[Surfactant replacement therapy] / Terapêutica de reposição de surfactante.

OBJECTIVE: To analyze and update information about surfactant therapy replacement in newborns with lung diseases. SOURCES: Literature review, including textbooks, meta-analyses, prospective, randomized controlled trials, retrospective assessments and case studies. Literature was reviewed based on the authors clinical and scientific experience regarding surfactant replacement therapy in neonatal lung diseases. SUMMARY OF THE FINDINGS: Surfactant replacement therapy for the neonatal respiratory distress syndrome improves respiratory function, and reduces the need for oxygen supplementation and pressure support ventilation, in addition to minimizing the air leak syndrome. However, the use of surfactant did not prevent the occurrence of other intercurrent diseases such as patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and bronchopulmonary dysplasia. The surfactant treatment decreased neonatal mortality up to 40%. The effectiveness of exogenous surfactant on other respiratory diseases with surface film dysfunction, such as meconium aspiration syndrome, pneumonia, acute respiratory distress syndrome and congenital diaphragmatic hernia has not yet been widely accepted. CONCLUSIONS: Surfactant replacement is now considered the standard treatment for newborns with respiratory distress syndrome. We hope that, in the future, new synthetic surfactant preparations will be more effective in treating other infant respiratory diseases.

The recognition of facial expression of pain in full-term newborns by parents and health professionals.

OBJECTIVE: To determine whether adults can recognize neonatal facial expression of pain. DESIGN: A cross-sectional study. SETTING: Neonatal intensive care unit, nursery, and outpatient clinic of one university hospital and one private hospital in São Paulo, Brazil. PATIENTS: Four hundred five adults divided into 2 groups: health and nonhealth professionals. INTERVENTION: The faces of 3 healthy full-term newborns who needed glucose screening were photographed at rest and during light exposure, heel rubbing, and heel puncture. A series of adults answered a questionnaire on personal and professional data and then they analyzed for 1 minute each of the 3 sets of pictures to answer the following question: "In which picture of this set do you think that the baby is feeling pain?" MAIN OUTCOME MEASURE: Number of correct answers for the 3 sets of photographs shown to the adults. RESULTS: Seventy-four percent of the health professionals and 86% of the nonhealth professionals indicated correctly the picture with facial expressions of pain in at least 2 of the 3 sets. Regarding which picture was picked out by the interviewee, 94% of the health professionals and 92% of the nonhealth professionals indicated the picture taken during the heel puncture in set 1. The same observation was made by 53% and 54% of the health professional and by 68% and 66% of the nonhealth professional interviewees for sets 2 and 3, respectively. CONCLUSIONS: Facial expression of pain represents an effective neonatal communication tool. However, the health professional group achieved a lower level of recognition of neonatal facial expressions of pain. Factors related to the personal and professional characteristics of the adults interviewed probably contributed to this result.

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.

[Pain in intubated and ventilated preterm neonate: multidimensional assessment and response to fentanyl analgesia]. / A dor do recém-nascido prematuro submetido a ventilação mecânica através de cânula traqueal.

The purpose of this study was to verify if multidimensional pain assessment, performed through physiologic and behavioral measures, together with this assessment modifications in response to opioid analgesia, could determine the presence of pain in preterm neonates (PT) under mechanical ventilation through endotracheal tube (ETT). The population consisted of 22 PT with gest. age < or = 32 weeks, between 12-48 h of life. All of them had an ETT and an umbilical arterial line in place and were on mechanical ventilation. The infants were admitted at São Paulo Hospital NICU from 11/91 to 11/92. Neonates' observation was performed in three 10 minute periods: prior medication (Pre-Analgesia), 30 min (Analgesia 1) and 60 min (Analgesia 2) after the injection of either fentanyl (3 mcg/kg) or sterile water (0.2 ml). In each period an arterial blood gas was drawn and the following parameters were recorded: ventilator settings, heart rate, non-invasive blood pressure and 02 saturation. Behavioral measures were also observed: ATTIA scale, MCGRATH scale and GRUNAU & CRAIG pain facial features. In Pre-Analgesia and Analgesia 2 periods, blood samples were obtained and serum cortisol, serum GH, plasmatic glucose and lactate were measured. Patients were filmed through the study and behavioral measures applied for each patient film. The research author was blind to the medication until final results. High levels of serum cortisol, serum GH and plasmatic lactate were present in the whole study population prior to medication. They also presented low ATTIA scale scores and pain facial mimic, as per MCGRATH and GRUNAU & CRAIG evaluations. Patients that received fentanyl exhibited decrease in the maximum heart rate, decrease in serum cortisol, increase in serum GH, stability in blood glucose levels, better ATTIA scale comfort scores and less pain facial movements. None of these occurred in neonates that received placebo. Critically ill intubated and ventilated PT do feel pain, as assessed by this multidimensional evaluation. Analgesia should be considered in order to treat these patients' pain.