pain management in NICU

  1. I wrote our first pain management protocol in 2001. It needs updating, and I'd like to ask everyone: What does your unit use for Opiods, and what is used for sedation? We have had recovering micropreemies still on vents, but off perenteral fluids. We usually give po Morphine in these cases. What about vented babies who are on fentanyl already, and still are agitated? I've read several articles which are questioning the safety of Midazolam. Some give Ativan, and that can cause seizures. What about Nembutal or Chloral hydrate? I know CH was booed yrs ago. I really worry about the liitle brains and playing with their memories. I need help. Thanks in advance.

    Connie RNC pain resource nurse
    Neonatal ICU
    Sarasota Memorial Hopital
    Sarasota Fl
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    Joined: Jun '05; Posts: 8; Likes: 1

    9 Comments

  3. by   BittyBabyGrower
    We use Morphine or Fentanyl drips on our vented kids with an order for PRN ativan or versed for breakthru agitation. We don't like to bolus with Fentanyl because of the risk of chest rigidity if pushed to fast (seen it and it is scary!). We don't use chloral hydrate at all anymore, it takes way to long to take effect. As for po we go with either morphine or ativan. We have also used Methadone with good results, both IV and PO for the older more chronic kids that have been on every sedation around and are tolerant.
  4. by   SteveNNP
    We use fentanyl drips initially on almost all vented kids, using prn midazolam for breakthrough agitation. If the kid is expected to come off the vent before the end of the shift, we may just give a dose or two of morphine or fentanyl and versed. We've had good luck with the fentanyl gtts, which usually control pain very well, not too much problems with bowel motility, and usually wean pretty easily. We can bolus directly off our syringe pumps over 15-30 min for increased pain, or procedures. There have been a few that had to wean off on methadone. Methadone is the only po pain med we give other than sweetease. Our neos don't like using Ativan, they say it has something to do with the benzyl alcohol it's suspended in, which can be toxic in high doses.
  5. by   lovemyjob
    Are we the only unit that does not routinely sedate vented kids? The kid has to post-op for ANYTHING close to a narcotic (hah, they sometimes try tylenol depending on the surgery) or VERY unstable.

    When we do sedate, we use ativan and fentanyl, but generally just fentanyl.

    I have been very lucky to not have seen chest wall rigidity, have been told it takes a fairly large dose to cause that. We do occasionally use chloral. What is the concern with it?
  6. by   BittyBabyGrower
    Chloral is on the wayward side now. It takes too long to take effect most of the time. We were using for procedures and we weren't getting good effect from it. It has anunpredictable onset, long duration, and there isn't a reversal agent.

    You can get chest wall rigidity with any fent. if it is pushed too fast. When you start getting over 6mcg/kg/min (don't quote me on that) then they are a very high risk for CWR and then we switch over to a methodone gtt.

    We sedate, or at least have a PRN order, for any intubated kid. You don't want them agitated, esp if small due to increasing intracranial pressures and increased chance of shunting with the sicker big kids. We use our pain scales for this.
  7. by   TiffyRN
    Quote from lovemyjob
    Are we the only unit that does not routinely sedate vented kids? The kid has to post-op for ANYTHING close to a narcotic
    Nope, you're not the only ones; same thing with post-op pain management. The kids have to practically have PPHN to get sedation. It's not unheard of; occasionally a chronic will get meds if the nurses advocate long and hard enough, and very rarely will a regular preemie in the first weeks of life get sedation/narcotics.

    Sure wish we did. . .
  8. by   RNCRICE
    Quote from TiffyRN
    Nope, you're not the only ones; same thing with post-op pain management. The kids have to practically have PPHN to get sedation. It's not unheard of; occasionally a chronic will get meds if the nurses advocate long and hard enough, and very rarely will a regular preemie in the first weeks of life get sedation/narcotics.

    Sure wish we did. . .
    To TiffieRn SOOOO sorry to hear you're having so much trouble with pain mgt. We do at times, but at least our Neo's will comply when we really want to increase the dose, etc. I understand their hesitency. Those little micropeemie brains are so so open to experiences. Most of ours are bad. Perhaps you could present the information to them as a group about what stress and pain do to their brains. There are loads of research about this. Always need more though. Even the AAP has their position statement about it. They feel relief of pain and stress is pretty much a right of everyone, even our youngest. Good luck RNCRICE
  9. by   justjenny
    Quote from TiffyRN
    Nope, you're not the only ones; same thing with post-op pain management. The kids have to practically have PPHN to get sedation. It's not unheard of; occasionally a chronic will get meds if the nurses advocate long and hard enough, and very rarely will a regular preemie in the first weeks of life get sedation/narcotics.

    Sure wish we did. . .
    Same with us....sigh. There are days when it is a major factor in my consideration to leave. I once had NIGHTMARES about a little one that they stopped the fentanyl drip and she bucked and fought the vent and satted 60's on 100%....sigh. I called and called, and all I got was "well..I'm not going to do anything about it" even the parents spoke with Docs and finally got a PRN for Fentanyl and the next day or two they started Chloral Hydrate.

    What makes me so MAD is that our unit thinks they are SOOO progressive in pain management...but we hardly ever use pain meds! We are now limited in our use of Sucrose!!!!!!!!!!
    Don't get me started....

    Jenny
  10. by   lovemyjob
    I am so sorry to hear you guys are having this much trouble. I do have to say, at least our neos will if forced to by decompensation.


    I was so angry.... the other day they brought a kid back s/p laproscopic anorectal pullthrough, extubated...... arched, tight, stridorous, retracting to the backbone, BP 120/80. It is not anesthesias job to wean from the vent.... the kid had to be reintubated (they wouldnt let me give fent until after intubation) and it took FOREVER b/c his airway was so swollen... probably had ten people practice on him in the OR. Ugh, he was in so much pain :angryfire
  11. by   SFRN
    We use morphine quite a bit for pain management, sometimes fentanyl---but not as much. We use Ativan for sedation and rarely versed--usually for larger babies. We also continue to use chloral hydrate which I like quite a bit. For MRI sedation we use pentobarbital (Nebutal).

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