Type of procedure | Suggested multimodal pain management regimen | Additional comments |
Simple procedures associated with mild pain - Heel lance or finger stick
- Venipuncture or peripheral IV catheter insertion
- IM or SubQ injection
- NG tube insertion
- Bladder catheterization
- Dressing change/tape removal
| Both of the following: - Nonpharmacologic measures (eg, skin-to-skin contact, non-nutritive sucking)*
- Oral sucrose
| - A topical anesthetic (eg, EMLA) can also be used for some procedures in this category (eg, IV catheter insertion, IM or SubQ injection)¶ but not others (eg, NG tube insertion, bladder catheterization, dressing change).
- EMLA is not routinely used for heel lance since it appears to be ineffective in this setting.
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Simple procedures associated with moderate pain - LP
- Peripheral arterial puncture or catheterization
- Umbilical venous or arterial catheterization
- Intraosseous cannulation
| All of the following: - Nonpharmacologic measures (eg, skin-to-skin contact, non-nutritive sucking)*
- Oral sucrose
- Topical anesthetic (eg, EMLA), if appropriate¶
| - In our experience, the combination of these 3 measures usually permits successful completion of the procedure.
- Rarely, neonates who do not achieve adequate analgesia from these measures may require a low-dose short-acting opioid (eg, fentanyl, sufentanil).
- Opioids should be used with caution in nonintubated patients.
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More complex proceduresΔ - Percutaneous CVC placement
- PICC placement
- Chest tube placement
| All of the following: - Nonpharmacologic measures (eg, non-nutritive sucking, facilitated tucking)*
- Topical and/or local anesthesia (eg, EMLA and/or lidocaine)¶
- Acetaminophen
- Short-acting sedative/analgesic (eg, ketamine, fentanyl, sufentanil), if needed
| - We prefer short-acting over longer-acting opioids in this setting because these procedures are usually brief.
- Opioids should be used with caution in nonintubated patients.
- Using a local anesthetic and acetaminophen reduces the amount of opioid required.
|
Specific procedures |
Circumcision◊ | All of the following: - Nonpharmacologic measures (eg, non-nutritive sucking, facilitated tucking)*
- Oral sucrose
- Local anesthesia (eg, ring block or dorsal penile nerve block)
- Acetaminophen for postprocedure pain control
| - Local or topical analgesia is routinely provided for neonatal circumcision since it reduces procedural pain with minimal risk.
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ROP examination | All of the following: - Nonpharmacologic measures (eg, non-nutritive sucking, facilitated tucking)*
- Oral sucrose
- A topical anesthetic (eg, proparacaine), depending on the preference of the ophthalmologist
| - The interventions listed are generally sufficient for routine screening or follow-up examination.
- Additional analgesia/sedation is required when ROP treatment is administered during the procedure (eg, laser therapy or anti-VEGF injection). We use a short-acting agent (eg, ketamine, fentanyl, sufentanil) for this purpose.
- Opioids should be used with caution in nonintubated patients.
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Elective endotracheal intubation | Options include: - Ketamine (preferred agent at the author's institution)
- or
- Short-acting opioid (eg, fentanyl, sufentanil, remifentanil)
| - The combination of an opioid plus a benzodiazepine (eg, midazolam) is another alternative; however, this does not appear to improve intubation success rates compared with an opioid alone.
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