Requires O2, Increased vital signs, Expression, Sleeplessness) Cry, Requires O2, Increased vital signs, Expression, Sleeplessness Postopetive COMFORT Scale (0-3 yr old) Movement, Calmness, facial tension, alertness, RR, HR, BP Postoperative, critical care, sedated, 14. Relaxed restful face/neutral expression score - 0 Grimace Tight facial muscles furrowed brow, chin & jaw Score - 1 15. No Cry Quiet, not crying 0 Whimper Mild moaning, intermittent 1 Vigorous cry Loud cry, shrill, continuous - 2 16. Relaxed Usual pattern for that baby - 0 Change in breathing Indrawing , irregular, fast than usual, gagging, breath holding - 1 17. Relaxed No muscular rigidity, occasional random movements 0 Flexed/Extended Tense straight arms/legs, rigid, rapid flexion/extension - 1 18. Sleeping/awake Quiet, peaceful sleeping, occasional random legs/arm movements 0 Fussy Alert restless and trashing - 1 19. Neonatal infant pain scale = SUM(points for the 6 parameters) Interpretation: minimum score: 0 maximum score: 7 Pain Level Intervention 0-2 = mild to no pain None 3-4 = mild to moderate pain Non-pharmacological intervention with a reassessment in 30 minutes >4 = severe pain Non-pharmacological intervention and possibly a pharmacological intervention with reassessment in 30 minutes 20. PIPP (Premature Infant Pain Profile) (27 wks term) Indicators: (1) gestational age (2) behavioral state before painful stimulus (3) change in heart rate during painful stimulus (4) change in oxygen saturation during painful stimulus (5) brow bulge during painful stimulus (6) eye squeeze during painful stimulus (7) nasolabial furrow during painful stimulus 21. Scoring instructions: (1) Score gestational age before examining infant. (2) Score the behavioral state before the potentially painful event by observing the infant for 15 seconds . (3) Record the baseline heart rate and oxygen saturation. (4) Observe the infant for 30 seconds immediately following the painful event. Score physiologic and facial changes seen during this time and record immediately 22. premature infant pain profile = SUM(points for all 7 indicators) Interpretation: minimum score: 0 maximum score: 21 The higher the score the greater the pain behavior. 23. Prevention is better than cure Procedure Prevention/Management Removing adhesive tapes Use ether, pull slowly Burns from transcutaneous probes and cold light. Frequent change of probes every 2 hrly. Careful use of cold light. Diaper change, daily weights Minimal handling Rectal stimulation Xylocaine jelly Heel sticks, venipunctures Sucrose 0.5ml 2 min before Tracheal suctioning Sedation Lumbar puncture EMLA patch, local anestetic NEC, meningitis, mechanical ventilation, chest tubes, postoperative Sedation 24. Non pharmacological interventions facilitated tucking (holding the infants extremities close to the body, promoting flexion), swaddling, nesting, use of nonnutritive sucking minimal handling protocols lowering noise levels in the NICU avoiding exposure to bright lights promoting of day/night light cycles.