Z Geburtshilfe Neonatol 2003; 207(6): 199-207
DOI: 10.1055/s-2003-45170
Übersicht
© Georg Thieme Verlag Stuttgart · New York

Konzepte zur Schmerzreduktion in der neonatalen Intensivtherapie

Plans to Reduce Pain in the Neonatal Intensive CareA. Hübler1
  • 1Klinik für Kinder- und Jugendmedizin der Friedrich-Schiller-Universität Jena
Herrn Professor Dirk Schramm zum 60. Geburtstag
Further Information

Publication History

Eingereicht: 20.8.2003

Angenommen nach Überarbeitung: 17.10.2003

Publication Date:
19 December 2003 (online)

Zusammenfassung

Prolongierte Schmerzen beeinflussen bei frühgeborenen Kindern unter neonataler Intensivtherapie das Verhalten und die physiologische Regulation. Aus unzureichender Schmerzbehandlung resultieren erhöhte Morbidität und Mortalität. Langfristige Konsequenzen von Schmerz und Stress für die spätere Entwicklung sind unklar, jedoch werden neurologische und verhaltensbezogene Spätfolgen diskutiert. Zur Objektivierung kindlicher Schmerzreaktionen stehen eine Anzahl von psychometrischen Konstrukten (Schmerzskalen) zur Verfügung, auf deren Grundlage die Notwendigkeit einer Behandlung überprüft werden kann. Typische Indikationsgruppen für eine Therapie sind schmerzhafte interventionelle Prozeduren, eine Analgosedierung unter Beatmungstherapie sowie die Unterdrückung von Stressantwort auf chirurgische Maßnahmen. Nichtmedikamentöse Ansätze zur Reduzierung von Schmerz und Stress beziehen sich auf das Verhalten des Kindes, unterstützende Maßnahmen durch das Personal und die Optimierung der Umgebungsbedingungen. Für die analgetische Pharmakotherapie stehen bei leichten Schmerzen Acetaminophen, bei moderaten und schweren Schmerzen hauptsächlich die Opioide Fentanyl und Morphin zur Verfügung. Unter weniger schmerzhaften Bedingungen kann eine ausschließliche oder zusätzliche Sedierung die physiologische Stabilität des Kindes verbessern. Individuelle Behandlung, engmaschige klinische Überwachung und Dosisanpassung entsprechend einer standardisierten Schmerzbeurteilung sind erforderlich. Die aktuelle Datenlage ermöglicht auch bei sehr unreifen Frühgeborenen eine effektive Schmerzreduktion. Es bestehen jedoch eine Reihe von Unklarheiten über frühkindliche Schmerz- und Stressreaktionen, so dass in jedem Fall eine sorgfältige Nutzen-Risiko-Abwägung erforderlich ist.

Abstract

Prolonged pain influences behaviour and physiological regulation in preterm infants undergoing intensive care. Insufficient pain treatment results in increased morbidity and mortality. Long-term consequences of stress and pain yet are not clear, but associations with neurobehavioral and developmental sequelae are discussed. A number of psychometric constructs (pain scales) are available to identify pain indicators. These pain scales represent the basis to consider treatment strategies. Mainindications are painful interventional procedures, analgesia during mechanical ventilation and the reduction of pain following surgery. Supporting approaches to reduce pain and stress relate to infant’s behaviour, care of the professionals and improvement of „infant’s world”. Pharmacologic interventions are practicable with acetaminophen in mild pain and with opioid drugs (fentanyl and morphine) in moderate and severe pain. A pure or complementary sedative agend can provide physiological stability in settings in which there are less acutely painful stimuli. After standard pain evaluation it is necessary to individualize treatment, to monitor clinical situation and to adjust dosage. Actual knowledge allows an effective reduction of pain even in very premature infants. Because of lack of clarity about early development of pain and stress reactivity at the time it is necessary to estimate benefits against potential risks of therapy.

