SEDATE BEFORE YOU INTUBATE THAT NEONATE!!!!!!
By: Virteeka Sinha
Energy and restlessness are the two faces of pediatric emergency medicine that we are all aware of. I am not talking about the extensively keen physicians with loads of energy and enthusiasm. I am talking about the child that will not sit still for a procedure or the test you intend to perform. I refer to the neonate that will cry and jerk when you want a still image or absolutely no movement. Neonatal and infant sedation is a challenge in the vibrant pediatric ED.
It is surprising to know that neonatal sedation has only found its way into clinical practice about 15 years back. 84 % of NICUs performed awake intubations in the year 2001. As many as 97% never used any muscle relaxants!!!! In 2010 the American Academy of Pediatrics came out with the guidelines that recommend the routine use of sedatives and muscle relaxants prior to intubations or painful procedures. The utilization of sedation in neonates and infants has increased since then.
While considering the optimal choices for sedation in the neonatal period, it is important to consider the type of procedure or test, the duration, the pharmacokinetics of the medication and the risk VS benefit ratio. It is mandatory to consider the importance of joint decision making with obtaining appropriate consent from caretakers clearly explaining to them the risks and benefits involved. The type of resources, ability to monitor, experience of the personnel and the training of ancillary staff assisting with sedation are also very important. Unplanned sedations, unprepared personnel and unfamiliarity with the choice of agents can be disastrous to the procedure and the patient.
Neonatal sedation offers the greatest challenge as it is a relatively new concept, there is paucity of data for application and there are extreme risks associated with prematurity. The routes of sedation can be broadly classified as nonpharmacological and pharmacological. Commonly employed nonpharmacological measures include the use of pacifiers, breastfeeding, multisensory stimulation, kangaroo care, swaddling, oral sucrose, infant massage and skin-to-skin contact with mother. These can be tried for most painful procedures and most emergent imaging studies. Ideal time for short procedures is about 20 to 30 minutes post feeding, when the neonate is falling asleep. The advantage that this offers over medication use is no real side effects, no post procedural monitoring, inexpensive and relatively easy to do. The main disadvantages are increased chances of failure to obtain adequate sedation level, inappropriate for still imaging test and increased downtime in the ED while waiting for the baby to fall asleep.
That’s when the pharmacological modalities come into use. The most common medications used are benzodiazepines. Midazolam and Lorazepam have traditionally been used for most procedures and imaging studies. There is some risk with extreme prematurity and with patients on ECMO. However most babies tend to tolerate this class well and no long term complications have been reported thus far.
The utilization of ketamine for neonatal sedation is limited. Though it has been found to be neuroprotective in the presence of pain, animal studies have shown some neurodegenerative effects. The dose has not been well established and no current recommendation has been made for ketamine use in neonates.
Propofol is a medication appropriate for short procedures. However the dose has not been studied in neonates. The risks of hypotension and respiratory depression have been inversely proportional to gestational age. Thus it is not considered a very safe option for neonates with prematurity.
Use of barbiturates has shown promising outcomes after 6 months of age. Limited data exists on use in younger babies. No current practice guidelines recommend its use in neonate and extremely young infants.
The current field of neonatal and infant sedation is challenging. It offers immense opportunities for research and revisions before clinical recommendations can be made. Current guidelines support the incorporation of non-pharmacological measures in addition to medications for painful procedures or radiological testing. Benzodiazepines have been used successfully and offer the best first alternative to not sedating and awake procedures. Current research and better monitoring are encouraging in the path for better sedation in the coming future!!!!
REFERENCES:
- AAP practice recommendations for neonatal sedation, 2010
- http://www.ncbi.nlm.nih.gov/pubmed/cochrane
- Intranasal Midazolam Versus Intranasal Ketamine to Sedate Newborns University Hospital, Montpellier
- Bhutada A, Sahni R, Rastogi S, Wung JT ,Arch Dis Child Fetal Neonatal Ed. 2000 Jan; 82(1):F34-7.
- Pain and Sedation in the NICU Dennis E. Mayock, MD, Christine A. Gleason, MD, 2013
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