Yerkes Pereira Silva

Morphine versus remifentanil for intubating preterm neonates.

A double-blind, randomised controlled study was conducted to evaluate the intubation conditions in 20 preterm neonates following the use of either morphine or remifentanil as premedication. The findings suggest that the overall intubation conditions were significantly better (p = 0.0034) in the remifentanil group than in the morphine group. No severe complications were observed in either group.

Remifentanil in neonatal intensive care and anaesthesia practice

Remifentanil is a relatively new ultrashort action synthetic opioid. Studies on the use of remifentanil in neonatology have emerged demonstrating its effectiveness and safety in neonates. The present study describes the use of remifentanil in both full‐term and premature newborns, highlighting the theoretical benefits for this population in terms of both neonatal intensive care and anaesthesia. A Medline search was undertaken of all reviews and reports about the use of remifentanil in neonates published between 1996 and 2009 using MeSH search terms ‘remifentanil’, ‘analgesia’, ‘anaesthesia’, ‘newborn’ and ‘neonate’. The review points that remifentanil has been used with advantages in newborns including preterm neonates and even for foetal anaesthesia. It proved to be a good option to attenuate the hemodynamic/endocrine markers of stress related to surgery. Owing to its unique pharmacokinetic profile, shorter extubation times can be achieved what makes the drug also a good option for short duration invasive procedures in NICUs (InSurE). A concern on its use is that the hemodynamic response (hypotension) may become significant when the drug is associated to other drugs like sevoflurane.

Avaliação da dor em neonatologia

JUSTIFICATIVA Y OBJETIVOS: El estudio del dolor ha avanzado mucho en las ultimas decadas haciendo con que la evaluacion y la intervencion sean una preocupacion creciente entre los profesionales de la salud. El objetivo de la evaluacion del dolor debe ser el de proporcionar datos precisos para determinar cuales acciones deben ser toma de las para aliviarlo o eliminarlo y la mismo tiempo, evaluar la eficacia de esas acciones. La finalidad de esta revision fue discutir los metodos utilizados en la evaluacion del dolor en neonatologia, cuando las estrategias de tratamiento utiliza de las sin una evaluacion sistematica del dolor no son eficaces o adecua de las. CONTENIDO: No existe ninguna tecnica ampliamente aceptada y facilmente ejecutable y uniforme para la evaluacion del dolor en ninos, especialmente en los recien nacidos y lactantes que pueda ser utilizada en todas las situaciones. Antes de confiar en la exactitud de los datos de Evaluacion, se hace necesario que los profesionales de la salud se sientan seguros con los instrumentos usados en la recoleccion del esos datos. Varios indicadores pueden ser usados en la evaluacion, cuantificacion y calificacion del estimulo doloroso, y cuando se analizan en conjunto, permiten el desglose entre el dolor y los estimulos no dolorosos. Aunque sea deseable la estandarizacion objetiva para la medicion de la intensidad del dolor, tal medida no existe todavia. La medicion ene sea franja etaria es hecha por medio de parametros fisiologicos (frecuencia cardiaca, frecuencia respiratoria, presion arterial, etc) y comportamentales (expresion facial, postura y vocalizacion o verbalizacion), utilizando escalas de evaluacion, cada una con sus ventajas y limitaciones. CONCLUSIONES: La actual atencion para mejores metodos de medida y evaluacion del dolor aporto para aumentar la sensibilidad de los profesionales de salud con relacion a la naturaleza de las experiencias dolorosas. El dolor debe ser entendido como la quinta senal vital y evaluada de manera sistematizada, tambien en los recien nacidos.BACKGROUND AND OBJECTIVES The study of pain has seen a great development in the last decades, making evaluation and intervention a growing concern among health professionals. The objective of pain evaluation should be to provide accurate data to determine the actions that should be taken to relieve or abolish it and, at the same time, to evaluate the efficacy of those actions. The objective of this review was to discuss the methods used to evaluate pain in neonatology, since treatment strategies used without systematic pain evaluation are not effective or adequate. CONTENTS A widely accepted, easy to apply and uniform technique to evaluate pain in children, especially newborns and infants, that can be used in all situations does not exist. Before trusting the accuracy of the data, it is necessary that health professionals trust the instruments used to collect the data. Several indicators can be used to evaluate, quantify, and qualify the painful stimulus and, when analyzed as a set, allow the discrimination between pain and non-painful stimuli. Although the objective standardization of measuring pain severity is desirable, it does not exist. Measurement of pain in this age group is done by assessing physiological (heart rate, respiratory rate, blood pressure, and etc.) and behavioral (facial expression, posture, and vocalization or verbalization) parameters using evaluation scales, each one with its advantages and limitations. CONCLUSIONS The current concern with better methods to measure and evaluate pain contributed to increase the sensitivity of health professionals regarding the nature of painful experiences. Pain should be valued as the fifth vital sign and evaluated in a systemized manner, including in newborns.