Literatur

  • 1 McGrath P J, Unruh A M. The social context of neonatal Pain.  Clin Perinatol. 2002 Sep;  29(3) 555-72
  • 2 Menon G, Anand K J, McIntosh N. Practical approach to analgesia and sedation in the neonatal intensive care unit.  Semin Perinatol. 1998;  22(5) 417-24
  • 3 Haxhija E Q, Rosegger H, Prechtl H F. Vagal response to feeding tube insertion in preterm infants: Has the key been found?.  Early Hum Dev. 1995;  41 15-25
  • 4 Grunau R E, Oberlander T F, Whitfield M F, Fitzgerald C, Lee S K. Demographic and therapeutic determinants of pain reactivity in very low birth weight neonates at 32 Week’s postconceptional age.  Pediatrics. 2001;  107(1) 105-12
  • 5 Anand K JS. Clinical importance of pain and stress in preterm neonates.  Biol Neonate. 1998;  73 1-9
  • 6 Barker D P, Rutter N. Exposure to invasive procedures in neonatal intensive care unit admissions.  Arch Dis Child. 1995;  72 47-8
  • 7 Korner A F, Stevenson D K, Forrest T, Constantinou JC; Dimiceli S, Brown B S. Preterm medical complications differentially affect neurobehavioral functions: Results from a new neonatal medical index.  Infant Behav Dev. 1994;  17 37-43
  • 8 Okado N. Development of the human cervical spinal cord with reference to synapse formation in the motor nucleus.  J Comp Neurol. 1980;  191(3) 495-513
  • 9 Okado N. Onset of synapse formation in the human spinal cord.  J Comp Neurol 1981 Sep. 10;  201(2) 211-9
  • 10 Frank E. New life in an old structure: the development of synaptic pathways in the spinal cord.  Curr Opin Neurobiol. 1993;  3(1) 82-6
  • 11 Wolf A R. Analgesia in the neonate. In: Rennie JM, Roberton NR (ed) Textbook of Neonatology. Edinburg 1999: 435-41
  • 12 McVey C. Pain in the very preterm baby: „suffer little children?”.  Pediatr Rehabil. 1998;  2:2 47-55
  • 13 Howard V A, Thurber F W. The interpretation of infant pain: physiological and behavioral indicators used by NICU nurses.  J Pediatr Nurs. 1998;  13:3 164-74
  • 14 Partanen T J, Wasz-Hockert O, Vuorenkoski V, Theorell K, Valanne E H, Lind J. Auditory identification of pain cry signals of young infants in pathological conditions and its sound spectrographic basis.  Ann Paediatr Fenn. 1967;  13(2) 56-63
  • 15 Lind J, Wasz-Hockert O, Vuorenkoski V, Partanen T J, Theorell K, Valanne E. Vocal response to painful stimuli in newborn and young infant.  Ann Paediatr Fenn. 1966;  12(2) 55-63
  • 16 Gleiss J, Hohn W. Crying of newborn premature infants with and without respiratory distress in response to constant painful stimulation.  Dtsch Z Nervenheilkd. 1968;  194(4) 311-7
  • 17 Taylor A F, Lally K P, Chwals W J, McCurnin D C, Gerstmann DR; Shade R A, deLemos R A. Hormonal response of the premature primate to operative stress.  J Pediatr Surg. 1993;  28(6) 844-6
  • 18 Barker D P, Rutter N. Stress, severity of illness, and outcome in ventilated preterm infants.  Arch Dis Child Fetal Neonatal Ed. 1996;  75(3) 187-90
  • 19 Goldman R D, Koren G. Biologic markers of pain in the vulnerable infant.  Clin Perinatol. 2002;  29(3) 415-25
  • 20 Fitzgerald M, Millard C, MacIntosh N. Hyperalgesia in premature infants.  Lancet. 1988;  1 292
  • 21 Tiffany M, Field P hD. Stimulation of preterm infants.  Pediatrics in Review.. 2003;  24(1) 4-11
