Guidelines for Pain Assessment and Management for Neonates

2/18/2015 GuidelinesforPainAssessmentandManagementforNeonates

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GuidelinesforPainAssessmentandManagementforNeonates

Validonlyondateprinted:20120918.Discardimmediatelyafteruse!

GuidelinesforPainAssessmentandManagementforNeonatesLastReviewDate:20110628

OriginalapprovalbyNICUInterprofessionalPracticeNov26,20101.0IntroductionAllneonatesintheNICUwillhavestandardassessmentsofpain,whichincludePIPPscoresforpretermandterminfantslessthan2monthsofage,andFLACCscoresforpretermandterminfantswhoaremorethan2monthsofage.

2.0DefinitionsPIPP:PrematureInfantPainProfileisabiobehaviouralobservationaltoolforacuteandproceduralpain.FLACC:Face,Legs,Activity,Cry,Consolabilityisabehaviouralobservationaltoolforacutepain.

3.0ClinicalPracticeRecommendations

ThegradingsysteminTable1servesasaguidelinefortheuseraboutthehierarchyofevidenceavailabletosupporteachrecommendation.

Table1.GradesofRecommendationA Recommendationsupportedbyatleastonerandomizedcontrolledtrial,systematic

reviewormetaanalysis.

B Recommendationsupportedbyatleastonecohortcomparison,casestudyorotherexperimentalstudy.

C Recommendationsupportedbyexpertopinionorexperienceofaconsensuspanel.

3.1PainAssessmentPIPPorFLACCscoresshouldbedocumentedoneachpatientonceashift,onadmission,andbefore,duringandafteran

invasiveprocedureasperhospitalpolicy.SeePainAssessment==> Inaddition,PIPP5orFLACC4scoresshouldbedonemorefrequently:

1. Followingpostoperativeprocedures.SeePainManagementGuidelinesforPostOperativePatientsintheNICU==>

2. Toassesspainininfantswithknownmedicalconditionsorinterventionsthatmaycausepain(e.g.NEC,chesttubesetc)

3. Followingchangestocontinuousanalgesia.4. Toevaluateweaningofpharmacologicaltreatmentsforinfantswhohavebeenonshorttermopioids.Forpatientswith

treatmentlengthsgreaterthan35daysutilizeroutineNeonatalAbstinenceScoringforwithdrawalofopioids.SeePainManagementGuidelinesforPostOperativePatientsintheNICU==>

3.2PainManagementForgeneralprinciplesofpainmanagment,seePainManagementClinicalPracticeGuideline==> Someadditionalstrategiesforneonatalproceduralpainmanagementareoutlinedbelow.

3.2.1Allinfantsshouldreceivephysical/psychologicaldevelopmentallyappropriatestrategiesduringallpainfulprocedures2

(GradeB).Developmentalstrategiesinclude:

1. Nonnutritivesucking2. Positioningandcontainment3. Swaddling4. Reductionoflightandsoundlevels5. Minimalhandling6. Auditoryandvisualdistraction7. Skintoskincontact8. Breastfeedingdepedentoninfants'conditionandifmotherisbreastfeedingandavailableduringprocedure.

3.2.2Inadditiontodevelopmentalstrategies,pharmacologicalstrategiesshouldbeusedconsideredbasedonthetypeofprocedure.Localtopicalanalgesicsmaybeusedwithsomeproceduresbutmaybelimitedifvasoconstrictionwouldinhibitthesuccessoftheprocedure(eg.IVstarts).AmetopisthestandardtopicalanalgesiafortheNICUandcanbeusedforprematureinfantsandfullterminfants,howeveritshouldnotbeusedinprematureinfantslessthan27weeksgestationalage

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prematureinfantsandfullterminfants,howeveritshouldnotbeusedinprematureinfantslessthan27weeksgestationalageunlesstheyaregreaterthan14daysofage(seeSickKidseformulary).Alternatively,EMLAcanalsobeusedforterminfants

orprematureinfantswhoaregreaterthanonemonthofage8(GradeC)(seeSickKidseformulary).

3.2.3SucroseAdministrationSeePainManagementClinicalPracticeGuideline==>

3.3AdjunctManagementforProceduralPainThefollowingchartrecommendsappropriateoptionsforpainmanagementforthemostcommonneonatalprocedures.Inadditiontorecommendedmanagementbelow,administrationofappropriatedevelopmentalstrategiesforpainmanagement(seenonpharmacologicalguidelinesforpainmanagement)shouldalwaysbeutilized.

