Search PubMed⌕ Search

Biomedical subjects

K J Anand

Publications and source records attributed to K J Anand.

At least 37 records · Page 2Linked to original sources
PubMed1998

Physiological, hormonal, and behavioral responses to a single fentanyl dose in intubated and ventilated preterm neonates.

OBJECTIVE: To study the responses of ventilated preterm neonates to a single dose of opioid. STUDY DESIGN: In a randomized, double-blind, controlled trial, 22 mechanically ventilated preterm infants (< or = 32 weeks) were observed before medication and at 30 and 60 minutes after administration of fentanyl (3 micrograms/kg) or placebo. Heart rate, blood pressure, arterial blood gases, ventilator settings, and behavioral measures (Neonatal Facial Coding System and Modified Postoperative Comfort Score) were recorded during each period. Blood cortisol, growth hormone, glucose, and lactate were measured before and at 60 minutes after analgesia. Behavioral measures were assessed at the bedside and from video films recorded during each observation period. RESULTS: Patients presented high basal levels of cortisol, growth hormone, and lactate. Behavioral scales indicated the presence of pain before any medication. In the fentanyl group, the maximum and minimum heart rate decreased and growth hormone level increased after analgesia. At the video analysis of behavioral measures, postoperative comfort score increased and neonatal facial coding system score decreased in the fentanyl group. CONCLUSION: Single doses of fentanyl analgesia can reduce the physiologic/behavioral measures of pain and stress associated with mechanical ventilation in preterm infants.

Analgesia↗
PubMed1998

Lidocaine iontophoresis for topical anesthesia before intravenous line placement in children.

In a double-blind randomized trial including 42 children aged 7 to 18 years, less pain occurred with intravenous placement after iontophoresis of 2% lidocaine with epinephrine, as reported by patients (p = 0.005), parents (p = 0.001), intravenous personnel (p = 0.009), and investigators (p = 0.0002) compared with placebo therapy. Lidocaine iontophoresis provides rapid and effective topical anesthesia for intravenous access in children.

Adolescent↗
PubMed1998

Practical approach to analgesia and sedation in the neonatal intensive care unit.

The anatomic and physiological bases for nociception are present even in very preterm neonates. Neonates show the same behavioral, endocrine, and metabolic responses to noxious stimuli as older subjects. Preterm infants appear to be more sensitive to painful stimuli and have heightened responses to successive stimuli. Infants receiving intensive care are subjected to frequent stressful procedures and also chronic noxious influences related to the environment of care. Inflammatory conditions such as necrotizing enterocolitis may also cause pain. Untreated pain in babies is associated with increased major morbidity and mortality. Nonpharmacological interventions, including environmental modification and comforting during procedures reduce stress. Intravenous opiates are the mainstay of pharmacological analgesia. A pure sedative agent can provide physiological stability in settings in which there are less acutely painful stimuli or when there are adverse effects from, or tolerance to, opiates. Local anesthesia of skin and mucous membranes is helpful for invasive procedures. Antipyretic analgesics such as acetaminophen have a role in inflammatory pain.

Analgesia↗
PubMed1998

Opioid tolerance in neonates: mechanisms, diagnosis, assessment, and management.

Opioid tolerance and withdrawal have been challenges for decades. The neurochemical mechanisms of tolerance and dependence are clinically important only because they can affect weaning schedules and the adjustment of doses for neonates. Analgesic effects are characterized by an increased depolarization threshold for the neuron, shorter duration of the action potential generated, and reduced release of neurotransmitters. Tolerance and withdrawal are associated with the reversal of these cellular effects. Adverse clinical effects associated with the use of opioids in neonates include respiratory depression, chest wall rigidity, urinary retention, and decreased gastrointestinal motility. The physiological systems most prominently affected by opioid withdrawal include the central nervous system, gastrointestinal system, and the autonomic nervous system. Opioid withdrawal symptoms in neonates can be assessed by using easily available scoring systems, although these need to be validated for different populations. Management of opioid withdrawal includes the use of other opioids, benzodiazepines and alpha-2 adrenergic receptor antagonist, clonidine. Careful titration of opioids with attention given to appropriate weaning schedules can reduce the incidence of withdrawal in neonates.

Drug Tolerance↗
PubMed1998

Bilateral vocal cord paralysis after meningitis due to Streptococcus pneumoniae.

