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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