Remifentanil for sedation and analgesia in a preterm neonate with respiratory distress syndrome

We present the efficacy and safety of the use of remifentanil for intubation, sedation and analgesia in a preterm infant during mechanical ventilation for respiratory distress syndrome. A 34‐week‐old baby, born by cesarean delivery that developed respiratory distress, required intubation and ventilatory support. For intubation, the baby was given midazolam (0.2 mg·kg−1) and remifentanil (1 μg·kg−1). The intubation conditions were assessed and classified as excellent. The remifentanil infusion was started at dose 0.75 μg·kg−1·min−1 and the dose adjustments were made depending on the neonatal infant pain scale (NIPS), hemodynamic and respiratory changes or the presence of spontaneous movements. Pulse oximetry, respiratory rate, ECG and invasive blood pressure were continuously monitored. He was given surfactant within 2.5 h of life after which ventilator parameters could be progressively decreased. Three hours later, the remifentanil infusion was decreased to 0.5 μg·kg−1·min−1, and he remained sedated (NIPS < 2). Six hour after surfactant administration, blood gases and chest X ray were normal. The remifentanil infusion was then discontinued and 30 min later the baby was awake and extubated with success. There were no side effects after intubation or during the continuous infusion. The profile of remifentanil allowing a rapid recovery, the absence of side effects and a good level of sedation and analgesia support the choice of this opioid for sedation in the NICU.

Early awakening and extubation with remifentanil in ventilated premature neonates

Background:  Morphine is one of the most commonly used drugs for sedation and analgesia during mechanical ventilation, but its pharmacological profile has limitations, such as prolonged duration of action, especially in premature neonates. Because of its very short context‐sensitive half‐time, remifentanil has rapid onset and quickly decreases in plasma concentration after interrupting administration. The aim of the present study was to compare a continuous infusion of remifentanil and morphine during mechanical ventilation of premature neonates with respiratory distress syndrome (RDS).

EMLA versus glucose for PICC insertion: a randomised triple-masked controlled study

Preterm neonates experience a large number of painful procedures during their stay in the neonatal intensive care units (NICUs) and these procedures are often not accompanied by satisfactory analgesia.1 2 Peripherally inserted central catheter (PICC) insertion is a painful intervention employed recurrently to provide a secure venous access.3,–,7 The aim of this study was to determine whether 25% oral glucose or EMLA cream was a better strategy for controlling pain in preterm neonates undergoing PICC insertion. A randomised, triple-masked controlled trial was conducted at two tertiary NICUs in the city of Belo Horizonte, Brazil. Participants included 30 preterm neonates (≥28 and <37 weeks of gestational age) during the first week of life with a clinical indication …

Sedação e analgesia em neonatologia

BACKGROUND AND OBJECTIVES The study of pain in neonatology is important because pain and stress mean suffering and discomfort for newborns and, despite it, very little has been done to minimize them. In this revision we discuss: prevention of pain, non-pharmacological and pharmacological treatment, and sedation in newborns. CONTENTS Several non-pharmacological measures can be taken to prevent pain in Neonatal Intensive Care Units, and to humanize and reduce the stress on the environment for patients and their families. Pain treatment in the newborn consists of non-pharmacological (non-nutritive suckling, glucose) and pharmacological (non-opioid analgesics, opioids, and local anesthetics) measures. Sedation in the newborn is achieved with drugs that decrease activity, anxiety, and agitation of the patient, and that could lead to amnesia of painful and non-painful events. Sedation can be accomplished with chloral hydrate, barbiturates, propofol, and benzodiazepines. CONCLUSIONS Prevention of pain and the indication of analgesia should be individualized and always considered in every newborn with potentially painful disorders and/or undergoing invasive procedures, surgical or not.

Síndrome de Tako-Tsubo em decorrência de bloqueio neuromuscular residual: relato de caso

