Epidemiology and treatment of painful procedures in neonates in intensive care units

Ricardo Carbajal, MD, PhD; André Rousset, MD; Claude Danan, MD; Sarah Coquery, MD; Paul Nolent, MD; Sarah Ducrocq, MD; Carole Saizou, MD; Alexandre Lapillonne, MD, PhD; Michèle Granier, MD; Philippe Durand, MD; Richard Lenclen, MD; Anne Coursol, MD; Philippe Hubert, MD, PhD; Laure de Saint Blanquat, MD; Pierre-Yves Boëlle, PhD; Daniel Annequin, MD; Patricia Cimerman, RN; K. J. S. Anand, MBBS, DPhil; Gérard Bréart, MD, PhD

JAMA. 2008;300(1):60-70.

Context  Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain.

Objective  To report epidemiological data on neonatal pain collected from a geographically defined region, based on direct bedside observation of neonates.

Design, Setting, and Patients  Between September 2005 and January 2006, data on all painful and stressful procedures and corresponding analgesic therapy from the first 14 days of admission were prospectively collected within a 6-week period from 430 neonates admitted to tertiary care centers in the Paris region of France (11.3 millions inhabitants) for the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study.

Main Outcome Measure  Number of procedures considered painful or stressful by health personnel and corresponding analgesic therapy.

Results  The mean (SD) gestational age and intensive care unit stay were 33.0 (4.6) weeks and 8.4 (4.6) calendar days, respectively. Neonates experienced 60 969 first-attempt procedures, with 42 413 (69.6%) painful and 18 556 (30.4%) stressful procedures; 11 546 supplemental attempts were performed during procedures including 10 366 (89.8%) for painful and 1180 (10.2%) for stressful procedures. Each neonate experienced a median of 115 (range, 4-613) procedures during the study period and 16 (range, 0-62) procedures per day of hospitalization. Of these, each neonate experienced a median of 75 (range, 3-364) painful procedures during the study period and 10 (range, 0-51) painful procedures per day of hospitalization. Of the 42 413 painful procedures, 2.1% were performed with pharmacological-only therapy; 18.2% with nonpharmacological-only interventions, 20.8% with pharmacological, nonpharmacological, or both types of therapy; and 79.2% without specific analgesia, and 34.2% were performed while the neonate was receiving concurrent analgesic or anesthetic infusions for other reasons. Prematurity, category of procedure, parental presence, surgery, daytime, and day of procedure after the first day of admission were associated with greater use of specific preprocedural analgesia, whereas mechanical ventilation, noninvasive ventilation and administration of nonspecific concurrent analgesia were associated with lower use of specific preprocedural analgesia.

Conclusion  During neonatal intensive care in the Paris region, large numbers of painful and stressful procedures were performed, the majority of which were not accompanied by analgesia.