Tag: pediatric pharmacological pain relief

One of the most common measures required in neonatal and paediatric intensive care nursing is respiratory support. Such assistance for the neonate or paediatric patient may include the use of nasal prongs, high flow nasal cannulae, non-invasive ventilation, or invasive ventilation. Invasive ventilation should be left as a last resort in babies.

Respiratory Support Devices

BAG & MASK VENTILATION

NEOPUFF

NASAL PRONGS

OPTIFLOW

Non-Invasive Ventilation

Non-invasive ventilation (NIV) is a well recognised and increasingly prevalent intervention in the paediatric critical care setting. In the acute setting NIV is used to provide respiratory support in a flexible manner that avoids a requirement for endotracheal intubation or tracheostomy, with the aim of avoiding the complications of invasive ventilation.

Morley, 2016.

EasyFlow nCPAP Non-Invasive Ventilation

CPAP non-invasive ventilation leaves extra air in the lungs to keep the lungs slightly inflated; this minimises the effort required for the progressive breath.

Complications of Non-invasive Ventilation

• Nasal Septum Injury –
• Nasal Bridge Injury –
• Eye Puffiness & Hyperemia –
• Abdominal Distention –
• Pneumothorax –

Nasal Septum – retrieved from https://www.drugs.com/health-guide/deviated-septum.html; Nasal Bridge – retrieved from https://www.mountsinai.org/health-library/symptoms/low-nasal-bridge; Abdominal Distention – retrieved from https://adc.bmj.com/content/97/Suppl_2/A160.4.short on 27th January 2023

Ventilation

Ventilation is used as a last resort on babies.

CHILD VS ADULT AIRWAY

Unlike the adult’s airway, a baby’s airway is funnel-like, and the cricoid sits lower than in adults.

PAEDIATRIC LARYNGOSCOPY

The type of laryngoscope commonly used in case of ventilation of paediatric patients is the Miller Blade Laryngoscope with Fibre Optic.

CUFFED VS UNCUFFED ETT

• we are moving towards commonly using the inflated microcuff ETT for paediatric patients, since it helps minimise the risk of aspiration
• an inflated microcuff seals the trachea so as to prevent positive pressure from escaping the lower airway
• an inflated microcuff also seals the upper airway so that material above the glottis cannot enter the trachea

Intubation Drugs

Babies that are intubated right after birth are NOT administered any intubation drugs during the procedure. Otherwise, babies being intubated later on are administered drugs from the following intubation drugs list:

RAPID SEQUENCE INTUBATION DRUGS (RSI)

• Fentanyl – analgesic opioid
• Atropine – treats symptomatic bradycardia
• Suxamethonium – muscle relaxant

MAINTENANCE DRUGS

• Morphine – analgesic opioid
• Midazolam – benzodiazepine
• Atracurium – muscle relaxant

DOSAGE CALCULATION

Rapid Sequence Intubation Drugs and Maintenance Drugs dosages are administered based on the baby’s weight according to protocol.

For antibiotic and other pharmacological drug use:

Procedural Pain Relief

Measures related to the baby’s surrounding environment, preparation, and use of non-pharmacological pain relief methods can be taken for support:

• warmed area
• calm surrounding
• parental presence
• reduction of light, noise, and handling
• available staff to reduce interruptions and prepare requirements beforehand
• available staff to assume a parental role if parents are unavailable
• promote swaddling, nesting, tucking, holding, cuddling, skin-to-skin care, breast feeding, non-nutritive sucking, clean nappy, and distraction techniques.

24% sucrose solution ampoules (Babycalmine S) can be administered as a mild analgesic for short term pain and distress in neonates and infants up to 4 months of age during minor procedures, such as bloodletting and cannulation, invasive procedures including urinary catheterisation and lumbar puncture, as well as during IM or SC immunisation and other procedures which may require pain relief.

comprehensive assessment

Comprehensive assessment in neonatal and paediatric intensive care nursing needs to be based on observing and reading clinical signs, as well as interpreting different parameters:

• heart rate
• blood pressure
• signs of distress
• abdominal distention
• pressure exerted by lines
• cannula observation
• signs of sepsis
• functioning equipment observation

NOTE: a low temperature in a baby may be a sign of sepsis; capillary refill on a newborn is checked on the sternum.

The Nurse’s Role

INFANTS:

• prompt treatment may be required by premature babies suffering from respiratory difficulties
• nutritional needs of premature babies and sick neonates are calculated on the baby’s weight in kg
• encourage parents to stay with their infant
• provide the baby with opportunities for sucking
• provide toys to provide comfort and stimulate interest
• provide pharmacological and non-pharmacological pain control

TODDLERS:

• encourage independent behaviours eg. self-feeding, hygiene, dressing
• encourage continuation of toilet-training regime, accepting regression during hospitalisation
• provide vigilance and safety within the toddler’s environment
• provide short and simple explanations
• reward appropriate behaviour

PARENTS:

• support the parents, considering their possible anxiety and stress
• encourage an active role in the care of their own child
• teach parents to administer medications safely, to use any necessary equipment, to insert and/or use a feeding tube if needed
• discuss with parents subjects related to home routine, safety, and how to coax a reluctant baby to feed
• teach parents Basic Life Support
• provide reassurance during discharge planning, since this transition may be quite difficult and scary for the parents

The Parents’ Role

Parents of young patients staying at NPICU are usually allowed to enter, excluding time in which ward rounds, handover, emergencies and admissions are being performed. The NPICU promotes:

• family centered care
• parents’ empowerment to prevent loss of parental role
• interventions such as skin-to-skin contact and positive touch

Reference

Morley S. L. (2016). Non-invasive ventilation in paediatric critical care. Paediatric respiratory reviews, 20, 24–31. https://doi.org/10.1016/j.prrv.2016.03.001

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