Original Article
983
Remifentanil Analgesia during Laser Treatment for Retinopathy of Prematurity: A Practical Approach in Neonatal Intensive Care Unit Nihal Demirel, MD1 Ahmet Y. Bas, MD1 Sumru Kavurt, MD1 Istemi H. Celik, MD1 Dursun Turkbay, MD1 Emre Hekimoğlu, MD2 Orhan Koc, MD3
Teaching and Research Hospital, Ankara, Turkey 2 Department of Ophthalmology, Etlik Zubeyde Hanim Women’s Health Teaching and Research Hospital, Ankara, Turkey 3 Department of Health Politics, Turkish Ministry of Health, Ankara, Turkey
Address for correspondence Ahmet Y. Bas, MD, Etlik Zubeyde Hanim Women’s Health Teaching and Research Hospital, Yeni Etlik Caddesi 55, Etlik, 06010 Ankara, Turkey (e-mail: [email protected]).
Am J Perinatol 2014;31:983–986.
Abstract
Keywords
► retinopathy of prematurity ► laser photocoagulation ► remifentanil ► newborn ► NICU
Background Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. Aim The aim of this study is to determine the feasibility of remifentanil analgesia during laser treatment of ROP performed in the neonatal intensive care unit (NICU). Patients and Methods Remifentanil was infused continuously during the procedure starting with a dose of 0.2 µg/kg/min and increased gradually to 0.6 µg/kg/min to provide an adequate level of analgesia. Results We enrolled 64 infants. Remifentanil was infused continuously at a mean rate of 0.4 0.1 μg/kg/min. No major adverse effects were observed except in two patients with reversible bradycardia and hypotension. Premature infant pain profile (PIPP) scores revealed no pain. Patients with bronchopulmonary dysplasia had similar remifentanil dosage, intubation duration, and extubation time. Conclusions Remifentanil analgesia for ROP treatment performed in the NICU by pediatricians is a safe and effective modality. This modality offers a practical solution in hospitals without readily available pediatric anesthetists.
Incidence of retinopathy of prematurity (ROP) has been increased due to the recent developments in newborn care and increased availability of neonatal intensive care units (NICUs). Laser photocoagulation has become the standard treatment of ROP.1,2 Although the methods and forms of anesthesia used during laser treatment of ROP varies, many ROP treatments are performed under general anesthesia, for which infants are transferred to a center with onsite pediatric anesthesia.3,4 This condition frequently presents logistical difficulties. Babies undergoing treatment are frequently unwell and suffer from other complication of preterm delivery. In addition, there is a real risk that a general anesthesia at this
critic clinical picture may destabilize the infant again and there are transport-related risks such as hypothermia and instability between operating room and NICU.5 Remifentanil is a new ultra-short action synthetic opioid and metabolized by nonspecific esterases in blood and tissues. Remifentanil has a rapid plasma clearance and very rapid offset of action.6 As its pharmacokinetics is unaltered in the presence of renal and liver failure, it is a suitable drug for use in neonatology, considering the immaturity of these organs especially in preterm neonates.7,8 Moreover, its short recovery profile makes the appropriate time for extubation more predictible.9
received December 7, 2013 accepted after revision December 24, 2013 published online May 2, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1370348. ISSN 0735-1631.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
1 Department of Neonatology, Etlik Zubeyde Hanim Women’s Health
Husniye Yucel, MD1
Remifentanil Analgesia in Retinopathy of Prematurity
Demirel et al.
The aim of this study is to determine the feasibility and efficacy of remifentanil analgesia for the laser treatment of ROP performed in the NICU.
