How is pain treated in your NICU? (Particularly on HFOV or SIMV)

[hmarandola]

In my NICU the nurses are getting frustrated with docs who are resisting our push to prescribe Ativan and Morphine for little ones on vents. There is a group of docs who rotate through from a tertiary NICU nearby and they are now convinced, through research, that morphine and ativan cause brain damage. They also seem to want the little ones on HFOV to move around a bit and breath on their own too. (It used to be that they didn't want them to breathe on their own at all).

Anyhow, the problem we have (besides the docs inconsistency) is the fact that they don't share the evidence with the "dumb bedside nurse"...that's how it feels. AND they don't bother to study what alternative method they can use for the baby's terrible discomfort. We are the ones who watch them desat everytime we have to mess with them, or family visits, or it's too bright, too loud etc...We do very well with developmental support and compassionate touch, but there are limits to non-pharmaceutical interventions. Last night, when a doc denied pain meds for a baby on HFOV, the RT wryly suggested, "Why don't we intubate you and then not give you any pain meds."

We've already addressed this with our Neo Director and he's looking into it. But some of us were just curious how other NICU's were treating pain, primarily kids on vents. Please let us know.

Or if you know of specific research that shows that brain damage is directly caused by pain meds...last we heard, frequent, severe desats/hypoxia also damages tiny brains. And the O2 required to bring them up can cause ROP. Is it a lose-lose situation?

[lovemyjob]

Our docs do not prescribe pain meds for the sole reason of being ventilated. I wish we did because I cant imagine being on an oscillator and being conscious.

I have read that versed has an increased risk of IVH when used on neonates, but not morphine or ativan. Our pain committee put out a pain packet that had studies that showed versed used for sedation while intubated had an increased risk of IVH. I dont really see ativan as a pain management tool because it does not block pain receptors, it is nothing but an anti-anxiety. We have a lot of pain management issues also with treatmening post-op pain. I was actually planning on posting a thread on fentanyl dosing post op.

[Sweden]

We don´t routinely sedate or use painmedication for our vent babies. The only time we give medication is if the child is very agitated (wich translates to bigger, stronger and not used to be on ventilator) and sometimes when they are on HFOV and don´t let the ventilator do the work for them.

Anna

[justjenny]

We don't medicate vented babies either...sure there may be an exception every blue moon or so. The only vented baby with pain meds would be post-op and then they would be on a fentanyl drip. NO versed, ativan, etc. on my unit!

Jenny

[hmarandola]

Our docs do not prescribe pain meds for the sole reason of being ventilated. I wish we did because I cant imagine being on an oscillator and being conscious.

I have read that versed has an increased risk of IVH when used on neonates, but not morphine or ativan. Our pain committee put out a pain packet that had studies that showed versed used for sedation while intubated had an increased risk of IVH. I dont really see ativan as a pain management tool because it does not block pain receptors, it is nothing but an anti-anxiety. We have a lot of pain management issues also with treatmening post-op pain. I was actually planning on posting a thread on fentanyl dosing post op.

We don't consider ativan as a "Pain reliever" but generally believe it helps their discomfort by relieving "anxiety". Their innate fear does seem to agitate the babies, often resulting in an unstable kid. It's so hard to define pain in a neonate, let alone have an accurate tool to "Measure" it...don't you think?

[SteveNNP, MSN, NP]

OH MY GOSH!!!!

I can't believe I'm reading this.........:angryfire

How as a patient advocate, can you not relieve your pt's pain and anxiety? There are HUNDREDS of studies out there that show that neonates/preemies feel pain even in the womb. I would venture a guess that not one intubated, catheterized, cannulated, poked, pricked and prodded adult goes without pain meds and/or sedation. I have developed an IVH prevention protocol for our unit, and the latest research shows that inadequate pain control/sedation is a leading cause of germinal matrix hemorrhage/IVH. There are several Pain scales out there such as CRIES, NIPPS, PIPPS and NPASS that when properly used can diagnose pain in the critically ill neonate. Our IVH rate has decreased from 22% to about 2% among

[hmarandola]

Thanks for your input Steve!!! We definitely are trying to advocate for our babies. That's why everyone's responses are valuable to us!

