To Sedate or Not to Sedate for Less Invasive Surfactant Administration: An Ethical Approach

Abstract

Less invasive surfactant administration (LISA) is an effective, minimally invasive technique of administering surfactant to infants with respiratory distress syndrome. While termed less invasive, LISA still requires airway instrumentation with direct laryngoscopy, thus may be considered painful. However, the issue of whether or not to routinely sedate infants for LISA remains contentious, with significant variation in practice between centres. Proponents for giving pharmacological analgesia and/or sedation predominantly focus on patient comfort during the procedure. However, those who favour non-pharmacological measures of pain management focus on the potential for procedural success without the risk of adverse events, such as respiratory depression and potentially the need for escalation to intubation, which may occur with pharmacological agents. The neonatal population who may benefit from LISA is varied. Due to this variety in presentation type, gestational age, and unit experience, there is a need to provide an individualized, tailored approach to sedation and analgesia for these infants. Using a blanket approach to sedation will lead to infants being exposed to sedative medications on the assumption of potential distress, rather than in response to signs of actual distress. This places the infant at risk of the adverse reactions, potentially without them ever having needed the beneficial effect of the medications. This seems an unnecessary risk. This article explores the ethical arguments pertaining to analgesia and sedation during the LISA technique, concluding that a standardized approach to the usage of pharmacological sedation is undesirable. Moreover, we maintain that procedural analgesia and sedation should be based on individualized, infant-centred assessment, rather than on a rigid, standardized approach.

Analgosedation before Less-Invasive Surfactant Administration: A Systematic Review

“…The ideal drug would suppress pain and discomfort, while maintaining cardiorespiratory stability and having a minimal impact on the respiratory drive. Moreover, it would allow a rapid onset and offset and be safe in the long term [6, 14, 33]. To optimize the effect of the chosen drug, the time interval before procedure varies according to its pharmacokinetics properties.…”

Should less invasive surfactant administration (LISA) become routine practice in US neonatal units?

“…46 This poses challenges in balancing the pain and discomfort from laryngoscopy against the harmful effects of intubation and MV that might result from use of sedation. 47 THE EVIDENCE FOR LISA Thus far LISA has been evaluated in 20 trials in preterm infants, [28][29][30][31][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] of which 17 are summarized in this review. Three are excluded-one that evaluated CPAP and NIPPV, and two that evaluated the role of sedation during LISA.…”

“…Until we have more evidence, it is reasonable to consider an individualized approach based on an infant's GA, respiratory drive, and bedside assessment of pain and distress to guide the use of opioids and sedatives. 47 If a decision is made to administer medication for pain, slow infusion of low dose fentanyl (0.7 mcg/kg) as recommended by a consensus guideline from the United Kingdom is prudent. 3 In addition, non-pharmacological measures such as swaddling, oral/buccal sucrose or breast milk may be used for infants receiving LISA.…”

Surfactant Replacement Therapy: What’s the New Future?

“…130, 131 However, no drug is without unwanted adverse effects, and studies indicate that premedication may help to reduce pain scores, but may interfere with spontaneous breathing especially in preterm infants, who are even more sensitive to these effects. 130-133…”

“…Nonpharmacological methods such as swaddling, containment holding, or sucrose can be considered. 133…”