Patients and Methods This study was performed in the Department of Neonatology, Etlik Zubeyde Hanim Maternity and Women’s Health Research Hospital (Ankara, Turkey) between November 1, 2010, and June 31, 2012. The Ethic Committee of Ankara Gazi University approved the study. Approximately 2,250 infants are admitted to our NICU annually and 465 of which are very low birth weight (VLBW) infants (< 1,500 g). In our unit, any stage ROP, stage 3 ROP, and bronchopulmonary dysplasia (BPD) rates of VLBW infants were 25.3, 4.5, and 12.9%, respectively. We were previously using Sevoflurane (Ultane, Abbott Laboratories, North Chicago, IL) for induction and maintenance of general anesthesia in the operating room and then the patient was transferred to the NICU. We had difficulties in the arrangement of pediatric anesthetic specialist and operating room because our hospital is a maternity and women’s health research hospital, and we had to change our protocol to bedside remifentanil analgesia. Medical data were collected and evaluated prospectively. Our hospital is a perinatal center which also receives extramural candidates for ROP treatment from all over Turkey, especially eastern and southeast Turkey. Retinal photocoagulation with the diode laser was applied for eyes with higher risk prethreshold ROP, any stage ROP with plus disease, stage 3 ROP without plus disease on zone 1, and stage 2 or 3 ROP with plus disease on zone 2 consistent with Type 1 ROP as defined in the Early Treatment of Retinopathy of Prematurity study in 2003.10 Parental consent for ROP treatment with remifentanil analgesia was obtained. All treatments were performed by the same surgeon. Intravenous bolus of midazolam was administered with a dose of 0.1 mg/kg to all patients before intubation. Infants were intubated and ventilated using synchronized intermittent mandatory ventilation (Galileo-Neonate, Hamilton Medical, Bonaduz, Switzerland). Remifentanil powder (diluted with 0.9% saline to 100 µg/mL concentration), was infused continuously during the procedure beginning with a dose of 0.2 µg/kg/min and increased gradually to 0.6 µg/kg/min to provide an adequate level of analgesia taking into account hemodynamic and respiratory changes or spontaneous movements. The remifentanil infusion was administered by a neonatologist or pediatrician and discontinued at the end of the surgical procedure. Pain was evaluated using scale of the premature infant pain profile (PIPP).11 The PIPP is a seven-indicator composite measure that includes behavioral, physiologic, and contextual indicators. These indicators include gestational age (GA), behavioral state, heart rate, oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow. Each indicator is rated on a four-point scale (0, 1, 2, and 3) for a possible total score of 0 to 21, depending on the GA of the neonate. PIPP scores < 7 are indicative of no pain, 7 to 12 are intermediate, and > 12 are indicative of significant pain. In addition, increases in scores American Journal of Perinatology
Vol. 31
No. 11/2014
4 points are considered to be a pain response. Heart rate, oxygen saturation, noninvasive blood pressure, and electrocardiography were monitored during the procedure. Patients were grouped into two groups to evaluate effects of remifentanil analgesia on the respiratory status of infants with BPD: Group A, patients with BPD; Group B, patients without BPD. Diagnosis of BPD was done according to the criteria of Jobe and Bancalari.12 GA, birth weight, postmenstrual age, body weight at the time of operation, the duration of operation, and postoperative extubation times were recorded.
Statistical Analysis Data are expressed as mean and standard deviation and t-test was used to compare the quantitative variables. Statistical analysis was performed using the SPSS statistical package (SPSS Inc, Chicago, IL). A p value of 0.05 was considered as significant.
Results The study population consisted of 64 infants, 17 of which were referred from other hospitals. All of the patients required laser therapy to both eyes in one treatment session. Surgical procedure was successful in all the patients according to postoperative and follow-up examinations. Demographic and operational data are shown in ►Table 1. Remifentanil was infused continuously at a mean rate of 0.4 0.1 μg/kg/min (0.2–0.6 μg/kg/min). The adverse effects of treatment included temporary hypotension (one patient) and bradycardia (one patient). PIPP score, blood pressure, heart rate, and oxygen saturation of patients were listed in ►Table 2. PIPP score revealed no pain. None of the patients needed general anesthesia because of remifentanil anesthesia failure. None of the patients in Group A needed nasal continuous positive airway pressure or mechanical ventilation support before operation. Patients in Groups A and B had similar birth weight, GA, postmenstrual age, and weight at the time of treatment (p > 0.05). BPD did not affect remifentanil dose regimen. Operation durations of patients in Groups A and B were 71 and 60 minutes (p > 0.05), respectively, whereas extubation times were 210 and 151 minutes (p ¼ 0.048),
Table 1 Demographic and operational characteristics of patients (n, 64) Female/male
31/33
Gestational age (w)
27.3 2.4
Birth weight (g)
965 299
Postmenstrual age at treatment (w)
37.1 3
Weight at treatment
1,913 479
Duration of operation (min)
67.7 28.6
Extubation time (min)
189 110
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
984
Remifentanil Analgesia in Retinopathy of Prematurity
Demirel et al.