  • 22 Oberlander T F, Eckstein Grunau R, Fitzgerald C, Ellwood A L, Misri S, Rurak D, Riggs K W. Prolonged prenatal psychotropic medication exposure alters neonatal acute pain response.  Pediatr Res. 2002;  51(4) 443-53
  • 23 Guinsburg R, de Araujo Peres C, Branco de Almeida M F, de Cassia Xavier Balda R, Cassia Berenguel R, Tonelotto J, Kopelman B I. Differences in pain expression between male and female newborn infants.  Pain. 2000;  85(1 - 2) 127-33
  • 24 Marx C M, Smith P G, Lowrie L H, Hamlett K W, Ambuel B A, Yamashita T S, Blumer J L. Optimal sedation in mechanically ventilated pediatric critical care patients.  Critical Care Medicine. 1994;  22 163-70
  • 25 Craig K D, Hadjistavropoulos H D, Grunau R V, Whitfield M F. A comparison of two measures of facial activity during pain in the newborn child.  J Pediatr Psychol. 1994;  19(3) 305-18
  • 26 Grunau R E, Oberlander T, Holsti L, Whitfield M F. Bedsides application of the Neonatal Facial Coding System in pain assessment of premature neonates.  Pain. 1998;  76:3 277-86
  • 27 Blauer T, Gerstmann D. A simultaneous comparison of three neonatal pain scales during common NICU procedures.  Clin J Pain 1998. Mar;  14(1) 39-47
  • 28 Hudson-Barr D, Capper-Michel B, Lambert S, Palermo T M, Morbeto K, Lombardo S. Validation of the Pain Assessment in Neonates (PAIN) scale with the Neonatal Infant Pain Scale (NIPS).  Neonatal Netw. 2002;  21(6) 15-21
  • 29 Anand K JS, McIntosh N, Lagercrantz H, Pelausa E, Young T E, Vasa R. Analgesia and sedation in preterm neonates who require ventilatory support: results from the NOPAIN trial. Neonatal Outcome and Prolonged Analgesia in Neonates.  Arch Pediatr Adolesc Med. 1999;  153:4 331-8
  • 30 Mitchell A, Brooks S, Roane D. The premature infant and painful procedures.  Pain Manag Nurs. 2000 Jun;  1(2) 58-65
  • 31 Debillon T, Zupan V, Ravault N, Magny J F, Dehan M. Development and initial validation of the EDIN scale, a new tool for assessing prolonged pain in preterm infants.  Arch Dis Child Fetal Neonatal Ed. 2001;  85 36-41
  • 32 Van Dijk M, Koot H M, Saad H H, Tibboel D, Passchier J. Observational visual analog scale in pediatric pain assessment: useful tool or good riddance.  Clin J Pain. 2002;  18(5) 310-6
  • 33 Krechel S V, Bildner J. CRIES a new neonatal postoperative pain measurement score. Initial testing of validity and reliability.  Paediatr Anaesth. 1995;  5(1) 53-61
  • 34 Manworren R C, Hynan L S. Clinical validation of FLACC: preverbal patient pain scale.  Pediatr Nurs. 2003 Mar-Apr;  29(2) 140-6
  • 35 Horgan M R, Glenn S, Choonara I. Further development of the Liverpool Infant Distress Scale.  J Child Health Care. 2002;  6(2) 96-106
  • 36 Buchholz M, Karl H W, Pomietto M, Lynn A. Pain scores in infants: a modified infant pain scale versus visual analogue.  J Pain Symptom Manage. 1998;  15(2) 117-24
  • 37 Johnston C C, Stevens B, Craig K D, Grunau R V. Developmental changes in pain expression in premature, full-term, two- and four-month-old infants.  Pain. 1993;  52(2) 201-8
  • 38 Abu Saad H H, Bours G J, Stevens B, Hamers J P. Assessment of pain in the neonate.  Semin Perinatol. 1998;  22:5 402-16
  • 39 Gradin M. Need for reliable pain evaluation scale in the newborn in Sweden.  Acta Anaesthesiol Scand. 2000;  44(5) 552-4
