Partridge J C, Wall S N
Department of Pediatrics, University of California, San Francisco, USA.
Pediatrics. 1997 Jan;99(1):76-9. doi: 10.1542/peds.99.1.76.
To determine the frequency of opiate analgesia administration to infants when life support is discontinued and to determine whether infant characteristics, such as birth weight and diagnosis, or the physician's reasons for discontinuing life support influence either the decision to provide opioid agents or the dosages administered.
We reviewed all 165 deaths in a 3-year period at a university-based level III intensive care nursery. Of the 121 deaths attributable to withdrawal or withholding of mechanical ventilation and/or extracorporeal membrane oxygenation, we ascertained whether opioid analgesics (morphine sulfate [MS] or fentanyl) were administered either concurrent with or after life-support withdrawal and at what doses. We examined whether these end-of-life practices varied according to birth weight, diagnoses, and the reasons documented by the neonatologist for discontinuing life support.
Opioid analgesia was provided to 84% of infants as their life support was either withheld or withdrawn. Infants with necrotizing enterocolitis and major anomalies or chromosomal disorders were more likely to be given opiates than infants with other diagnoses. Birth weight was not different for infants who received opiates compared with those who were not given opiates. Opioid analgesia was provided to all 18 infants for whom physicians documented the patients' suffering as a reason to discontinue life support. Sixty-four percent of infants who received opiates were given doses in the usual pharmacologic range of 0.1 to 0.2 mg/kg MS. Of the 36 infants given more than 0.2 mg/kg MS, all but 2 were receiving ongoing treatment with opioid agents.
In most cases of withholding or withdrawal of life support in critically ill infants, neonatologists provided opioid analgesia to these infants at the end of life, despite the potential respiratory depression of opioid agents in infants whose respiratory support is discontinued.
确定在停止生命支持时给予婴儿阿片类镇痛药的频率，并确定婴儿特征（如出生体重和诊断）或医生停止生命支持的原因是否会影响提供阿片类药物的决定或给药剂量。
我们回顾了一所大学三级重症监护病房3年内的所有165例死亡病例。在121例因撤机或停止机械通气和/或体外膜肺氧合导致的死亡病例中，我们确定是否在停止生命支持的同时或之后给予了阿片类镇痛药（硫酸吗啡[MS]或芬太尼）以及给药剂量。我们研究了这些临终处理方法是否因出生体重、诊断以及新生儿科医生记录的停止生命支持的原因而有所不同。
84%的婴儿在生命支持被停止或撤机时接受了阿片类镇痛治疗。患有坏死性小肠结肠炎以及严重畸形或染色体疾病的婴儿比患有其他诊断的婴儿更有可能接受阿片类药物治疗。接受阿片类药物治疗的婴儿与未接受治疗的婴儿出生体重并无差异。对于医生记录为因患者痛苦而停止生命支持的所有18例婴儿，均给予了阿片类镇痛治疗。接受阿片类药物治疗的婴儿中有64%的给药剂量在MS通常的药理范围内，即0.1至0.2mg/kg。在36例接受超过0.2mg/kg MS治疗的婴儿中，除2例之外，其余婴儿均在持续接受阿片类药物治疗。
在大多数重症婴儿停止生命支持的情况下，尽管停止呼吸支持的婴儿使用阿片类药物可能会导致呼吸抑制，但新生儿科医生在临终时仍为这些婴儿提供了阿片类镇痛治疗。
