Good Practice in Postoperative and Procedural Pain Management ...

Section 4.0Medical ProceduresContents4.1 General considerations4.2 Procedural pain in the neonate4.2.1 Blood sampling4.2.2 Ocular examination for retinopathy of prematurity4.2.3 Lumbar puncture4.2.4 Urine sampling4.2.5 Chest drain (tube) insertion and removal (see 4.3.3)4.2.6 Nasogastric tube placement (see 4.3.5)4.2.7 Immunization and intramuscular injection4.3 Procedural pain in infants and older children4.3.1 Blood sampling and intravenous cannulation4.3.2 Lumbar puncture4.3.3 Chest drain (tube) insertion and removal4.3.4 Bladder catheterization and urine sampling procedures4.3.5 Insertion of nasogastric tubes4.3.6 Immunization and intramuscular injection4.3.7 Repair of lacerations4.3.8 Change of dressings in children with burns4.3.9 Botulinum injections for children with muscle spasm4.1 General considerationsRoutine medical care involving blood sampling andother painful diagnostic and therapeutic procedurescan cause great distress for children and their families.When such procedures are essential, it is importantthat they should be achieved with as little pain as possible.For many children who have chronic illness,these procedures often need to be repeated, and thiscan generate very high levels of anxiety and distress iftheir previous experience has been poor. The 10 generalprinciples, which apply to the management of allprocedures at any age, are listed below. Further advicefor use in specific age-groups, and specifically for someof the most common procedures, is described in sections4.2 and 4.3.1. Infants and children of all ages, including prematureneonates, are capable of feeling pain and require analgesiafor painful procedures.2. Developmental differences in the response to painand analgesic efficacy should be considered whenplanning analgesia.3. Consider whether the planned procedure is necessary,and how the information it will provide mightinfluence care? Avoid multiple procedures if possible.4. Plan the timing of procedures to minimize the frequencyof a painful procedure.5. Are sedation or even general anesthesia likely to berequired for a safe and satisfactory outcome?6. Would modification of the procedure reduce pain?For example, venepuncture is less painful than heellance.7. Is the planned environment suitable? Ideally, thisshould be a quiet, calm place with suitable toys anddistractions.8. Ensure that appropriate personnel who possess thenecessary skills are available, and enlist experiencedhelp when necessary.9. Allow sufficient time for analgesic drugs and otheranalgesic measures to be effective.10. Formulate a clear plan of action should the procedurefail or pain become unmanageable using the techniquesselected.Good practice pointPain management for procedures should include bothpharmacological and nonpharmacological strategieswhenever possible.4.2 Procedural pain in the neonatePremature neonates are able to perceive pain, but theresponse to both pain and analgesia is dependant ondevelopmental age. Because of this, pain assessment inthis age-group is particularly difficult (see section 3),and the low sensitivity of many pain measurementtools can complicate the interpretation of evidence.Clinically, neonates appear to be sensitive to theadverse effects of many drugs, including analgesics;ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 17