Analgesia Versus Sedation During Broviac Catheter Placement

Abstract

Premature infants are capable of mounting physiologic and metabolic responses to pain. Systemic and local anesthesia reduce stress responses to major and minor surgical procedures. We evaluated the effects of local anesthesia (5 mg/kg lidocaine) preceded by either 1 mg/kg secobarbital (S) intravenously or by 2 micrograms/kg fentanyl (F) intravenously on the stress response to Broviac catheter placement. Twenty-nine premature infants ages 5 to 30 days, weighing between 650 and 1350 gm, were randomly assigned to either S or F groups. Age, birthweight, sex, race, and severity of illness were similar among S and F groups. Heart rate and blood pressure remained unchanged throughout the procedure. Oxygen saturation (O2sat) declined significantly in both groups during skin preparation and wound closure, but not during incision, dissection, or tunneling. In spite of fractional inspired oxygen adjustments made in 13 of 14 S- and 3 of 15 F-treated patients, decline in O2sat was more common and more pronounced (p less than 0.01) in S-treated babies. Hyperglycemic responses occurred in all S- and in none of the F-treated patients (p less than 0.001). Norepinephrine plasma concentrations did not change during Broviac catheter placement in either F or S group. Epinephrine concentrations were more elevated in S- than in F-treated patients, although these differences were not statistically significant. Low-dose fentanyl analgesia effectively complements local lidocaine anesthesia during Broviac catheter placement. Sedatives neither abolish metabolic responses to surgical stress nor prevent profound and persistent oxygen desaturation.

Consensus Statement for the Prevention and Management of Pain in the Newborn

“…33,35,36 • Behavioral methods, including sucrose and nonnutritive sucking. 12,20,[37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56] • Pharmacological agents for preemptive analgesia 20,[57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76] (Table 4). …”

“…58,70 • Consider slow intravenous opioid infusion (morphine sulfate* or fentanyl citrate*). 73,76 • Consider using general anesthesia for the procedure. 15,70,76,91 Umbilical Catheter Insertion (Umbilical Arterial/Umbilical Venous)…”

“…33,35,36 • Behavioral methods, including sucrose and nonnutritive sucking. 12,20,37-56 • Pharmacological agents for preemptive analgesia 20,[57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76] (Table 4). • Pharmacological therapy for ongoing pain 17,19,34,58,[71][72][73][74][75][76][77][78][79][80] (Table 4).…”

Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement

“…They preferred placement in the groin, through the long saphenous vein. An elegant prospective randomized study by Cordero et al [7] showed that low-dose fentanyl analgesia complemented local lidocaine anesthesia effectively. Our study capitalized on all these elements and confirmed that tunneled groin lines can be placed safely in neonates in the NICU under lidocaine local anesthesia with fentanyl analgesia.…”

Pharmacological therapy for analgesia and sedation in the newborn

“…To obtain a desired clinical effect, initial intravenous boluses of 0.5-2 mg/kg may be given every 2-5 min, followed by infusions of 0.2-2 mg/kg/h for maintained analgesia. [30][31][32] One blinded randomised controlled trial (RCT) found that a single dose of fentanyl given to ventilated preterm neonates (,32 weeks, n = 22) considerably reduced pain behaviours and changes in heart rate, and increased growth hormone levels. 30 Mean fentanyl infusion rates of 0.64 mg/kg/h in ventilated infants of ,34 weeks gestation and 0.75 mg/kg/h in infants of >34 weeks gestation produced adequate analgesia, stable blood pressures and few adverse effects in a case-control study.…”