Professional Documents
Culture Documents
Mohamed Khashaba,MD
Professor of
Pediatrics/Neonatology
Head NICU
Objectives
Psychogenic pain
There is no or little physical evidence
of organic disease.
Modulation of pain
Franck(1986)
• Preterm infants may uniquely
respond to
• acute pain by increased flexion and
extension
Very premature babies
Inadequate muscle strength,
posture, tone, and movement
compared to term infants
• Physiologic changes and behavior
cues are non reliable indicators.
• Awake or alert infants demonstrate a
more robust reaction to painful
stimuli than sleeping infant.
• Arterial puncture
• Bronchoscopy
• Endoscopy
• Heel lancing
• Lumbar puncture
• ROP examination
• Suprapubic bladder tap
• Venipuncture
B. Therapeutic
• Bladder catheterization
• Central line insertion/removal
• Chest tube insertion/removal
• Chest physiotherapy
• Dressing change
• Gavage tube insertion
• Intramuscular injection
• Peripheral venous catheterization
• Mechanical ventilation
• Postural drainage
• Removal of adhesive tape
• Suture removal
• Tracheal intubation/extubation
• Tracheal suctioning
• Ventricular tap
nonpharmacologic
approaches
• Behavioral and Environmental
strategies
• Reduce the number of painful
procedures performed on infants .
• Using noninvasive monitoring
techniques
• Critically evaluating the need for all
practices, such as the number and
grouping diagnostic procedures,
Windup phenomenon
• Painful procedures should not be
performed at the same time as other,
nonemergency routine care .
• Evidence suggests that after exposure
to a painful stimulus, a preterm infant’s
pain sensitivity is accentuated by an
increased excitability of nociceptive
neurons in the dorsal horn of the spinal
cord
• Grunau,Oberlander,&Whitfield, 2005).
• This sensory hypersensitivity, may exist
for prolonged periods after a painful
• Swaddling during and after a
heel stick reduces the
physiological and behavioral pain
indicators in preterm neonates
facilitated tucking
• Hand-swaddling technique
• (i.e., holding the infant’s extremities
flexed and contained close to the
trunk), during a painful procedure
may significantly reduce pain
responses in preterm infants
• Morphine
• 0.05-0.15 mg/kg IV or SQ.*
• Fentanyl
• 0.5-2 ug/kg IV**
• Routine continuous infusion is not
recommended.
• * 1/2 this dose in non ventilated.
• ** 1/3 this dose in non ventilated.
Fentanyl
• IV infusion over > 10 minutes.
• Dose repeated every 2-4 hours.
• Maximum conc. Is 10ug/ml.
Morphine
• IV Given over > 5 min.
• Can be given IM or SQ.
• Conc. 0.01-0.02 mg/kg/hr. infusion.
Indications of Opiates
• Elective intubation and ventilation.
• During ventilation.
• Chest tube insertion and removal.
• Umbilical catheterization.
• CVC placement.
• Pre and post operative.
Analgesics
( Acetaminophen)
• 10-15 mg/kg oral/PR /6 Hrs.
• Max. daily dose is 40mg/kg.
Sedatives
• Midazolam*
• Only in full terms.
• 0.05-0.1 mg/kg IV or nasal.
• Chloral Hydrate*
• 20-30 mg/kg PO
• Phenobarbital**
• PO,IV
• * short acting ** Long acting
Summary
•
• There is good scientific evidence that
babies feel as much pain as adults do
• treating established pain, and
ensuring adequate analgesia before
painful procedures, improves the
outcome of injuries and procedures
• Untreated pain in the newborn may
have harmful effects which last into
childhood and possibly longer.
• Ordinary loving physical care and
comforting has been scientifically
shown to be effective, and remains
the mainstay of managing infants in
pain.
• We should learn to use analgesics
appropriately. Infant should not be
given analgesics without a diagnosis
of their pain