We report the clinical course of a 15-month-old boy who had fever, decreased activity, and weakness, with severe respiratory distress during transport to the hospital. Laboratory evaluation confirmed the diagnosis of meningitis due to Streptococcus pneumoniae. He was intubated on arrival and required 4 days of ventilatory support. Soon after extubation, he had marked stridor and dyspnea that were unresponsive to standard therapy with nebulized racemic epinephrine and intravenous dexamethasone. Magnetic resonance imaging of the brain revealed nonspecific findings, and airway endoscopy showed bilateral vocal cord paralysis. Repeated endoscopy showed no improvement in vocal cord function and a deficient swallowing mechanism. Tracheostomy was done to facilitate airway management before discharge from the pediatric intensive care unit. We propose that the diagnosis of vocal cord paralysis must be considered in patients with meningitis and respiratory compromise.

Bronchoscopy↗
PubMed1998

Clinical importance of pain and stress in preterm neonates.

Clinical and laboratory investigations of neonatal pain suggest that preterm neonates have an increased sensitivity to pain and that acute painful stimuli lead to the development of prolonged periods of hyperalgesia. Non-noxious stimuli during these periods of hyperalgesia may expose preterm neonates to established or chronic pain. Acute physiologic changes caused by painful or stressful stimuli can be implicated as important factors in the causation or subsequent extension of early intraventricular hemorrhage (IVH) or the ischemic changes leading to periventricular leukomalacia (PVL). Therapeutic interventions that provide comfort/analgesia in preterm neonates were correlated with a decreased incidence of severe IVH. Long-term follow-up studies of preterm neonates may substantiate the preliminary data associating repetitive painful experiences with some of the neurobehavioral and developmental sequelae resulting from neonatal intensive care.

Analgesics, Opioid↗
PubMed1997

A cross-sectional survey of pain and pharmacological analgesia in Canadian neonatal intensive care units.

OBJECTIVE: To determine current practices for the use of analgesia term and preterm neonates cared for in Neonatal Intensive Care Units (NICUs). DESIGN: One-week survey of medical charts of current patients. SETTING: NICUs in Canada. PARTICIPANTS: A total of 14 of 38 invited NICUs participated. These units were not different on number of beds, admissions per year, or university affiliation from the nonparticipating units. MAIN OUTCOME MEASURES: Daily logs were kept of the frequency and type of procedures and analgesia administration for all ill neonates in each NICU during the study period. RESULTS: The sample consisted of 239 patients. A total of 2,134 invasive procedures were performed. Medication was given specifically 18 times for 17 invasive procedures (0.8%). For another 129 invasive procedures, the patient was receiving analgesia for reasons other than the procedure. Sixteen patients had surgery during the survey period, and another 14 had surgery prior to but within 4 days of the survey. Fifty-one patients received anaesthesia or analgesia specifically related to surgery (39 times), procedures (35 times), or other reasons (34 times), a total of 108 courses. Opioids were the most frequently used medications and were given for all reasons, by continuous infusion, intermittent bolus, or sometimes both methods for the same patient. CONCLUSIONS: Postoperative pain in neonates in Canadian NICUs appears to be consistently treated, primarily with opioid analgesics, but analgesia, opioid or nonopioid is rarely given for nonsurgical invasive procedures.

Analgesics↗
PubMed1997

Pain management in the pediatric intensive care unit.

Critically ill pediatric patients are frequently exposed to acute, established, and chronic pain as a result of their disease processes or intensive care therapies. Despite the availability of many drugs and techniques for providing analgesia, these painful conditions are not adequately treated in a large proportion of children. This article reviews some of the reasons for provision of adequate analgesia and sedation, describes the various classes of drugs commonly used in the pediatric intensive care unit, and lists the techniques and indications for regional and topical anesthesia as well as specific clinical applications for adjuvant analgesic agents. Analgesic approaches that do not have an established record of safety and efficacy in pediatric patients are not reviewed. We propose that adequate and early analgesic interventions will minimize patient's discomfort, maintain metabolic homeostasis, and improve a patient's tolerance of intensive care unit therapies and nursing interventions. Adequate analgesia can be provided to even the sickest child using the drugs, techniques, and novel approaches reviewed.

Analgesics↗
PubMed1996

Intratracheal administration of fentanyl: pharmacokinetics and local tissue effects.

