LINDSEY GRACE ADAMSHONORS COLLEGE FELLOWUNIVERSITY OF ARKANSAS

ELEANOR MANN SCHOOL OF NURSING

Evaluation of the Use of the Neonatal Procedures

Analgesic Ladder (NPAL) in Peripherally Inserted Central

Catheter Insertions

Neonate Pain

Pain, as defined by the International Association of Pain, is the “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Despite the understanding that neonates endure frequent painful procedures, pain is frequently not treated adequately or effectively in neonates .

Unresolved, prolonged pain in infants may delay procedural recovery and inhibit the healing of infections and diseases thus resulting in increased health care costs

Neonatal Infant Pain Scale (NIPS)

The use of a multi-dimensional assessment is necessary for neonates because they lack the ability to self report their pain level

Based on five behavioral items- facial expression, crying, arms, legs, state of arousal, and the physiologic indicator assessing breathing patterns

An intraclass correlation coefficient with a 95% confidence interval was 0.98 indicates that the NIPS has exceptional reliability correlating with other neonate pain scales

Pharmacologic vs. Nonpharmacologic Pain Management

Pharmacologic Pain Interventions- Opioid analgesics, topical anesthetics, sedatives, hypnotics, and nonopioid analgesics

Nonpharmacologic Pain Management Examples- Facilitated tucking or swaddling, non-nutritive sucking, sucrose, and skin-to-skin

Peripherally Inserted Central Catheters (PICC)

Long-term IV catheters used for medicine and electrolyte administration, collecting blood samples, or parenteral nutrition, and PICC lines minimize the pain of repeated venipuncture

Since the 1970s, PICC lines have been used in infants in the NICU who require long-term

intravenous hyperalimentation, medication, or electrolyte administration, or blood sampling.

Neonatal Procedures Analgesic Ladder (NPAL)

Pain intervention protocol for managing neonate pain during painful procedures, including PICC line insertions

K. Anand via personal communication has said that the NPAL tool may be used in the current study.

NPAL protocol steps during PICC line insertions Step 1- Using a pacifier with sucrose and swaddling or

facilitated tucking Step 2- Applying topical EMLA cream Step 3- Acetaminophen, orally or rectally Step 4- Slow IV opioid infusion of morphine or fentanyl Step 5- Subcutaneous infiltration or nerve blocks Step 6- General anesthesia or deep sedation if necessary

Purpose

The purpose of this study is to evaluate the use of the Neonatal Procedures Analgesic Ladder (NPAL) in an urban hospital Neonatal Intensive Care Unit (NICU) in Northwest Arkansas.

Aim 1

Aim 1: To determine if the implementation of NPAL nursing policy changes pain interventions prior to insertion of PICC lines. Research Question 1: What is the level of

compliance of staff with the NPAL nursing protocol following implementation?

Research Question 2: Are there differences in types and frequencies of neonate pain interventions post NPAL implementation for PICC insertions?

Aim 2

Aim 2: To determine if there is a difference in post procedural pain levels of neonates who receive PICC insertions. Research Question 1: Is the Neonatal

Infant Pain Scale (NIPS) score lower post procedure following implementation of the NPAL protocol?

Approval and Funding

Received an Honors College Undergraduate Research Grant

The University of Arkansas’ Institutional Review Board (IRB) approval and the hospital’s IRB approval were obtained prior to data collection

Slow progress in receiving approval contributed to the small sample size

Sample

Infants admitted to the NICU of an urban hospital in Northwest Arkansas between November 1, 2010 and February 28, 2011 requiring a PICC line

Must have parental consent form signed for chart review

The sample size was 22 with 18 including usable data due to the limited number of PICC lines inserted during the allotted time frame

Design

Retrospective chart review evaluating the effectiveness of the NPAL protocol implementation before, during, and after PICC insertions

Study variables will include NIPS rating before, during, and 10 minutes after PICC insertion and types of pain management interventions used.

Demographic information will be collected on all infants.

Following chart review, there will be no way to trace information back to the individual patient.

Study Variable Definitions

Gestational Age: Infant age as calculated from counting weeks since mother’s last menstrual period

Chronological Age: Age of infant since day of birth Oxygen Administration: O2 during PICC insertion EMLA Cream: Application of topical lidocaine and prilocaine

mixture 30 minutes prior to insertion SQ Lidocaine: Subcutaneous lidocaine injection 30 minutes

prior to PICC insertion Acetaminophen- Oral or rectal administration IV opioids- Usually Fentanyl intravenously Nerve Blocks and General Anesthesia: Rarely used during

PICC insertions Sucrose: Oral sucrose solution administered with pacifier

during PICC insertion

Study Variable Definitions (Continued)

Neutral Thermal Environment: Incubator or warmer used to maintain basal body temperature or specifically during PICC insertion for comfort

Removing wet diaper: Changing diaper prior to PICC insertion Cluster Care: Limiting touch time and clustering activities, not

included because non clearly defined in the protocol and poorly documented

Distraction: Tactile stimulation, music, or vocalization during PICC insertion

Pacifier: Given during insertion for non-nutritive sucking or in association with the sucrose

Swaddling / Facilitated Tucking / Containment: Similar terms referring to wrapping the infant in a secure position

Repositioning: Changing the infant’s position for comfort or to facilitate the PICC line insertion

