Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice?

Ojha, Shalini; Abramson, Janine; Dorling, Jon

Abstract

Mechanical ventilation is an uncomfortable and potentially painful intervention. Opioids, such as morphine and fentanyl, are used for analgesia and sedation but there is uncertainty whether they reduce pain in mechanically ventilated infants. Moreover, there may be short-term and long-term adverse consequences such as respiratory depression leading to prolonged mechanical ventilation and detrimental long-term neurodevelopmental effects. Despite this, opioids are widely used, possibly due to a lack of alternatives.

Dexmedetomidine, a highly selective alpha-2-adrenergic agonist with analgesic and sedative effects, currently approved for adults, has come into use in newborn infants. It provides analgesia and simulates natural sleep with maintenance of spontaneous breathing and upper airway tone. Although data on pharmacokinetics–pharmacodynamics in preterm infants are scant, observational studies report that using dexmedetomidine in conjunction with opioids/benzodiazepines or on its own can reduce the cumulative exposure to opioids/benzodiazepines. As it does not cause respiratory depression, dexmedetomidine could enable quicker weaning and extubation. Dexmedetomidine has also been suggested as an adjunct to therapeutic hypothermia in hypoxic ischaemic encephalopathy and others have used it during painful procedures and surgery. Dexmedetomidine infusion can cause bradycardia and hypotension although most report clinically insignificant effects.

The increasing number of publications of observational studies and clinical use demonstrates that dexmedetomidine is being used in newborn infants but data on safety and efficacy are scant and not of high quality. Importantly, there are no data on long-term neurodevelopmental impact on preterm or term-born infants. The acceptance of dexmedetomidine in routine clinical practice must be preceded by clinical evidence. We need adequately powered and well-designed randomised controlled trials investigating whether dexmedetomidine alone or with opioids/benzodiazepines in infants on mechanical ventilation reduces the need for opioids/benzodiazepine and improves neurodevelopment at 24 months and later as compared with the use of opioids/benzodiazepines alone.

Citation

Ojha, S., Abramson, J., & Dorling, J. (2022). Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice?. BMJ Paediatrics Open, 6(1), Article e001460. https://doi.org/10.1136/bmjpo-2022-001460

• Journal Article Type: Review
• Acceptance Date: Apr 22, 2022
• Online Publication Date: May 10, 2022
• Publication Date: 2022
• Deposit Date: Jun 7, 2023
• Publicly Available Date: Jun 9, 2023
• Journal: BMJ Paediatrics Open
• Electronic ISSN: 2399-9772
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 6
• Issue: 1
• Article Number: e001460
• DOI: https://doi.org/10.1136/bmjpo-2022-001460
• Keywords: Pediatrics, Perinatology and Child Health
• Public URL: https://nottingham-repository.worktribe.com/output/8227015
• Publisher URL: https://bmjpaedsopen.bmj.com/content/6/1/e001460