OBJECTIVE: To study the pharmacokinetics and local tissue effects resulting from the intratracheal administration of preservative-free fentanyl. DESIGN: Prospective, randomized, blinded and controlled animal study. SETTING: University research laboratory. SUBJECTS: Eighteen adult male New Zealand rabbits. INTERVENTIONS: Preservative-free fentanyl citrate or normal saline was administered by the intratracheal (i.t.) and intravenous (i.v.) routes to randomized groups of rabbits. The animals were killed at 24, 48 and 72 h following administration. MEASUREMENTS AND MAIN RESULTS: Plasma concentrations of fentanyl were measured before administration and at 2, 5, 10, 30, 60 and 120 min following administration by a specific radioimmunoassay. A detailed histological examination of the lung and tracheal tissue was performed to identify local side effects. There were no significant differences in the plasma fentanyl concentrations resulting from the i.v. or i.t. route of administration. In both groups, the concentrations of fentanyl were within the therapeutic range (i.t. 2.37 ng/ml, i.v. 2.53 ng/ml) by 2 min after injection and reached a maximum concentration within 5 min. The bioavailability of i.t. fentanyl was 71%. Microscopic examination of the respiratory system did not show significant differences between the two random groups overall. However, in the sub-group of animals killed at 24 h, more animals in the i.t. group showed signs of inflammation in the lung parenchyma. CONCLUSIONS: There is rapid absorption of fentanyl following i.t. administration. Pharmacokinetic parameters for fentanyl were not significantly altered by the route of administration. Although there were no signs that i.t. administration of preservative-free fentanyl produces lung injury, a transient and mild inflammatory response was detected at 24 h after administration.

Analgesics, Opioid↗
PubMed1996

Laceration repair using a tissue adhesive in a children's emergency department.

OBJECTIVE: To determine the effectiveness of a tissue adhesive, Histoacryl Blue (HAB), for laceration repair in children. DESIGN: Prospective, randomized clinical trial. SETTING: A tertiary care pediatric emergency center at Egleston Children's Hospital. PARTICIPANTS: Children who presented for laceration repair between October 1994 and February 1995 were prospectively evaluated. Patients less than 1 or greater than 18 years of age, those with lacerations greater than 5 cm, and those with lacerations located on the eyelids, ears, nose, lips, hands, feet, joints, or perineum were excluded. INTERVENTIONS: Following consent and routine wound management, including subcutaneous closure when deemed necessary, patients were randomized to receive skin sutures or HAB for cutaneous closure. METHODS: Length of time required for laceration repair was recorded. Parental perception of the pain experienced by their child was assessed using a visual analogue scale. Photographic documentation of scar appearance at the 2-month follow-up visit was evaluated by plastic surgeons using a visual analogue scale. RESULTS: Sixty-one children were enrolled: HAB group (N = 30), suture group (N = 31). No differences occurred between groups in laceration length, depth, location, or patient demographics. Length of time required for repair was decreased (median, HAB 7 minutes vs suture 17.0 minutes) and parental assessment of their child's pain was significantly less in the HAB group. Parents were more likely to recommend HAB over suturing to other parents or guardians. Cosmetic outcome in the HAB group was assessed to be as good as, or better than, the cosmetic outcome in the suture group as evaluated by two plastic surgeons. CONCLUSION: The use of HAB for laceration repair is an acceptable alternative to conventional suturing with a comparable cosmetic outcome. Advantages include less pain to the child, no need for suture removal, and more efficient use of physician time. Parents were also more likely to recommend HAB over suturing for laceration repair.

Adolescent↗
PubMed1994

Opioid tolerance and dependence in infants and children.

OBJECTIVES: To review the definitions and scientific basis for opioid tolerance and dependence in neonates and older children; to assess objective methods for the clinical evaluation of opioid abstinence syndromes in this age group; and to suggest therapeutic strategies for the treatment of opioid abstinence in critically ill neonates and children. DATA SOURCES: The published literature on opioid tolerance and dependence in pediatric patients was reviewed. Data from current clinical practices, nursing procedures, and ongoing clinical research were evaluated. DATA SYNTHESIS: Currently proposed mechanisms of opioid tolerance and dependence are assessed, with particular relevance to the developing human central nervous system. The validity and clinical role of currently available objective methods for the assessment of opioid abstinence in neonates and older infants are defined. The efficacy of various pharmacologic and nonpharmacologic modalities for the treatment of opioid abstinence is evaluated and compared, and a therapeutic approach based on receptor mechanisms, clinical monitoring data, and pharmacologic efficacy is suggested. CONCLUSIONS: Important parallels for therapeutically-induced opioid tolerance and withdrawal may be drawn from the assessment and management of neonates born from opioid-addicted mothers. Opioid withdrawal can be prevented with appropriate weaning schedules, diagnosed by objective clinical methods, and treated by a variety of pharmacologic and non-pharmacologic means. Pharmacologic therapy includes the use of opioids, with adjuvant drugs such as diazepam, clonidine, or chlorpromazine. The pathophysiology and assessment of therapeutically induced opioid tolerance and withdrawal merit further research in critically ill pediatric patients.

