NAS -2.txt

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NAS -2.txt
2010-03-28 20:54:14
Lecture # 1 Management

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  1. What is the incidence of NAS?
    Occurs in 60% of infants exposed to drugs in utero
  2. What are the common drugs of abuse?
    • Marijuana
    • Cigarettes
    • Heroin (diamorphine)/methadone
    • Cocaine/crack
    • Opiates (ie. morphine, oxycodone)
    • Barbiturates (ie. Phenobarbital, Seconal)
    • Benzodiazepines (ie. Valium, Ativan)
    • EtOH (alcohol)
  3. What are the general symptoms of NAS
    • Hyperactivity
    • Irritability
    • Poor sucking
    • Hyperphagia (> 190 ml/kg/day)
    • Crying
    • Tremors
    • Poor sleeping patterns
    • Sleep-wake abnormalities
    • Vomiting/diarrhea
    • Dehydration
    • Poor weight gain
    • Seizures
    • Tone abnormalities
  4. What are the different tone abnormalities associated with alcohol, cocaine and cigarettes?
    • Fetal alcohol syndrome: hypotonia
    • Cocaine: hypertonia
    • Cigarette smoking + cocaine: hypertonia
  5. When does hypertonia usually resolve.
    Hypertonia resolves by 2 yrs of age and does not seem to be a marker for cerebral palsy
  6. When do symptoms of NAS usually show up
    Usually within 24-72 hrs following birth
  7. What effects the time of onset of NAS?
    • Type of drug used
    • Methadone exposed infants may not present until 96 hrs after delivery
    • Timing of last dose prior to delivery
    • The closer to delivery the greater the delay of onset and the more severe the symptoms
    • Amount & strength of drug
  8. What are the adverse effects of neonatal drug abuse.
    • Prematurity
    • Low birthweight, length, and head circumference
    • Abnormal neurologic exam
  9. What is Tolerance
    “an altered state of response to an agent in which increasing amounts of the agent are required to produce or maintain the same effect”
  10. What is Receptor tolerance –
    downregulation of receptor
  11. What is Metabolic tolerance –
    induction of degradative enzymes
  12. What is Dependence
    “a physiologic state produced by continued administration of an agent which results in an abstinence syndrome if the administration of the agent is discontinued”
  13. What is Physical dependence –
    physiologic need for a drug
  14. What is Psychologic dependence –
    desire for the euphoric effects of drugs, usually recreational use of benzodiazepines, narcotics, and amphetamines
  15. What is Neonatal Abstinence
    A generalized disorder characterized by signs and symptoms of CNS hyperirritability, GI dysfunction, respiratory distress, and vague autonomic symptoms.
  16. Who developed a Scoring system for NAS?
    developed by Loretta Finnegan in 1974
  17. What are the pros of Neonatal Abstinence Scoring
    • Assess the need for pharmacotherapy
    • Monitor therapeutic efficacy
    • Correlate drug-related neurodysfunction with eventual neurobehavioral outcome
  18. What are the cons of Neonatal Abstinence Scoring?
    • Symptom severity scales may be inadequate or inappropriate for preterm infants
    • Scoring scales do not take into account differences for gestational age
    • Published data on neurodevelopmental outcome is inconsistent
  19. What are the rules of NAS Scoring System
    • Assess high-risk infants 2 hrs after birth, then q4h until 96 hrs of life if pharmacotherapy is not needed
    • Notify NP/MD to assess for pharmacotherapy or need to change pharmacotherapy if infant :
    • Scores 8 or greater on 3 consecutive assessments
    • Scores 12 or greater on 2 consecutive assessments
    • Has a seizure
  20. What are the Characteristics of Neonatal Abstinence
    • Preemies (< 35 wks) have less abstinence symptoms and CNS manifestations than term infants
    • Signs of opioid abstinence are related to developmental maturity
    • Preemies are less likely to require specific pharmacotherapy than term infants
    • Peak severity of symptoms occurs 1-2 days later in preterm than term infants
  21. What are the Signs and Symptoms of Neonatal Abstinence
    • Autonomic symptoms: sweating, yawning, sneezing, dilated pupils, diarrhea, gooseflesh, rhinorrhea
    • Tremor
    • Irritability
    • Insomnia
    • Feeding intolerance
    • Seizures
  22. What are Midazolam Withdrawal Symptoms
    • Poor communication
    • Agitation
    • Visual hallucinations
    • Facial grimacing
    • Generalized seizures
  23. What are the characteristics of Midazolam (versed) Withdrawal
    • Peak withdrawal occurs 2 days after discontinuing drug
    • Severity and duration of symptoms increase with duration of midazolam administration