985
Table 2 PIPP score, blood pressure, heart rate, oxygen saturation of patients SBP
DBP
HR
SO2
PIPP
Baseline
102 4.2
67 3.2
145 15
95 2
4.5
Ts
95 4.1
63 2.9
138 12
94 3
6.8
T2e
101 3.9
65 3.5
141 16
95 3
5.1
Baseline
98 3.8
64 3.1
142 14
97 2
4.6
Ts
93 4.0
61 2.3
136 11
94 2
6.6
T2e
97 3.9
63 3.7
140 15
96 3
4.9
Group A (n, 43)
Abbreviations: Baseline, preoperative; DBP, diastolic blood pressure; Group A, patients with bronchopulmonary dysplasia; Group B, patients without bronchopulmonary dysplasia; HR, heart rate; PIPP, premature infant pain profile; SBP, systolic blood pressure; SO2, oxygen saturation; Ts, onset of surgical time; T2e, 2 hours past end of surgery.
respectively. Overall respiratory status remained unchanged after extubation within 48 hours in all patients.
Discussion Many ROP treatments are performed under general anesthesia in an operating room where appropriate pediatric anesthetic expertise is available. In contrast, most ROP screening occurs in NICUs of obstetric hospitals where pediatric anesthetic cover is not available. This poses several problems for many units. When laser treatment is indicated, a considerable amount of planning is required. Infants generally compete with other emergency cases to place on the operating list; delay in treatment of this emergent situation may result in a less favorable visual outcome.5 Remifentanil is an ultra-short acting opiate that can achieve its peak analgesic effect within a minute of administration. Studies on the use of remifentanil have demonstrated its effectiveness in neonates.6,13 Remifentanil enables rapid transition from hypnosis to the development of regular spontaneous breathing.9 Silva et al reported that remifentanil was effective in early awakening and extubation of preterm neonates.14 Lago et al used remifentanil during the implantation of a percutaneous intravenous central catheter in premature newborns with no serious adverse effects.15 Sammartino et al reported that a remifentanil-based regimen was effective in the provision of optimal analgesia sedation for preterm infants undergoing laser therapy in NICU. In their study, a midazolam bolus (0.2 mg/kg) was administered and remifentanil was infused during the operation with a beginning dose of 0.75 to 1 µg/kg/min.6 In our study, initial and maintenance remifentanil dosage after 0.1 mg/kg midazolam was lower than their study and we did not need to increase remifentanil dose over 0.6 µg/kg/min. We think that this dose regimen of remifentanil and midazolam was effective for analgesia because our patients were clinically stable with low PIPP scores. The main adverse effects of remifentanil are bradycardia, hypotension, respiratory depression, chest wall rigidity, nau-
sea, and vomiting. These adverse effects appear to be less frequent or with less magnitude in neonates.8 We experienced reversible bradycardia in one patient and hypotension in one patient. In patients with BPD, abnormalities of pulmonary function include decreased tidal volume, increased airway resistance, and decreased dynamic lung compliance.16 Perioperative confounding factors, which may increase respiratory instability related to BPD, may cause prolonged postoperative extubation. Although patients with BPD were extubated in a longer time than the patients without BPD in our study, we observed no case of extubation failure due to apnea or/and insufficient respiratory drive. ROP is an emerging problem due to recent developments in newborn care and increased survival of VLBW infants in our country. Laser treatment for ROP with remifentanil infusion in NICU offers a practical solution in units without readily available pediatric anesthetists. In conclusion, sedoanalgesia with combination of midazolam and remifentanil can be performed under the supervision of a neonatologist in an NICU, thus avoiding transfer of patients to a pediatric hospital. This protocol may be particularly useful in developing countries. To the best of our knowledge, this study includes the largest series of patients managed with this method.
Conflict of Interest There is no conflict of interest or any financial relationship.