Humans↗
PubMed1992

Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery.

BACKGROUND: Extreme hormonal and metabolic responses to stress are associated with increased morbidity and mortality in sick adults. We hypothesized that administering deep opioid anesthesia to critically ill neonates undergoing cardiac surgery would blunt their responses to stress and might improve clinical outcomes. METHODS: In a randomized trial, 30 neonates were assigned to receive deep intraoperative anesthesia with high doses of sufentanil and postoperative infusions of opiates for 24 hours; 15 neonates were assigned to receive lighter anesthesia with halothane and morphine followed postoperatively by intermittent morphine and diazepam. Hormonal and metabolic responses to surgery were evaluated by assay of arterial blood samples obtained before, during, and after the operations. RESULTS: The neonates who received deep anesthesia (with sufentanil) had significantly reduced responses of beta-endorphin, norepinephrine, epinephrine, glucagon, aldosterone, cortisol, and other steroid hormones; their insulin responses and ratios of insulin to glucagon were greater during the operation. The neonates who received lighter anesthesia (with halothane plus morphine) had more severe hyperglycemia and lactic acidemia during surgery and higher lactate and acetoacetate concentrations postoperatively (P less than 0.025). The group that received deep anesthesia had a decreased incidence of sepsis (P = 0.03), metabolic acidosis (P less than 0.01), and disseminated intravascular coagulation (P = 0.03) and fewer postoperative deaths (none of 30 given sufentanil vs. 4 of 15 given halothane plus morphine, (P less than 0.01). CONCLUSIONS: In neonates undergoing cardiac surgery, the physiologic responses to stress are attenuated by deep anesthesia and postoperative analgesia with high doses of opioids. Deep anesthesia continued postoperatively may reduce the vulnerability of these neonates to complications and may reduce mortality.

Acetoacetates↗
PubMed1992

Neonatal pain management.

Neonatal pain management is a challenge for the clinician. Research is just beginning to uncover the neonates' capability of expression of pain, explore pharmacologic management strategies, and identify the spectrum of intrusions that may precipitate pain or distress in the critically ill neonate. This article reviews the neonatal biologic, behavioral, and physiologic responses to pain and describes recommendations for clinical management and decision-making.

Critical Care↗
PubMed1990

Hormonal-metabolic stress responses in neonates undergoing cardiac surgery.

Hormonal and metabolic responses were measured in 15 neonates who underwent repair of complex congenital heart defects during a standardized anesthetic protocol. Four of the 15 neonates died postoperatively in the intensive care unit. Analysis of arterial plasma samples obtained before, during, and 24 h after surgery showed that plasma epinephrine, norepinephrine, cortisol, glucagon, and beta endorphin increased in all patients (P less than 0.05). Insulin levels increased only at the end of surgery but remained elevated for 24 h postoperatively (P less than 0.02). Intraoperative metabolic changes were characterized by hyperglycemia and lactic acidemia that persisted postoperatively. This pattern of neonatal stress responses is distinct from and more extreme than that seen in adult cardiac surgical patients. The four neonates who died postoperatively tended to have higher stress responses intra- and postoperatively despite having been indistinguishable from survivors by the usual clinical and hemodynamic criteria. These preliminary results suggest that neonatal hormonal and metabolic responses to cardiac surgical operations in neonates are extreme and are associated with a high hospital mortality rate.

Alanine↗
PubMed1990

Neonatal stress responses to anesthesia and surgery.

Neonatal stress responses have been investigated only in recent years. Term neonates mount substantial hormonal and metabolic responses, which are distinct from those of adult patients. These responses can be altered significantly by the effects of prematurity, the effects of graded surgical stress, and the anesthetic techniques used during surgery. In addition, neonatal stress responses may have important implications for the clinical outcome following surgery in neonates.

Anesthesia↗