    • After 3 weeks of therapy , detoxification requires 7-10 days
  24. What are the Indications for Pharmacotherapy for Neonatal Abstinence?
    • Seizures
    • Vomiting and diarrhea
    • Inability to sleep
    • Fever unrelated to infection
    • Severe hyperactivity and irritability
  25. What are the indications Not to Start Pharmacotherapy for Neonatal Abstinence?
    • Jitteriness
    • Hyperreflexia
    • Sneezing
  26. What are Non-pharmacologic Interventions for Neonatal Abstinence
    • Calm, quiet, warm, dark environment
    • Gentle handling; gentle rocking
    • Swaddling to decrease sensory stimulation
    • Non-nutritive sucking
    • Frequent small feedings; gavage feeding if necessary to promote rest periods; high caloric feeds to meet metabolic demands
  27. What are the Pharmacotherapy Treatment Options for Neonatal Abstinence
    • Replacement therapy
    • Blockade therapy
    • Nonspecific supportive or symptomatic therapy
  28. What is the approach to Pharmacotherapy for Neonatal Abstinence
    • Gradual tapering of the drug of choice
    • Substitution of the drug of choice with a cross-tolerant medication
    • Combination therapy
  29. What are Literature Recommendations for Detoxification
    • Opiates - methadone
    • Benzodiazepines - phenobarbital
    • Heroin – paregoric/methadone
    • Methadone-treated Moms – paregoric/methadone
    • Barbiturates – phenobarbital
    • Alcohol - benzodiazepines
  30. How does Phenobarbital work for Neonatal Abstinence
    • Controls symptoms associated with opiates and barbiturates
    • Modifies hyperactive behavior due to sedative and anticonvulsant properties
    • Dosage and therapeutic level necessary to control symptoms are not well established
  31. What is the recommendations for Phenobarbital for Neonatal Abstinence
    • Goals of Therapy:
    • Serum level = 20-30 mcg/ml
    • Note: Each 1 mg/kg of phenobarbital will raise serum level 1-2 mcg/ml.
  32. What are the two methods of Phenobarbital for Neonatal Abstinence
    • Loading dose approach
    • Score titration method
  33. What is Phenobarbital Loading Dose Approach
    • Loading Dose: 20 mg/kg
    • Maintenance Dose: 5-8 mg/kg/day divided q12h
    • Dosage Increase: 10 mg/kg q12h until control is achieved or plasma level of 70 mcg/ml is reached or signs of clinical toxicity appear
    • Control abstinence for 72 hours
    • Initiate detoxification process
  34. What is the Goal of Detox:
    allow PB level to decrease 10% every 24 hours
  35. What is the Score Titration Approach to Treat Neonatal Abstinence
    • Dosage adjustment based on symptoms until NAS is less than 8:
    • Phenobarb: q8h
    • Paregoric: q4h
    • Give dose on schedule (ex. Phenobarb: 8 hours from previous dose)
  36. What is Methadone
    • Long-acting synthetic opiate agonist (t 1/2 = 12-24 hours)
    • Good oral bioavailability (F = 90%)
    • Causes respiratory depression and sedation
    • Causes little euphoria and little constipation
    • Dosage: 0.05-0.1 mg/kg/dose q12h/q8h
    • Wean dose by 10-20% until discontinue therapy (may take 6 weeks)
  37. What is Paregoric
    • Anhydrous morphine 0.4 mg/ml
    • Contains camphor (CNS stimulant), papaverine (antispasmodic), ethanol (~50%), benzoic acid
    • Increase dosage in increments of 0.5 mls/dose q4h
    • Detox by decreasing dose by 10% every 2-3 days
    • Caution: Tincture of Opium is anhydrous morphine 10 mg/ml. Dilute to 0.4 mg/ml before administration!
  38. How is Diazepam used for Neonatal Abstinence
    • Controls tremulousness and irritability
    • Eliminates abnormal sucking behavior
    • No longer recommended for neonatal drug withdrawal
  39. What are the Treatment of Withdrawal Seizures
    • Phenobarbital
    • Benzodiazepines
    • Morphine
    • Paregoric