Clinical and laboratory observations Use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units H o w a r d B a u c h n e r , MD, A r i a n e M a y , MD, a n d Ellen C o a t e s From the Department of Pediatrics, Division of General Pediatrics, Boston City Hospital and Boston University School of Medicine, Boston, Massachusetts

The purpose of this study was to assess the use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units. The directors of 38 pediatric units and 31 neonatal units reported that analgesics were infrequently used for intravenous cannulation (10%), suprapubic bladder aspiration (8%), urethral catheterization (2%), or venipuncture (2%). Analgesics were used significantly more regularly in pediatric than in neonatal intensive care units for arterial line placement, bone marrow aspiration, central line placement, chest tube insertion, paracentesis, and lumbar puncture. (J PEDIATR1992; 121:647-9) The development of successful multidisctplinary models to treat pain in children, along with the development of new anesthetic agents, has led to the assumption that we are currently more effective than previously at treating pain in children and neonates. 1-5 However, it is unclear whether the advances in pain control have affected care given in intensive care units. 6, 7 The work of Anand et al. 8, 9 dispelled the myth that neonates do not feel pain. The neurophysiologic pathways that conduct Pain are intact at birth, and neonates have physiologic responses that are consistent with the sensation of pain. Recently, Anand and Hickey 1~ described the beneficial effects of deep anesthesia in 30 neonates undergoing cardiac surgery; those receiving deep anesthesia had a decreased incidence of sepsis, metabolic acidosis, and disseminated intravascular coagulation. In an accompanying editorial, Rogers 11 also addressed the question of "minor" surgical procedures as follows: "It seems that we are better Supported in part by grants from the Maternal and Child Health Bureau (MCH-250602) and the Bureau of Health Professions (D28 PE51008), U.S. Public Health Service, Health Resources Administration. Submitted for publication April 9, 1992; accepted May 27, 1992. Reprint requests: Howard Bauchner, MD, Boston City Hospital/ Talbott 103, 818 Harrison Ave., Boston, MA 02118. 9/26/39708

able to tolerate an infant's pain than to deal with our own discomfort and insecurity about the correct dose of pain medication to give the infant." The purposes of this study were (1) to assess the use of analgesics for invasive medical procedures in neonatal and pediatric intensive care units and (2) to contrast the use of analgesia for similar procedures in the two sites. METHODS

A self-administered questionnaire inquiring about the use of analgesia for 10 commonly performed pediatric proI

NICU PICU

Neonatal intensive care unit Pediatric intensive care unit

]

cedures was sent to the fellowship directors of all PICUs and to a random sample of fellowship directors of NICUs in the United States and Canada. The procedures listed in the survey ranged from venipuncture and intravenous cannulation to chest tube insertion and central line placement. Open-ended questions about the use of behavioral techniques to control pain (examples given in the questionnaire included hypnosis, pop-up books, and mental imagery) and the presence of parents during procedures were also included. Six weeks after the initial mailing, a second mailing was sent to the directors who had not responded.

647

648

Clinical and laboratory observations

The Journal of Pediatrics October 1992

Table I. Description of PICUs and NICUs

Respondents (No.) Beds* Fellows* Full-time faculty* Average yearly census*

PICU$

NICUs

38 17 (6-51) 3 (0-13) 4 (0-6) 1197 (350-8000)

31 34 (5-80) 5 (0-19) 8 (1-30) 725 (100-2000)

*Valuesare expressed as mean,with range in parentheses. The responses to the use of analgesia for each procedure included "almost never," "rarely," "sometimes," "often," and "almost always." For the purposes of analysis, "often" and "almost always" were combined and will be referred to as "regular use." To determine whether the size of the PICU or NICU influenced responses, we related differences in the use of analgesics to the mean number of fellows and mean number of full-time faculty members. All responses were entered into the R-Base data base (Redmond, Wash.) and analyzed by the METSTAT computer program (Metstat, Cleveland, Ohio). Differences in the use of analgesics between PICUs and NICUs were determined by chi-square tests. Fisher Exact tests were used when appropriate. A p value of

Use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units.

The purpose of this study was to assess the use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units. Th...
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