  • 40 Aucott S, Donohue P K, Atkins E, Allen M C. Neurodevelopmental care in the NICU.  Ment Retard Dev Disabil Res Rev. 2002;  8(4) 298-308
  • 41 Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2001
  • 42 Field T, Gondson E. Pacifying effects of nonnutritive sucking on term and preterm neonates during heelstick procedures.  Pediatrics. 1984;  74 1012-5
  • 43 Franco P, Scaillet S, Wermenbol V, Valente F, Groswasser J, Kahn A. The influence of a pacifier on infants’ arousals from sleep.  P Pediatr. 2000;  136 775-9
  • 44 Abad F, Diaz-Gomez N M, Domenech E, Gonzales D, Robayna M, Feria M. Oral sucrose compares favourably with lidocaine-prilocaine cream for pain relief during venepuncture in neonates.  Acta Paediatr. 2001;  90 160-5
  • 45 Carbajal R, Lenclen R, Gajdos V, Jugie M, Paupe A. Crossover trial of analgesic efficacy of glucose and pacifier in very preterm neonates during subcutaneous injections.  Pediatrics. 2002;  110(2 Pt 1) 389-93
  • 46 Pinelli J, Symington A, Ciliska D. Nonnutritive sucking in high-risk infants: benign intervention or legitimate therapy?.  J Obstet Gynecol Neonatal Nurs. 2003;  31(5) 582-91
  • 47 Johnston C C, Filion F, Snider L, Majnemer A, Limperopoulos C, Walker C D, Veilleux A, Pelausa E, Cake H, Stone S, Sherrard A, Boyer K. Routine sucrose analgesia during the first week of life in neonates younger than 31 week’s postconceptional age.  Pediatrics. 2002;  110(3) 523-8
  • 48 Bauer K, Uhrig C, Sperling P, Pasel K, Wieland C, Versmold H T. Body temperatures and oxygen consumption during skin-to-skin (kangaroo) care in stable preterm infants weighing less than 1500 grams.  J Pediatr. 1997;  130(2) 240-4
  • 49 Carbajal R, Veerapen S, Couderc S, Jugie M, Vill E Y. Analgesic effect of breast feeding in term neonates: randomised controlled trial.  BMJ. 2003;  4,326(7379) 13
  • 50 Gray L, Watt L, Blass E. Skin-to-skin contact is analgesic in healthy newborns.  Pediatrics. 2000;  105 1-6
  • 51 Prince J, Firleu M, Harvey D. Contact between babies in incubators and their caretakers. In: Blimblecombe F, Richards M, Roberton N (ed) Separation and special care baby units. Clinics in developmental Medicine. No 68. Heinemann Medical Books London; 1978: 55-63
  • 52 Nagy S. A comparison of the effects of patients’ pain on nurses working in burns and neonatal intensive care units.  J Adv Nurs. 1998;  27(2) 335-40
  • 53 Craig K D, Korol C T, Pillai R R. Challenges of judging pain in vulnerable infants.  Clin Perinatol. 2002;  29(3) 445-57
  • 54 Modrcin McCarthy M A, McCue S, Walker J. Preterm infants and STRESS: a tool for the neonatal nurse.  J Perinatol Neonatal Nurs. 1997;  10(4) 62-71
  • 55 Scott S, Lucas P, Cole T, Richards M. Weight gain and movement patterns of very low birthweight babies nursed on lambswool. Lancet 1983: 1014-6
  • 56 Hübler A, Schramm D, Scheidt B, Sander I. Einfluss von Licht auf die infrarotspektroskopisch gemessene Hirndurchblutung Frühgeborener (abstr.)  Monatsschr Kinderheilkd. 1999;  Suppl.2 147(8) 198
  • 57 Fearon I, Kisilevsky B S, Hains S M, Muir D W, Tranmer J. Swaddling after heel lance: age-specific effects on behavioral recovery in preterm infants.  J Dev Behav Pediatr. 1997;  18 222-32
  • 58 Shah V S, al Khannan M, Quinn M W, Tripp J H. Is venepuncture in neonatal research ethical?.  Arch Dis Child Fetal Neonatal Ed. 1997 Sep;  77:2 141-2