Procedure RecommendedPainManagement

LumbarPuncture Applylocaltopicalanestheticcream(Ametop)4045minutespriortoprocedure(mustbe>27wksgestationand/or>14daysofage)Usepacifierwith24%Sucrose0.52.0mlpo2minutespriortoprocedure6(GradeB).SeePainManagementClinicalPracticeGuideline(CPG)==> orEformulary:SucroseCautiousphysicalhandlingisadvised

ChestTubeInsertion

Morphine0.1mg/kg/doseIV20minutespriortoprocedureorFentanyl1mcg/kg/doseIV35minutespriortoprocedure.AdministerfentanylbyslowIVpushover2minutes

Usepacifierwith24%Sucrose0.52.0mlpo2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:SucroseBufferedlidocaine1%SQaslocalanestheticStartmorphineinfusionof510mcg/kg/hrfollowingbolusandassessinfantasperguidelinesforsubacutepainmanagement

ChestTubeRemoval

Usepacifierwith24%Sucrose0.52.0mlpo2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:Sucrose

Immunization/IntramuscularInjection

Usepacifierwith24%Sucrose0.52.0mlpo2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:SucroseApplylocaltopicalanestheticcream(Ametop)4045minutespriortoprocedure(mustbe>27wksgestationand/or>14daysofage)Acetaminophen1015mg/kg/dosepo1hourpriortoprocedureandthenQ4Hprnx24hrsifrequiredforfeverorlocalinflammationtomaximumdailydose65mg/kg/dayFollowhospitalwideIMInjectionPolicyrecommendations.

SubcutaneousInjection Usepacifierwith24%Sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:SucroseApplylocaltopicalanestheticcream(Ametop)4045minutespriortoprocedure(mustbe>27wksgestationand/or>14daysofage)

EyeExams Usepacifierwith24%Sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:Sucrose

Intubation SeeNeonatalEndotrachealIntubationguidelines

HeelLance Usepacifierwith24%Sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:Sucrose

Venipuncture/IntravenousCatheterInsertion

Usepacifierwith24%sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:SucroseAmetopmaybechosenifnonurgent

Peripheralarterialpuncture/Peripheralarterialline

Usepacifierwith24%sucrose0.52.0ml2minutespriortotheprocedure6(GradeB).SeePainManagementCPG==> orEformulary:Sucrose

PICCLine

Note:ifpatientalreadyreceivingopoidinfusion,theystillrequirebolusprePICCforacutepainmanagement.

NICUPICCsPrematurePatients

Usepacifierwith24%sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:SucroseNONINTUBATED:Fentanyl0.5mcg/kg/dose5minutespriortoprocedureINTUBATED:Fentanyl1mcg/kg/dose5minutespriortoprocedure

TermPatients

Usepacifierwith24%sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:SucroseNONINTUBATED&INTUBATED:Fentanyl1mcg/kg/dose5minutespriortoprocedureORmorphine0.1mg/kg/dose20minutespriortoprocedure

IGTPICCsPrematurePatients

Usepacifierwith24%sucrose2minutespriortoprocedureaspersucroseguidelines.SeePainManagementCPG==> orEformulary:SucroseApplylocaltopicalanestheticcream(Ametop4045minutespriortoprocedure)ifinfantis>27weeksand/or>2weekspostnatalageNONINTUBATED:Fentanyl0.5mcg/kg/dose5minutespriortoprocedureINTUBATED:Fentanyl1mcg/kg/dose5minutespriortoprocedure

TermPatients



TermPatients

Usepacifierwith24%sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:SucroseApplylocaltopicalanestheticcream(Ametop)4045minutespriortoprocedureNONINTUBATED&INTUBATED:Fentanyl1mcg/kg/dose5minutespriortoprocedureORmorphine0.1mg/kg/dose20minutespriortoprocedureMidazolam50mcg/kg/dose(0.05mg/kg/dose)5minutespriortoprocedureMayrepeatmidazolam50mcg/kgx1,30minutesafterfirstdoseifinadequatesedation

PICCRemoval(IGTlinesonly)SeeRemovalofaPICC==>

CuffedIGTlinesmustberemovedbyIGTstaffandwillbeorganizedbyVASstafftooccurintheNICUorinIGT

