Alejandro Avila-Alvarez

Sedation and analgesia practices in neonatal intensive care units (EUROPAIN): results from a prospective cohort study

BACKGROUND Neonates who are in pain or are stressed during care in the intensive care unit (ICU) are often given sedation or analgesia. We investigated the current use of sedation or analgesia in neonatal ICUs (NICUs) in European countries. METHODS EUROPAIN (EUROpean Pain Audit In Neonates) was a prospective cohort study of the management of sedation and analgesia in patients in NICUs. All neonates admitted to NICUs during 1 month were included in this study. Data on demographics, methods of respiration, use of continuous or intermittent sedation, analgesia, or neuromuscular blockers, pain assessments, and drug withdrawal syndromes were gathered during the first 28 days of admission to NICUs. Multivariable linear regression models and propensity scores were used to assess the association between duration of tracheal ventilation (TV) and exposure to opioids, sedatives-hypnotics, or general anaesthetics in neonates (O-SH-GA). This study is registered with ClinicalTrials.gov, number NCT01694745. FINDINGS From Oct 1, 2012, to June 30, 2013, 6680 neonates were enrolled in 243 NICUs in 18 European countries. Mean gestational age of these neonates was 35.0 weeks (SD 4.6) and birthweight was 2384 g (1007). 2142 (32%) neonates were given TV, 1496 (22%) non-invasive ventilation (NIV), and 3042 (46%) were kept on spontaneous ventilation (SV). 1746 (82%), 266 (18%), and 282 (9%) neonates in the TV, NIV, and SV groups, respectively, were given sedation or analgesia as a continuous infusion, intermittent doses, or both (p<0.0001). In the participating NICUs, the median use of sedation or analgesia was 89.3% (70.0-100) for neonates in the TV group. Opioids were given to 1764 (26%) of 6680 neonates and to 1589 (74%) of 2142 neonates in the TV group. Midazolam was given to 576 (9%) of 6680 neonates and 536 (25%) neonates of 2142 neonates in the TV group. 542 (25%) neonates in the TV group were given neuromuscular blockers, which were administered as continuous infusions to 146 (7%) of these neonates. Pain assessments were recorded in 1250 (58%) of 2138, 672 (45%) of 1493, and 916 (30%) of 3017 neonates in the TV, NIV, and SV groups, respectively (p<0.0001). In the univariate analysis, neonates given O-SH-GA in the TV group needed a longer duration of TV than did those who were not given O-SH-GA (mean 136.2 h [SD 173.1] vs 39.8 h [94.7] h; p<0.0001). Multivariable and propensity score analyses confirmed this association (p<0.0001). INTERPRETATION Wide variations in sedation and analgesia practices occur between NICUs and countries. Widespread use of O-SH-GA in intubated neonates might prolong their need for mechanical ventilation, but further research is needed to investigate the therapeutic and adverse effects of O-SH-GA in neonates, and to develop new and safe approaches for sedation and analgesia. FUNDING European Communitys Seventh Framework Programme.

Assessment of continuous pain in newborns admitted to NICUs in 18 European countries

Continuous pain occurs routinely, even after invasive procedures, or inflammation and surgery, but clinical practices associated with assessments of continuous pain remain unknown.

Valoración clínica del dolor en unidades de cuidados intensivos neonatales españolas

INTRODUCTION Clinical scales are currently the best method to assess pain in the neonate, given the impossibility of self-report in this age group. A study is designed with the aim of determining the current practices as regards the clinical assessment of pain in Spanish Neonatal Units and the factors associated with the use of clinical scales. METHODS A prospective longitudinal observational study was conducted. A total of 30 Units participated and 468 neonates were included. RESULTS Only 13 Units (43.3%) had pain assessment protocols. Pain was evaluated with a scale in 78 neonates (16.7%, 95% CI; 13.1-20.1) and the mean number of pain assessments per patient and per day was 2.3 (Standard Deviation; 4.8), with a median of 0.75. Of the total number of 7,189 patient-days studied, there was at least one pain assessment in 654 (9.1%). No pain assessment was performed with a clinical scale on any patient in 20 (66.7%) Units. Among those that did, a wide variation was observed in the percentage of patients in whom pain was assessed, as well as in the scales used. The CRIES (C-Crying; R-Requires increased oxygen administration; I-Increased vital signs; E-Expression; S-Sleeplessness) scale was that used in most Units. In the multivariate analysis, only invasive mechanical ventilation was associated with receiving a pain assessment with a scale (OR 1.46, P=.042). DISCUSSION The majority of neonates admitted into Intensive Care in Spain do not receive a pain assessment. Many units still do not routinely use clinical scales, and there is a wide variation between those that do use them. These results could serve as a basis for preparing national guidelines as regards pain in the neonate.

Cierre quirúrgico del ductus arterioso persistente del prematuro: ¿influye la técnica quirúrgica en los resultados?