[Gompers, BSN, RN]

We are very big on pain control where I work. We have a policy that EVERY baby on the vent has to be given narcotic pain relief.

If we are intubating a baby who doesn't have an IV (like in the delivery room) then we will just tube the baby without pain meds, because in that situation the priority is to get that baby oxygenated. But if the baby is on the unit and has IV access, we will not intubate without first giving at least 2 mcg/kg of Fentanyl.

Once a baby is tubed, if it looks like it's going to be for a decent amount of time (micropreemie, PPHN, etc.) then a Fentanyl drip is ordered. We'll usually start at 0.5 mcg/kg/hr and will titrate up if we have to. We also give a bolus of Fentanyl equal to 1 hour's worth of the drip when either starting or increasing a drip, to help increase the blood level of Fentanyl and then the drip maintains that level. We'll try and wean the Fentanyl drip down as the baby nears extubation, but will not wean more than 0.5mcg/kg/day. We routinely extubate babies who are still on Fentanyl drips, and find it much easier to wean them off the drip after extubation because they are more comfortable. Then we start bolus morphine at 0.1 mg/kg Q4H and gradually, over the course of many days or weeks, we'll decrease the dosage and frequency. Most of the babies who've been on drips for a long time do not seem to have respiratory depression from these meds so we're okay with giving them to an extubated baby.

In the cases where a baby will probably not be intubated for very long (post-op, mild newborn RDS, etc.) then we'll just do bolus Morphine, starting at 0.05 mg/kg Q4H and increasing as needed. When the baby is nearing extubation, we'll hold the Morphine for at least four hours and then extubate so tht they have the best chance at successfully breathing on their own.

ETA: Over the past few years, we have stopped using Ativan on babies under 36 weeks corrected gestation. There have been reports that it does cause neurological damage. We also don't routinely give morphine to micropreemies anymore because it seems to cause more GI motility problems than Fentanyl. In preemies, we will use Fentanyl to control pain and it does help to sedate them if they are given the proper dose (which can be monitored by doing pain scores and also withdrawl scores when weaning the drip).

[fergus51]

I would be horrified if I was a parent and my baby was on HFOV without any pain meds or sedation. We put them on fentanyl (or less often morphine) drips routinely as well as versed drips as needed.

I will say I don't love giving fentanyl before intubations. If you see one bad chest lockdown despite it being given very slowly, it kind of freaks you out.

[Gompers, BSN, RN]

I would be horrified if I was a parent and my baby was on HFOV without any pain meds or sedation. We put them on fentanyl (or less often morphine) drips routinely as well as versed drips as needed.

I will say I don't love giving fentanyl before intubations. If you see one bad chest lockdown despite it being given very slowly, it kind of freaks you out.

This is one of the reasons that we are now trialing using a combination of Fentanyl, Atropine, and Rocuronium for intubation. It is a spectacular combination and we are having much success with it! The Rocuronium causes temporary paralysis, so the babies can't clamp down. I've seen that before, and it is indeed scary!

[fergus51]

I would love that Gompers. I don't mind giving morphine pre-intube, but Fentanyl really makes me uncomfortable. A friend of mine had a baby clamp down so bad they wound up coding him. I'd rather give nothing than Fentanyl alone.

[Gompers, BSN, RN]

I would love that Gompers. I don't mind giving morphine pre-intube, but Fentanyl really makes me uncomfortable. A friend of mine had a baby clamp down so bad they wound up coding him. I'd rather give nothing than Fentanyl alone.

I hope we keep using this combo. Right now, it's for a study, but who knows. The Rocuronium causes paralysis for something like 2-60 minutes, so the baby isn't trashing against the laryngascope and can't clamp the lungs down. The atropine seems to keep their heart rates up during intubation attempts - it's pretty cool. These intubations seem to go very smoothly. Even our residents are having better luck and are getting more and more tubes in the first time. It's such a controlled situation, and it seems to be less traumatic to the baby. It's rare that we have...uh...bloody intubations anymore. God I hate those!