EMLApatch8(GradeB)isoftenusedasperIGTSeeEformulary:EMLAUncuffedlinesmayberemovedbyNICUstaffatthediscretionofIGT

UmbilicalLines Usepacifierwith24%sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:Sucrose

NasogastricTubes Usepacifierwith24%sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:Sucrose

Urinarycatheters/Suprapubicbladdertap

Usepacifierwith24%sucrose0.52.0ml2minutespriortoprocedure6(GradeB).SeePainManagementCPG==> orEformulary:Sucrose

PalliativeCare PhysicalandpsychologicalstrategiesforpainmanagementOralmorphineorlorazepammaybeutilizedasrecommendedbythepalliativecareteam

3.3.1PostoperativePainManagementSeePainManagementGuidelinesforPostOperativePatientsintheNICU==>

4.0RelatedDocumentsPainAssessmentPolicy==>PainManagementClinicalPracticeGuideline==>PainManagementGuidelinesforPostOperativePatientsintheNICU==>RemovalofaPeripherallyInsertedCentralCatheter(PICC)==>Eformulary:EMLAEformulary:Sucrose

5.0ReferencesThegradingsysteminTable1servesasaguidelinefortheuseraboutthehierarchyofevidenceavailabletosupporteachrecommendation.

Table1.GradesofRecommendationA Recommendationsupportedbyatleastonerandomizedcontrolledtrial,systematic

reviewormetaanalysis.

B Recommendationsupportedbyatleastonecohortcomparison,casestudyorotherexperimentalstudy.

C Recommendationsupportedbyexpertopinionorexperienceofaconsensuspanel.

1. Anand,KJS,InternationalEvidenceBasedGroupforNeonatalPain(2001).Consensusstatementforthepreventionandmanagementofpaininthenewborn.ArchivesofPediatricAdolescentMedicine,155:173180.

2. Franck,L.S.Lawhorn,G.(1998).Environmentalandbehaviouralstrategiestopreventandmanagepain.SeminarsinPerinatology,22(5):434443.

3. Khuran,S,WhitHall,R,Anand,KJS.(2005).Treatmentofpainandstressintheneonate:Whenandhow.Neoreviews,6(2):e76e86.

4. Markel,S.L.,VoepelLewis,T.,Shayeviz,J.R.,&Malviya,S.(1997)TheFLACC:Abehaviouralscaleforscoringpostoperativepaininyoungchildren.PediatricNursing23:293297.

5. StevensB.,Johnston,C.,PetryshenP.etal.(1996)PrematureInfantPainProfile:developmentandinitialvalidation,ClinicalJournalofPain12:1322.

6. Stevens,B.,Yamada,J.,Ohlsson,A.(2006)Sucroseforanalgesiainnewborninfantsundergoingpainfulprocedures.CochraneDatabaseofSystemicReviews,1.

7. TaddioA,LeeC,YipA,ParvezB,McNamaraPJ,ShahV.(2006).Intravenousmorphineandtopicaltetracainefortreatmentofpaininpretermneonatesundergoingcentrallineplacement.JAMA,295(7):793800.

8. Taddio,A.,Ohlsson,A.Einarson,T.,Stevens,B.,Koren,G.(1998).Asystematicreviewoflidocaineprilocaine(EMLA)inthetreatmentofacutepaininneonates.Pediatrics,101(2),e19.

9. Walden,M.(2001)PainAssessmentandManagement:Guidelineforpractice.NationalAssociationofNeonatalNurses,124.

2011TheHospitalforSickChildren("SickKids").Allrightsreserved.Thisdocumentmaybereproducedorusedstrictlyfornoncommercialclinicalpurposes.However,bypermittingsuchuse,SickKidsdoesnotgrantanybroaderlicenceorwaiveanyofitsexclusiverightsundercopyrightorotherwiseatlawinparticular,thisdocumentmaynotbeusedforpublicationwithoutappropriateacknowledgementtoSickKids.ThisClinicalPracticeGuidelinehasbeendevelopedtoguidethepracticeofcliniciansatTheHospitalforSickChildren.Useofthisguidelineinanysettingmustbesubjecttotheclinicaljudgmentofthoseresponsibleforprovidingcare.SickKidsdoesnotacceptresponsibilityfortheapplicationofthisguidelineoutsideSickKids.



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