ICU Neonates Endure Painful Procedures, Usually Without Analgesia

A new study has found that neonates in intensive care units (ICUs) undergo a median of 10 painful procedures per day, 79% of them without analgesia.

Researchers at the Hôpital d'enfants Armand Trousseau (Paris, France) conducted a prospective observational study and collected round-the-clock bedside data on all painful or stressful procedures performed in 430 neonates admitted to 13 ICU's in tertiary care centers in Paris (France). Data were collected from the first 14 days of admission, during a six-week period. Painful procedures were considered as those that invaded a neonate's bodily integrity, and stressful procedures were defined as those that mainly caused physical uneasiness or annoyance. Pharmacological analgesia included intravenous opioids and topical drugs, and nonpharmacological analgesia as included administering sweet solutions or allowing nonnutritive sucking. The average gestational age was 33 weeks and the average ICU stay was 8.4 days.

The investigators identified 44 painful procedures, of which the six most common were nasal aspiration (28.9%), tracheal aspiration (23.3%), heel stick (19.8%), adhesive removal (12.7%), gastric tube insertion (2.4%), and venipuncture (1.8%). Of the 16 identified stressful procedures, the six most frequent were nursing care (39.2%), oral aspiration (26.9%), washing the neonate (8.5%), blood pressure measurement (8.5%), X-rays (6.0%), and infant weighing (5.8%). During the study period, neonates experienced 42,413 painful and 18,556 stressful first-attempt procedures, and 10,366 painful and 1,180 stressful supplemental-attempt procedures; each neonate experienced a mean of 16 painful plus stressful procedures each day, and some experienced as many as 62 procedures each day. Of the 42,413 painful procedures, only 20.8% were carried out with specific analgesia before the procedure; 2.1% were performed with pharmacological-only therapy, 18.2% with nonpharmacological therapy, and 0.4% with both. The study was published in the July 2, 2008 issue of the Journal of the American Medical Association (JAMA).

"The number of painful procedures is so high that the first step to improve procedural pain management must significantly reduce these numbers,” said lead author Ricardo Carbajal, M.D. "The knowledge that some vulnerable neonates underwent 153 tracheal aspirations or 95 heel sticks in a 2-week period should elicit a thoughtful and relevant analysis on the necessity and the risk/benefit ratio for our clinical practices.”

"Advances in neonatal care in recent decades, with increased survival of immature and sick neonates, have led to an increased number of invasive procedures that may cause pain in these vulnerable neonates,” concluded the authors. "The prevention of pain in critically ill neonates is not only an ethical obligation, it also averts immediate and long-term consequences.”


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Hôpital d'enfants Armand Trousseau