Good Practice in Postoperative and Procedural Pain Management ...

Analgesia Table 4.2.1aBlood sampling and peripheral cannulation in the neonateDirectevidenceLocal anesthesia Topical 1+Sucrose 1++Nonpharmacological 1+Procedure modifications 1+Analgesia Table 4.2.1bPercutaneous central venous catheter insertionDirectevidenceIndirectevidenceIndirectevidenceLocal anesthesia a Topical 1+Opioids Intravenous 1+Sucrose a 1+ 1++a Combined with Opioids.4.2.2 Ocular examination for retinopathy of prematurityPreterm infants ‘at risk’ of retinopathy of prematurity(ROP) should have regular ocular examination. Aneyelid speculum is inserted to hold the eye open, andthe retina is examined by indirect fundoscopy througha dilated pupil. In addition, a small proportion willrequire laser ablation of significant disease.RecommendationsSucrose may contribute to pain response reduction inexamination for retinopathy: Grade A (57–60).Infants undergoing examination for retinopathy shouldreceive local anesthetic drops in combination with othermeasures if an eyelid speculum is used: Grade B (61–65).Swaddling, developmental care, non-nutritive sucking,and pacifier should be considered for neonates undergoingexamination for retinopathy: Grade B(57,60,63,66).Laser treatment should be with general anesthesia iftimely treatment is needed: Grade D (63).EvidenceA combined analgesic approach using LA, a pacifier,swaddling, and the addition of a sweet solution islikely to be most effective for ROP screening examinationpain (57,65). Oral sucrose prior to the screenreduced the behavioral pain scores in small groupsof infants (59,60). Laser treatment is painful, andappropriate pain-relieving strategies should beemployed (63). Laser treatment may be more rapidlyavailable if sedation, analgesia, ventilation, andmuscle relaxation are possible on the neonatal unit(63). See section 6.7 for further information on theuse of sucrose.Analgesia Table 4.2.2 Retinopathy of prematurityLocal anesthesia Topical 1+Sucrose 1+Non-nutritive sucking 1+Comfort care package 1)Directevidence4.2.3 Lumbar puncture (LP) in the neonateIndirectevidenceSampling of cerebrospinal fluid is often regarded as aminor procedure in infants; nevertheless, it is associatedwith pain that can be reduced by suitable analgesia(67).RecommendationTopical local anesthesia is effective in reducing lumbarpuncture pain: Grade A (67,68).EvidenceThere have been few studies directly investigating LPpain in the neonate. Topical local anesthetic hasbeen found to be effective (67). Indirect evidencesuggests that subcutaneous infiltration of LA wouldalso be effective, but it has not been ‘consistently’shown to be superior to placebo in the neonate, incontrast to positive effects in older children andadults (69). A nomogram of weight to midspinaldepth allows estimation of the depth of insertion ofan LP needle (70,71). This has been correlated withª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 19