Good Practice in Postoperative and Procedural Pain Management ...

however, reductions in the response to pain have beenobserved following nontraditional analgesia such assucrose and physical and environmental measures, forexample, suckling or tactile stimulation, which are currentlynot known to have potentially harmful effects.A number of documents including reviews, guideline,and policy statements have been published recently onthe subject of procedural pain management in the neonate(1–4). On the basis of the currently available evidence,the following measures can be generallyrecommended for the management of procedural painin the neonate:RecommendationsBreast-feeding should be encouraged during the procedure,if feasible: Grade A (5–9).Nonpharmacological measures including non-nutritivesucking, ‘kangaroo care’, swaddling/facilitated tucking,tactile stimulation, and heel massage can be used forbrief procedures: Grade A (5,6,10–30).4.2.1 Blood sampling in the neonate(includes peripheral venous, arterial, andpercutaneous central venous cannulation)Blood sampling is a necessary and routine part of neonatalcare. Where an indwelling arterial catheter is notavailable, then venepuncture (VP) or heel prick bloodsampling (HPBS) is used. All newborn babies in theUK have a HPBS as part of the UK screening regime.Neonates admitted to intensive care or who are caredfor on postnatal wards will require frequent bloodsampling that has been identified in many studies as asignificant cause of pain and morbidity. HPBS requiresappropriate training and is used to collect small bloodsamples such as blood glucose, bilirubin newbornscreening tests, and capillary blood gases. VP alsorequires training but is technically more difficult and isused to collect larger blood samples. The principlesand techniques of pain relief are applicable to otherinvasive procedures such as peripheral arterial lineinsertion and percutaneous central venous catheters(i.e., long line). Please also see sections 4.0 and 4.1 onthe general management of procedural pain.RecommendationsSucrose or other sweet solutions can be used: Grade A(5,6,10–18,22,29,31–40).Nonpharmacological measures including tactile stimulation,breast-feeding, non-nutritive sucking, ‘kangaroocare’, and massage of the heel can be used for heel prickblood sampling: Grade A (12,19–28,30).Venepuncture (by a trained practitioner) is preferred toheel lance for larger samples as it is less painful: GradeA (18,41–43).Topical local anesthetics alone are insufficient for heellance pain: Grade A (44,45).Topical local anesthetics can be used for venepuncturepain: Grade B (44–47).Using the whole plantar surface of the heel reduces thepain of heel prick blood sampling: Grade B (48,49).Remifentanil and sucrose decreased central venous catheterpain: Grade B: (36).Topical tetracaine plus morphine is superior to topicalanalgesia alone for central venous catheter pain in ventilatedinfants: Grade B (50,51).EvidenceA large number of studies have demonstrated thatsucrose before VP or HPBS reduces the behavioralpain scores measured by a range of validated assessments(5,6,10–18,22,29,31–40,52). The dose of sucrosediffered across these studies.Relieving the pain of HPBS has been challengingwith pharmacological methods. However, nonpharmacologicalmethods including breast-feeding, non-nutritivesucking, kangaroo care, and premassage of theheel before and during HPBS have consistently demonstratedreduced behavioral pain scores and physiologicalmarkers (12,19–28).VP appears to be less painful than HPBS so is thepreferred option whenever practical (18,41,43). Topicallocal anesthesia (LA) can reduce the pain of VP andinsertion of central venous catheters (44–46,51,53).However, topical LA is not effective for HPBS (45).Morphine with topical LA was more effective than LAalone for central venous line placement in ventilatedneonates (50,51). In addition, low-dose remifentanilcombined with sucrose reduced the pain of insertion ofcentral venous catheters (36).HPBS pain can be reduced with procedure modificationsuch as using an automated spring-loaded device,avoiding squeezing the heel, and using a wider area ofthe plantar surface of the heel (48,49,54–56).18 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79