  • 59 Larsson B A, Tannfeldt G, Lagercrantz H, Olsson G L. Venipuncture is more effective and less painful than heel for blood tests in neonates.  Pediatrics. 1998;  101:5 882-6
  • 60 Lindh V, Wiklund U, Hákansson S. Heel lancing in term newborn infants: an evaluation of pain by frequency domain analysis of heart rate variability.  Pain. 1999;  80(1 - 2) 143-8
  • 61 Shah V, Ohlsson A. Venepuncture versus heel lance for blood sampling in term neonates. Cochrane Database 2000
  • 62 Evans J C, Vogelpohl D G. Bourguignon CM, Morcott CS. Pain behaviors in LBW infants accompany some „nonpainful” caregiving procedures.  Neonatal Netw. 1997;  16(3) 33-40
  • 63 Johnston C C, Colinge J M, Henderson S J, Anand K J. A cross-sectional survey of pain and phamacological analgesia in Canadian neonatal intensive care units.  Clin J Pain. 1997;  13(4) 308-12
  • 64 DeBoer S L, Peterson L V. Sedation for nonemergent neonatal intubation.  Neonatal Netw. 2001;  20(7) 19-23
  • 65 Saarenma E, Huttunen P, Leppäluoto J, Meretoja O, Fellmann V. Advantages of fentanyl over morphine in analgesia for ventilated newborn infants after birth: A randomized trial.  J Pediatr. 1999;  134(2) 144-50
  • 66 Guinsburg R, Kopelman B I, Anand K J, de Almeida M F, Peres C de A, Miyoshi M H. Physiological, hormonal, and behavioral responses to a single fentanyl dose in intubated and ventilated preterm neonates.  J Pediatr. 1998;  132(6) 954-9
  • 67 Furdon S A, Eastman M, Benjamin K, Horgan M F. Outcome measures after standardized pain management strategies in postoperative patients in the neonatal intensive care unit.  J Perinat Neonatal Nurs. 1998;  12 58-69
  • 68 Peters J W, Koot H M, de Boer J B, Passchier J, Bueno-de-Mesquita J M, de Jong F H, Duivenvoorden H J, Tibboel D. Major surgery within the first 3 months of life and subsequent biobehavioral pain responses to immunization at later age: a case comparison study.  Pediatrics. 2003;  111(1) 129-35
  • 69 Larsson B A, Tannfeldt G, Lagercrantz H, Olsson G L. Alleviation of the pain of venepunture in neonates.  Acta Paediatr. 1998;  87(7) 774-9
  • 70 Garcia O C, Reichberg S, Brion L P, Schulman M. Topical anesthesia for line insertion in very low birth weight infants.  J Perinatol. 1997;  17(6) 477-80
  • 71 Taddio A, Ohlsson A, Einarson T R, Stevens B, Koren G. A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates.  Pediatrics. 1998;  101(2) E1
  • 72 Anderson B J, van Lingen R A, Hansen T G, Lin Y C, Holford N H. Acetaminophen developmental pharmacokinetics in premature neonates and infants: a pooled population analysis.  Anesthesiology. 2002;  96(6) 1336-45
  • 73 Young T E, Mangum B. Neofax 15th edition. 2002: 132-3
  • 74 McRorie T I, Lynn A M, Nespeca M K. The maturation of morphine clearance and metabolism.  American Journal of Diseases of Children. 1992;  146 972-6
  • 75 Tendero G, Lopez M V, Arcas Martinez J, Roche Herrero M C, Martinez Bermejo A. Neonatal EEG trace of burst suppression. Etiological and evolutionary factors.  Rev Neurol. 2001;  16,33(6) 514-8
  • 76 Nguyen the Tieh S, Veechierinin M F, Debillon T, Pereon Y. Effects of sufentanil on electroencephalogram in very and extremely preterm neonates.  Pediatrics. 2003;  111(6) 123-8