References 1 Paysse E. Retinopathy of prematurity. In: UpToDate. Waltham, MA;
2009 2 Jalali S, Azad R, Trehan HS, Dogra MR, Gopal L, Narendran V. Technical
aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia. Indian J Ophthalmol 2010;58(6):509–515 3 Eipe N, Kim J, Ramsey G, Mossdorf P. Anesthesia for laser treatment for retinopathy of prematurity—all clear now? Paediatr Anaesth 2008;18(11):1103–1105
American Journal of Perinatology
Vol. 31
No. 11/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Group B (n, 21)
Remifentanil Analgesia in Retinopathy of Prematurity
Demirel et al.
4 Chen SD, Sundaram V, Wilkinson A, Patel CK. Variation in anaes-
5
6
7
8
9
10
thesia for the laser treatment of retinopathy of prematurity—a survey of ophthalmologists in the UK. Eye (Lond) 2007;21(8): 1033–1036 Kirwan C, O’Keefe M, Prendergast M, Twomey A, Murphy J. Morphine analgesia as an alternative to general anaesthesia during laser treatment of retinopathy of prematurity. Acta Ophthalmol Scand 2007;85(6):644–647 Sammartino M, Bocci MG, Ferro G, et al. Efficacy and safety of continuous intravenous infusion of remifentanil in preterm infants undergoing laser therapy in retinopathy of prematurity: clinical experience. Paediatr Anaesth 2003;13(7):596–602 Glass PS, Gan TJ, Howell S. A review of the pharmacokinetics and pharmacodynamics of remifentanil. Anesth Analg 1999;89(4): S7–S14 Penido MG, Garra R, Sammartino M, Pereira e Silva Y. Remifentanil in neonatal intensive care and anaesthesia practice. Acta Paediatr 2010;99(10):1454–1463 Welzing L, Vierzig A, Junghaenel S, et al. Remifentanil and propofol for weaning of mechanically ventilated pediatric intensive care patients. Eur J Pediatr 2011;170(4):477–481 Early Treatment For Retinopathy Of Prematurity Cooperative Group. Revised indications for the treatment of retinopathy of
American Journal of Perinatology
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11
12 13
14
15
16
prematurity: results of the early treatment for retinopathy of prematurity randomized trial. Arch Ophthalmol 2003;121(12): 1684–1694 Stevens B, Johnston C, Petryshen P, Taddio A. Premature infant pain profile: development and initial validation. Clin J Pain 1996;12(1): 13–22 Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001;163(7):1723–1729 Dahaba AA, Grabner T, Rehak PH, List WF, Metzler H. Remifentanil versus morphine analgesia and sedation for mechanically ventilated critically ill patients: a randomized double blind study. Anesthesiology 2004;101(3):640–646 e Silva YP, Gomez RS, Marcatto JdeO, Maximo TA, Barbosa RFe Silva AC. Early awakening and extubation with remifentanil in ventilated premature neonates. Paediatr Anaesth 2008;18(2):176–183 Lago P, Tiozzo C, Boccuzzo G, Allegro A, Zacchello F. Remifentanil for percutaneous intravenous central catheter placement in preterm infant: a randomized controlled trial. Paediatr Anaesth 2008; 18(8):736–744 Watts JL, Ariagno RL, Brady JP. Chronic pulmonary disease in neonates after artificial ventilation: distribution of ventilation and pulmonary interstitial emphysema. Pediatrics 1977;60(3): 273–281
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
986
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
983
Remifentanil Analgesia during Laser Treatment for Retinopathy of Prematurity: A Practical Approach in Neonatal Intensive Care Unit Nihal Demirel, MD1 Ahmet Y. Bas, MD1 Sumru Kavurt, MD1 Istemi H. Celik, MD1 Dursun Turkbay, MD1 Emre Hekimoğlu, MD2 Orhan Koc, MD3
Teaching and Research Hospital, Ankara, Turkey 2 Department of Ophthalmology, Etlik Zubeyde Hanim Women’s Health Teaching and Research Hospital, Ankara, Turkey 3 Department of Health Politics, Turkish Ministry of Health, Ankara, Turkey
Address for correspondence Ahmet Y. Bas, MD, Etlik Zubeyde Hanim Women’s Health Teaching and Research Hospital, Yeni Etlik Caddesi 55, Etlik, 06010 Ankara, Turkey (e-mail: [email protected]).