JUSTIFICATIVA Y OBJETIVOS: El Sindrome de Tako-Tsubo es una complicacion postoperatoria rara con una mortalidad en torno de un 5%. El objetivo de este relato es presentar el bloqueo neuromuscular residual como factor desencadenante del referido sindrome, discutir sobre el y alertar sobre el bloqueo neuromuscular residual. RELATO DEL CASO: Paciente del sexo femenino, 61 anos, estado fisico ASA I, sometida a la anestesia general asociada al bloqueo paravertebral cervical para la reparacion artroscopica de lesion de manguito de los rotadores. Despues de la extubacion, quedo demostrado el bloqueo neuromuscular residual a traves del examen clinico. En la sala de recuperacion postanestesica, evoluciono con somnolencia, taquicardia, hipertension arterial y acidosis respiratoria grave. Despues de la reintubacion evoluciono con parada cardiaca en actividad electrica sin pulso, revertida con adrenalina y masaje cardiaco externo. En el postoperatorio presento una elevacion de segmento ST, aumento de troponina y acinesia de segmento medio-apical del ventriculo izquierdo, con fraccion de eyeccion estimada en un 30%. La cineangiocoronariografia mostro coronarias exentas de ateromatosis significativa y un grave comprometimiento de la funcion sistolica con acinesia inferior y antero-septo-apical, con hipercontratilidad compensatoria de sus porciones basales. Con el tratamiento iniciado, hubo una recuperacion funcional completa. CONCLUSIONES: El bloqueo neuromuscular residual asociado a la paralisis diafragmatica y la posible atelectasia pulmonar, que conlleva a la insuficiencia respiratoria, hipercapnia y descarga adrenergica, fueron los factores desencadenantes del sindrome de Tako-Tsubo con su grave repercusion clinica.BACKGROUND AND OBJECTIVES Tako-Tsubo syndrome is a rare postoperative complication with a 5% mortality rate. The objective of this report was to present residual neuromuscular blockade as a trigger for this syndrome, discuss this disorder, and call attention to the risks of residual neuromuscular blockade. CASE REPORT A 61-year old female, physical status ASA I, who underwent general anesthesia associated with paravertebral cervical block for arthroscopic repair of a rotator cuff lesion. Physical exam after extubation detected residual neuromuscular blockade. In the post-anesthetic care unit the patient developed somnolence, tachycardia, hypertension, and severe respiratory acidosis. After reintubation the patient evolved for cardiac arrest with electrical activity without a pulse, which was reverted with the administration of adrenaline and external cardiac massage. In the postoperative period the patient presented elevation of the ST segment, increased troponin, and left ventricular medial-apical akinesia with an estimated ejection fraction of 30%. Cardiac catheterization showed absence of significant atheromatous lesions in the coronary vessels, and severe disruption of the systolic function with inferior and antero-septo-apical akinesia and compensatory basal hypercontractility. The patient had complete functional recovery with the treatment instituted. CONCLUSIONS Residual neuromuscular blockade associated with diaphragmatic paralysis and possible pulmonary atelectasis leading to respiratory failure, hypercapnia, and adrenergic discharge triggered the Tako-Tsubo syndrome with severe clinical repercussion.

Máscara laríngea ProSealTM como via de administração de surfactante no tratamento da síndrome do desconforto respiratório em recém-nascido pré-termo

The administration of surfactant via tracheal cannula with mechanical ventilation is the conventional treatment for infant respiratory distress syndrome. Hemodynamic and respiratory changes due to tracheal intubation and the need for premedication justify the search for less invasive alternatives of surfactant administration. The objective of this study was to describe the use of the ProSealTM laryngeal mask airway as an option for the treatment of respiratory distress syndrome in a premature infant born at 31 weeks of gestation, at 1335 g, with respiratory difficulty after the first hour of life and exhibiting the clinical and radiologic features of respiratory distress syndrome. The surfactant was administered with the use of the ProSealTM laryngeal mask airway at 3.5 hours of life. It was well tolerated, with no need for tracheal intubation. Normal gasometry and radiologic improvement were observed after three and six hours of administration. Oxygen administration was suspended after eight days, with no comorbidities at discharge. The laryngeal mask airway seems to be a painless and less invasive alternative to treat respiratory distress syndrome and may reduce the need for tracheal intubation and mechanical ventilation. The efficacy and advantages of this route of treatment should be confirmed in a study of an adequate sample.

Benefícios e limitações da utilização da glicose no tratamento da dor em neonatos: revisão da literatura

This article aims to review the main studies evaluating glucose as a therapeutic alternative during mildly to moderately painful procedures in neonatology, highlighting its benefits and limitations. During their stay in neonatal intensive care units, neonates are constantly subjected to a number of painful procedures without proper therapeutic management, although the medical literature emphatically recommends this type of management, highlighting the deleterious neurological consequences of pain. Most of these interventions are frequently necessary in neonatal intensive care units to maintain clinical stability in these children; the use of systemic analgesia, however, is not considered to be a good option. The administration of oral glucose solution is apparently effective and safe for pain control during procedures causing mild-to-moderate pain in neonate intensive care units, with rare adverse effects; however, its mode of action has not yet been described clearly in the literature. The administration of oral glucose solution is well described for use in venous punctures; it is apparently effective also for heel punctures, especially when associated with nonnutritive sucking, with most studies showing favorable results.