Elements of Chart Review

Demographics of Sample

Gender

Male 11

Female 7

Ethnicity

Caucasian 16

Hispanic 2

African American

0

Gestational Age at Birth

38-40 weeks 2

30-38 weeks 11

Less than 30 weeks

5

Pre-, During, and Post-NIPS Scores

Types and Frequency of Pain Management Interventions Used

Pain Management Interventions Used in Relation to other Pain Management

Interventions

Number of Non-pharmacological Interventions Implemented

Average Standard Deviation

Range

5.33 1.75 3-8

•10 possible non-pharmacologic interventions•Computerized charting may facilitate easier documentation of interventions performed

Level of Staff Compliance with NPAL Use During PICC Insertions

Pain Assessed and Documented

NPAL used

NPAL Step 1

NPAL Step 2

NPAL Step 3

NPAL Step 4

NPAL Step 5

NPAL Step 6

100% 100% 100% 0% 0% 0% 0% 0%

•100% compliance with pain assessment and documentation•Areas of improvement are the types and number of interventions used

Computerized Charting

Documentation easier to record and reviewStandardize cluster care and work towards

decreasing touch time pre- and post-procedure with every entry time-dated

Standardize nursing documentation with 10 non-pharmacologic and 6 pharmacologic interventions to select from

Computerized commands could remind nurse to follow step-wise pain management approach of the NPAL tool

Sucrose Administration

Found to be one of the most effective, safe, and convenient ways to decrease pain during procedures

Stimulates endorphin release in CNSFound to reduce procedural pain better than

EMLA in neonates (Gradin et al., 2002)Immediate effect > Used in emergent

situationsSucrose used in 55.6% of the sample >

increase to closer to 100%

EMLA Administration

Used in 0% of the sample despite literature supporting its benefits and the NPAL tool suggesting it should be used as Step 2 in pain management

Use is still inconclusive and controversial with some studies showing the placebo to be just as effective as topical EMLA cream and other studies showing it to decrease pain

Despite concerns about methemoglobinemia, EMLA was proven safe in all studies when used prudently

EMLA Administration

Pros Several neonate studies

support EMLA use to decrease venipuncture pain when applied 30 minutes prior to insertion

Provides pain relief non-pharmacologic interventions alone cannot provide

Possible additive pain relief effect when used with sucrose

Cons Only local anesthetic,

does not stimulate CNS like sucrose

30min wait time for effectiveness > cannot use in emergent situations

Placebo may be as effective

Concern of methemoglobinemia with multiple administrations

Pharmacologic Interventions

Not used on any infants in sample despite NPAL tool including pharmacologic interventions in Steps 2-6

Step 2- EMLA cream, SQ lidocaineStep 3- Oral or rectal acetaminophen

administrationStep 4- IV Fentanyl used with particularly

irritable infants for PICC insertionsStep 5-6- Nerve blocks and general anesthesia

rarely necessary for PICC insertionsNo specifications in protocol for when to

implement pharmacologic interventions

Nursing Implications

Pain is currently assessed and documented adequately in the NICU

Further non-pharmacologic and pharmacologic interventions can be made > Increase number of non-pharmacologic interventions provided and progress beyond Step 1

Computerized charting would standardize documentation and commands could remind nurses to follow the stair-step NPAL tool approach

Computerized charting would facilitate cluster care

Nursing Implications (Continued)

Current pain management protocol should be revised to include specifications on when each step should be implemented

Revisions should be decided by health care team based on the current research

Ex- EMLA cream should be used if infant has had a certain number of painful procedures

Ex- Pharmacologic interventions should be used if neonate’s pre-procedure pain level is above 0

Limitations

Small sample size > larger sample size may have resulted in cases proceeding past NPAL Step 1 to pharmacologic interventions

English-only consent form > Spanish and Marshallese translation would have broadened the diversity of neonates in study

Descriptive study post-NPAL implementation > comparative study pre and post-NPAL implementation would have been insightful if consent forms could have been obtained from discharged infants

Further Research

Studies assessing NPAL use during other painful procedures such as circumcision, heel lance, suctioning, venipuncture, and intubation

Larger study investigating NPAL use during PICC insertions may yield statistically significant relationships between NIPS scores and the number or type of pain interventions used

Because of inconclusive EMLA research, a study evaluating EMLA use with sucrose and compared with sucrose would be beneficial

Review Question 1

What are 3 examples of non-pharmacologic pain management techniques used in neonates?

Possible Answers: Swaddling, skin-to-skin contact, pacifier, sucrose, repositioning, distraction, containment, neutral thermal environment, facilitated tucking, oxgen

Review Question 2

What are 3 examples of pharmacologic pain management interventions used in neonates

Possible Answers: EMLA cream, acetaminophen, SQ lidocaine, nerve blocks, IV opioids, Fentanyl, nerve blocks, general anesthesia

Review Question 3

What are the steps of the NPAL?Step 1- Using a pacifier with sucrose and

swaddling or facilitated tuckingStep 2- Applying topical EMLA creamStep 3- Acetaminophen, orally or rectallyStep 4- Slow IV opioid infusion of morphine

or fentanylStep 5- Subcutaneous infiltration or nerve

blocksStep 6- General anesthesia or deep sedation

if necessary

Any Questions or Comments?

Regarding neonate pain Non-pharmacologic pain management

Pharmacologic pain managementDiffering interpretations of the dataFurther research suggestionsOther observed limitationsAnything else?

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