Am J Perinatol 2014;31:983–986.
Abstract
Keywords
► retinopathy of prematurity ► laser photocoagulation ► remifentanil ► newborn ► NICU
Background Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. Aim The aim of this study is to determine the feasibility of remifentanil analgesia during laser treatment of ROP performed in the neonatal intensive care unit (NICU). Patients and Methods Remifentanil was infused continuously during the procedure starting with a dose of 0.2 µg/kg/min and increased gradually to 0.6 µg/kg/min to provide an adequate level of analgesia. Results We enrolled 64 infants. Remifentanil was infused continuously at a mean rate of 0.4 0.1 μg/kg/min. No major adverse effects were observed except in two patients with reversible bradycardia and hypotension. Premature infant pain profile (PIPP) scores revealed no pain. Patients with bronchopulmonary dysplasia had similar remifentanil dosage, intubation duration, and extubation time. Conclusions Remifentanil analgesia for ROP treatment performed in the NICU by pediatricians is a safe and effective modality. This modality offers a practical solution in hospitals without readily available pediatric anesthetists.
Incidence of retinopathy of prematurity (ROP) has been increased due to the recent developments in newborn care and increased availability of neonatal intensive care units (NICUs). Laser photocoagulation has become the standard treatment of ROP.1,2 Although the methods and forms of anesthesia used during laser treatment of ROP varies, many ROP treatments are performed under general anesthesia, for which infants are transferred to a center with onsite pediatric anesthesia.3,4 This condition frequently presents logistical difficulties. Babies undergoing treatment are frequently unwell and suffer from other complication of preterm delivery. In addition, there is a real risk that a general anesthesia at this
critic clinical picture may destabilize the infant again and there are transport-related risks such as hypothermia and instability between operating room and NICU.5 Remifentanil is a new ultra-short action synthetic opioid and metabolized by nonspecific esterases in blood and tissues. Remifentanil has a rapid plasma clearance and very rapid offset of action.6 As its pharmacokinetics is unaltered in the presence of renal and liver failure, it is a suitable drug for use in neonatology, considering the immaturity of these organs especially in preterm neonates.7,8 Moreover, its short recovery profile makes the appropriate time for extubation more predictible.9
received December 7, 2013 accepted after revision December 24, 2013 published online May 2, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1370348. ISSN 0735-1631.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
1 Department of Neonatology, Etlik Zubeyde Hanim Women’s Health
Husniye Yucel, MD1
Remifentanil Analgesia in Retinopathy of Prematurity
Demirel et al.
The aim of this study is to determine the feasibility and efficacy of remifentanil analgesia for the laser treatment of ROP performed in the NICU.
Patients and Methods This study was performed in the Department of Neonatology, Etlik Zubeyde Hanim Maternity and Women’s Health Research Hospital (Ankara, Turkey) between November 1, 2010, and June 31, 2012. The Ethic Committee of Ankara Gazi University approved the study. Approximately 2,250 infants are admitted to our NICU annually and 465 of which are very low birth weight (VLBW) infants (< 1,500 g). In our unit, any stage ROP, stage 3 ROP, and bronchopulmonary dysplasia (BPD) rates of VLBW infants were 25.3, 4.5, and 12.9%, respectively. We were previously using Sevoflurane (Ultane, Abbott Laboratories, North Chicago, IL) for induction and maintenance of general anesthesia in the operating room and then the patient was transferred to the NICU. We had difficulties in the arrangement of pediatric anesthetic specialist and operating room because our hospital is a maternity and women’s health research hospital, and we had to change our protocol to bedside remifentanil analgesia. Medical data were collected and evaluated prospectively. Our hospital is a perinatal center which also receives extramural candidates for ROP treatment from all over Turkey, especially eastern and southeast Turkey. Retinal photocoagulation