Evidence‐based clinical guidelines on analgesia and sedation in newborn infants undergoing assisted ventilation and endotracheal intubation

Abstract

Aim: This review informed pain control guidelines for clinicians performing mechanical ventilation, nasal continuous positive airway pressure and endotracheal intubation on term and preterm newborn infants. Methods:We reviewed literature published between 1986 and June 2017 on analgesia and sedation during assisted ventilation and before endotracheal intubation in newborn infants admitted to neonatal intensive care units. The subsequent guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation approach.Results: Our review produced five strong standard of care recommendations. One, reduce neonatal stress and use nonpharmacological analgesia during invasive ventilation. Two, favour intermittent boluses of opioids, administered after pain scores and before invasive procedures, during short expected periods of mechanical ventilation, mainly in preterm infants affected by respiratory distress syndrome. Three, do not use morphine infusion in preterm infants under 27 gestational weeks. Four, always use algometric scores to titrate analgesic drugs doses. Five, use premedication before endotracheal intubation for a more rapid, less painful, less traumatic and safer manoeuvre. We also developed 30 conditional recommendations on therapeutic options. Conclusion:Our review produced 35 recommendations on standard care and therapeutic options relating to the analgesia and sedation of newborn infants during ventilation and before endotracheal intubation.208

Adequate analgesia and sedation should be given to neonates during non‐emergency endotracheal intubation

“…The same applied to endotracheal intubation. Since then, ethics and evidence have evolved, and evidence‐based clinical guidelines now recommend that neonates undergoing non‐emergency endotracheal intubation should receive appropriate premedication . This practice is an essential ethical requirement and best practice, according to the available scientific evidence.…”

“…This practice is an essential ethical requirement and best practice, according to the available scientific evidence. However, premedication practices for neonatal endotracheal intubation differ widely and many infants are still being intubated without any analgesia or sedation . The reasons why many neonatologists do not use appropriate premedication have been inadequately evaluated.…”

“…There is no proof that the short‐term use of hypnotics has an impact on neurological maturation or function in humans. There is sufficient evidence that repetitive painful experiences are associated with worse outcomes in neonates . Research has shown that premedication facilitates the intubation procedure and reduces the frequency of adverse events.…”

“…The vested interest in premedication is that this procedure will not cause long‐term sequelae. When we weight up these interests, the proven advantages of using premedication seem to outweigh the potential disadvantages . Premedication should be used based on first impressions.…”

“…The research on using premedication in neonatal intubation is abundant and controversial. An anticholinergic and an opioid are often recommended, as are neuromuscular blocking agents, and they are used in many neonatal centres . The opioid doses commonly used in neonatology provide sufficient analgesia, but little sedation and no significant hypnosis.…”