  • 77 Fahnenstich H, Steffan J, Kau N, Bartmann P. Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants.  Crit Care Med. 2000;  28(3) 836-9
  • 78 Pezzati M, Bertini G, Chiti G, Danesi G, Lachina L, Rubaltelli F F. Paralytic ileus in a mechanically ventilated preterm infant treated with fentanyl.  Pediatr Med Chir. 2001;  23(3 - 4) 201-2
  • 79 Das U G, Sasidharan P. Bladder retention of urine as a result of continuous intravenous infusion of fentanyl: 2 case reports.  Pediatrics. 2001;  108(4) 1012-5
  • 80 Taddio A. Opioid analgesia for infants in the neonatal intensive care unit.  Clin Perinatol. 2002;  29(3) 493-509
  • 81 McGuire W, Fowlie P W. Naloxone for narcotic-exposed newborn infants. Cochrane. Database Syst Rev 2002 4: CD003483
  • 82 Johnson K, Gerada C, Greenough A. Treatment of neonatal abstinence syndrome.  Arch Dis Child Fetal Neonatal Ed. 2003;  88 2-5
  • 83 Lynn A M, Nespeca M K, Bratton S L, Shen D D. Ventilatory effects of morphine infusions in cyanotic versus acyanotic infants after thoracotomy.  Paediatr Anaesth. 2003;  13(1) 12-7
  • 84 Kokki H. Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children.  Paediatr Drugs. 2003;  5(2) 103-23
  • 85 Cuzzolin L, Dal Cere M, Fanos V. NSAID-induced nephrotoxicity from the fetus to the child.  Drug Saf. 2001;  24(1) 9-18
  • 86 Lago P, Bettiol T, Salvadori S, Pitassi I, Vianello A, Chiandetti L, Saia O S. Safety and efficacy of ibuprofen versus indomethacin in preterm infants treated for patent ductus arteriosus: a randomised controlled trial.  Eur J Pediatr. 2002;  161(4) 202-7
  • 87 Morley G M. Safety and efficacy of ibuprofen versus indomethacin in preterm infants.  Eur J Pediatr. 2003;  162(1) 62
  • 88 Wooltorton E. Propofol. Contraindicated for sedation of pediatric intensive care patients.  CMAJ. 2002;  167(5) 507
  • 89 Hatch D J. Propofol-infusion syndrome in children.  Lancet. 1999;  353 1117-8
  • 90 Sloan J IA. Propofol syndrome in children.  CMAJ. 2003;  168(6) 669
  • 91 Ng E, Taddio A, Ohlsson A. Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit. Cochrane Database Syst Rev 2003 1: CD002052
  • 92 Taddio N E, Ohlsson A. Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit. Cochrane Database 2000
  • 93 Bittigau P, Sifringer M, Genz K, Reith E, Pospischil D, Govindarajalu S, Dzietko M, Pesditschek S, Mai I, Dikranian K, Olney J W, Ikonomidou C. Antiepileptic drugs and apoptotic neurodegeneration in the developing brain.  Proc Natl Acad Sci USA. 2002 Nov 12;  99(23) 15 089-94
  • 94 Saarenmaa E, Neuvonen P J, Huttunen P, Fellmann V. Ketamine for procedural pain relief in newborn infants.  Arch Dis Child Fetal Neonatal Ed. 2001;  85(1) 53-6
  • 95 Wereszczak J, Miles M S, Holditch Davis D. Maternal recall of the neonatal intensive care unit.  Neonatal Netw. 1997 Jun;  16:4 33-40
  • 96 Moore J. No more tears: a randomized controlled double-blind trial of Amethocaine gel vs. placebo in the management of procedural pain in neonates.  Adv Nurs. 2002;  34(4) 475-82

Dr. med. Axel Hübler

Abteilung Neonatologie und Pädiatrische Intensivmedizin

Klinik für Kinder- und Jugendmedizin

Friedrich-Schiller-Universität Jena

Kochstraße 2

07740 Jena

Phone: 03641-938259

Fax: 03641-938075

Email: Axel.Huebler@med.uni-jena.de