with the diode laser was applied for eyes with higher risk prethreshold ROP, any stage ROP with plus disease, stage 3 ROP without plus disease on zone 1, and stage 2 or 3 ROP with plus disease on zone 2 consistent with Type 1 ROP as defined in the Early Treatment of Retinopathy of Prematurity study in 2003.10 Parental consent for ROP treatment with remifentanil analgesia was obtained. All treatments were performed by the same surgeon. Intravenous bolus of midazolam was administered with a dose of 0.1 mg/kg to all patients before intubation. Infants were intubated and ventilated using synchronized intermittent mandatory ventilation (Galileo-Neonate, Hamilton Medical, Bonaduz, Switzerland). Remifentanil powder (diluted with 0.9% saline to 100 µg/mL concentration), was infused continuously during the procedure beginning with a dose of 0.2 µg/kg/min and increased gradually to 0.6 µg/kg/min to provide an adequate level of analgesia taking into account hemodynamic and respiratory changes or spontaneous movements. The remifentanil infusion was administered by a neonatologist or pediatrician and discontinued at the end of the surgical procedure. Pain was evaluated using scale of the premature infant pain profile (PIPP).11 The PIPP is a seven-indicator composite measure that includes behavioral, physiologic, and contextual indicators. These indicators include gestational age (GA), behavioral state, heart rate, oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow. Each indicator is rated on a four-point scale (0, 1, 2, and 3) for a possible total score of 0 to 21, depending on the GA of the neonate. PIPP scores < 7 are indicative of no pain, 7 to 12 are intermediate, and > 12 are indicative of significant pain. In addition, increases in scores American Journal of Perinatology
Vol. 31
No. 11/2014
4 points are considered to be a pain response. Heart rate, oxygen saturation, noninvasive blood pressure, and electrocardiography were monitored during the procedure. Patients were grouped into two groups to evaluate effects of remifentanil analgesia on the respiratory status of infants with BPD: Group A, patients with BPD; Group B, patients without BPD. Diagnosis of BPD was done according to the criteria of Jobe and Bancalari.12 GA, birth weight, postmenstrual age, body weight at the time of operation, the duration of operation, and postoperative extubation times were recorded.
Statistical Analysis Data are expressed as mean and standard deviation and t-test was used to compare the quantitative variables. Statistical analysis was performed using the SPSS statistical package (SPSS Inc, Chicago, IL). A p value of 0.05 was considered as significant.
Results The study population consisted of 64 infants, 17 of which were referred from other hospitals. All of the patients required laser therapy to both eyes in one treatment session. Surgical procedure was successful in all the patients according to postoperative and follow-up examinations. Demographic and operational data are shown in ►Table 1. Remifentanil was infused continuously at a mean rate of 0.4 0.1 μg/kg/min (0.2–0.6 μg/kg/min). The adverse effects of treatment included temporary hypotension (one patient) and bradycardia (one patient). PIPP score, blood pressure, heart rate, and oxygen saturation of patients were listed in ►Table 2. PIPP score revealed no pain. None of the patients needed general anesthesia because of remifentanil anesthesia failure. None of the patients in Group A needed nasal continuous positive airway pressure or mechanical ventilation support before operation. Patients in Groups A and B had similar birth weight, GA, postmenstrual age, and weight at the time of treatment (p > 0.05). BPD did not affect remifentanil dose regimen. Operation durations of patients in Groups A and B were 71 and 60 minutes (p > 0.05), respectively, whereas extubation times were 210 and 151 minutes (p ¼ 0.048),
Table 1 Demographic and operational characteristics of patients (n, 64) Female/male
31/33
Gestational age (w)
27.3 2.4
Birth weight (g)
965 299
Postmenstrual age at treatment (w)
37.1 3
Weight at treatment
1,913 479
Duration of operation (min)
67.7 28.6
Extubation time (min)
189 110
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
984
Remifentanil Analgesia in Retinopathy of Prematurity
Demirel et al.