INTRODUCTION Surgical closure of patent ductus arteriosus in premature neonates is an aggressive technique and is not free of complications. A study was designed with the aim of describing our experience with a less invasive technique, the extra-pleural approach via a posterior minithoracotomy, and to compare the results with the classic transpleural approach. PATIENTS AND METHODS A retrospective cohort study was conducted on premature neonates on whom surgical closure of the ductus was performed during a ten-year period (March 2005 to March 2015). A comparison was made of the acute complications, the outcomes on discharge, and follow-up, between the extra-pleural approach and the classic transpleural approach. The study included 48 patients, 30 in the classical approach and 18 in the extra-pleural group. RESULTS The demographic and pre-operative characteristics were similar in both groups. No differences were found between the 2 groups in the incidence of acute post-operative complications (56.6 vs. 44.4%), on the dependence on oxygen at 36 weeks (33.3 vs. 55.5%), or in hospital mortality (10 vs. 16.6%). As regards the short-term progress, the extra-pleural group required fewer days until the withdrawal of supplementary oxygen (36.3 vs. 28.9) and until hospital discharge (67.5 vs. 53.2), although only the time until extubation achieved a statistically significant difference (11.5 vs. 2.7, P=.03). CONCLUSIONS The extra-plural approach by posterior minithoracotomy for the surgical closure of ductus in the premature infant is viable and could bring some clinical benefits in the short-term.

Sedation And Analgesia For Neonates In Nicus Across Europe : The Europain Survey

Background Pain and stress induced by mechanical ventilation, invasive procedures, or painful diseases supports the use of sedation/analgesia (S/A) in newborns admitted to Neonatal Intensive Care Units (NICUs). To date, these practices have not been studied at a large scale. Objective To determine current clinical practices regarding the use of S/A drugs in NICUs across Europe. Methods This epidemiological observational study on bedside clinical practices regarding S/A collected data for all neonates in participating NICUs until the infant left the unit (discharge, death, transfer) or for up to 28 days. Data collection occurred via an online database for 1 month at each NICU. All neonates up to 44 weeks gestation were included. Results From October 2012 to June 2013, 243 NICUs from 18 European countries collected data on 6680 eligible neonates. Of these, 2142 received tracheal ventilation (TV), 1496 non-invasive ventilation (NIV) and 3042 only spontaneous ventilation (SV). The median (IQR) gestational age of TV, NIV and SV neonates were 32.1 (28.1–37.4), 33.6 (31.0–36.6) and 37.9 (35.0–39.9), respectively (p < 0.001). Overall, more TV neonates [81.5% (n = 1746)] received S/A drugs than NIV neonates [17.8% (n = 266)] and SV neonates [9.3% (n = 282)]; p < 0.001. Fig. shows the rate of S/A use by country; table shows S/A drugs used. Abstract O-103 Table 1 Sedation/analgesia drugs used in TV, NIV and SV neonates neonates Abstract O-103 Figure 1 Rate of Analgesia/sedation in 2142 tracheal ventilated neonates (TV) and 1496 Non invasive ventilated neonates (NIV) admitted to NIUC in 18 European countries Conclusions Most ventilated but few non-ventilated neonates (NIV and SV) receive S/A therapy in European NICUs. Wide variations in S/A use, drugs used, and mode of administration (continuous, bolus, or both) exist among countries.

Iatrogenic aortic dissection in a preterm neonate presenting as acute renal failure

Aortic dissection is a life-threatening condition that is very rare in neonates and children. We present here an iatrogenic aortic dissection in relation to umbilical artery catheterization in a preterm neonate, presenting as acute renal failure. In our case, a conservative non-surgical approach with antihypertensive therapy and management of renal injury was effective and led to a satisfactory outcome.

Réplica a: Analgesia no farmacológica en las unidades neonatales españolas

Agradecemos el interés mostrado por López-Maestro M et al.1. en nuestro estudio sobre el manejo de la sedación y la analgesia en unidades neonatales españolas2, así como que nos brinden la oportunidad de ampliar nuestra discusión sobre las medidas analgésicas no farmacológicas. En nuestro manuscrito no se compararon los resultados con el estudio de López Maestro et al.3 por una limitación de espacio, pero también porque existen importantes diferencias entre ambos trabajos. Nuestro estudio fue diseñado con el objetivo de «determinar las prácticas clínicas actuales en relación con el uso de fármacos sedantes y analgésicos», y los 2 estudios a los que se hace referencia en la carta3,4 se diseñaron con el objetivo de «describir el grado de implantación de los cuidados centrados en el desarrollo (CCD)». En estrecha relación con los objetivos está la metodología empleada en cada trabajo. Los estudios de los CCD fueron transversales tipo «encuesta» a diferencia del diseño longitudinal y prospectivo con recogida de datos reales a pie de cuna de nuestro estudio. Además, los estudios referidos se centran en el dolor asociado a procedimientos y no en el manejo global del dolor en las unidades neonatales. Como se señala en ambos trabajos, las encuestas a unidades adolecen de múltiples sesgos cuando intentan definir la práctica clínica real5. Es frecuente que responda una sola persona por unidad, que no siempre es la que realiza las tareas asistenciales que se pretenden estudiar y que a veces puede responder más lo que cree que se debe hacer que lo que realmente se hace. La gradación de frecuencia (rara vez, frecuentemente, a veces, casi siempre. . .) es subjetiva y muy variable, por lo que suele llevar a conclusiones más vagas e imprecisas. Por todo ello, a pesar del gran interés de ambos estudios, la posibilidad de comparar sus resultados con los nuestros es limitada. Sin embargo, como bien reflejan López-Maestro M et al.1, los resultados al respecto de la existencia de protocolos locales y el uso de sacarosa son similares, por lo que estamos de acuerdo en que esto otorga consistencia a ambos trabajos, y confirma que la información de 2 estudios distintos es con frecuencia complementaria. Esto no es sorprendente, dado que a pesar de que los criterios para seleccionar las unidades fueron distintos, casi el 75% (20) de las 27 unidades invitadas en el estudio de López Maestro et al. participaron también en nuestro estudio, incluyendo las 2 unidades a las que pertenecen los autores de los trabajos de 2006 y