985
Table 2 PIPP score, blood pressure, heart rate, oxygen saturation of patients SBP
DBP
HR
SO2
PIPP
Baseline
102 4.2
67 3.2
145 15
95 2
4.5
Ts
95 4.1
63 2.9
138 12
94 3
6.8
T2e
101 3.9
65 3.5
141 16
95 3
5.1
Baseline
98 3.8
64 3.1
142 14
97 2
4.6
Ts
93 4.0
61 2.3
136 11
94 2
6.6
T2e
97 3.9
63 3.7
140 15
96 3
4.9
Group A (n, 43)
Abbreviations: Baseline, preoperative; DBP, diastolic blood pressure; Group A, patients with bronchopulmonary dysplasia; Group B, patients without bronchopulmonary dysplasia; HR, heart rate; PIPP, premature infant pain profile; SBP, systolic blood pressure; SO2, oxygen saturation; Ts, onset of surgical time; T2e, 2 hours past end of surgery.
respectively. Overall respiratory status remained unchanged after extubation within 48 hours in all patients.
Discussion Many ROP treatments are performed under general anesthesia in an operating room where appropriate pediatric anesthetic expertise is available. In contrast, most ROP screening occurs in NICUs of obstetric hospitals where pediatric anesthetic cover is not available. This poses several problems for many units. When laser treatment is indicated, a considerable amount of planning is required. Infants generally compete with other emergency cases to place on the operating list; delay in treatment of this emergent situation may result in a less favorable visual outcome.5 Remifentanil is an ultra-short acting opiate that can achieve its peak analgesic effect within a minute of administration. Studies on the use of remifentanil have demonstrated its effectiveness in neonates.6,13 Remifentanil enables rapid transition from hypnosis to the development of regular spontaneous breathing.9 Silva et al reported that remifentanil was effective in early awakening and extubation of preterm neonates.14 Lago et al used remifentanil during the implantation of a percutaneous intravenous central catheter in premature newborns with no serious adverse effects.15 Sammartino et al reported that a remifentanil-based regimen was effective in the provision of optimal analgesia sedation for preterm infants undergoing laser therapy in NICU. In their study, a midazolam bolus (0.2 mg/kg) was administered and remifentanil was infused during the operation with a beginning dose of 0.75 to 1 µg/kg/min.6 In our study, initial and maintenance remifentanil dosage after 0.1 mg/kg midazolam was lower than their study and we did not need to increase remifentanil dose over 0.6 µg/kg/min. We think that this dose regimen of remifentanil and midazolam was effective for analgesia because our patients were clinically stable with low PIPP scores. The main adverse effects of remifentanil are bradycardia, hypotension, respiratory depression, chest wall rigidity, nau-
sea, and vomiting. These adverse effects appear to be less frequent or with less magnitude in neonates.8 We experienced reversible bradycardia in one patient and hypotension in one patient. In patients with BPD, abnormalities of pulmonary function include decreased tidal volume, increased airway resistance, and decreased dynamic lung compliance.16 Perioperative confounding factors, which may increase respiratory instability related to BPD, may cause prolonged postoperative extubation. Although patients with BPD were extubated in a longer time than the patients without BPD in our study, we observed no case of extubation failure due to apnea or/and insufficient respiratory drive. ROP is an emerging problem due to recent developments in newborn care and increased survival of VLBW infants in our country. Laser treatment for ROP with remifentanil infusion in NICU offers a practical solution in units without readily available pediatric anesthetists. In conclusion, sedoanalgesia with combination of midazolam and remifentanil can be performed under the supervision of a neonatologist in an NICU, thus avoiding transfer of patients to a pediatric hospital. This protocol may be particularly useful in developing countries. To the best of our knowledge, this study includes the largest series of patients managed with this method.
Conflict of Interest There is no conflict of interest or any financial relationship.
References 1 Paysse E. Retinopathy of prematurity. In: UpToDate. Waltham, MA;
2009 2 Jalali S, Azad R, Trehan HS, Dogra MR, Gopal L, Narendran V. Technical
aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia. Indian J Ophthalmol 2010;58(6):509–515 3 Eipe N, Kim J, Ramsey G, Mossdorf P. Anesthesia for laser treatment for retinopathy of prematurity—all clear now? Paediatr Anaesth 2008;18(11):1103–1105
American Journal of Perinatology
Vol. 31
No. 11/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Group B (n, 21)
Remifentanil Analgesia in Retinopathy of Prematurity
Demirel et al.
4 Chen SD, Sundaram V, Wilkinson A, Patel CK. Variation in anaes-
5
6
7
8
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