Chapter 41. Pain Management

• Sensory nerve terminals exist on all body surfaces by 22–29 wk of gestation.

• Pain assessment should be performed using validated tools in all patients upon admission and then at regularly defined intervals.
• Physiologic responses to pain include increased circulating levels of catecholamines, increased HR, and increased BP.

• Repeated or long-term painful stimuli result in long-term changes such as a lowered pain threshold.

• Response to painful stimuli contribute to physiologic disturbances such as hypoxia, hypercarbia, acidosis, and hyperglycemia; this may lead to alterations in oxygen delivery and cerebral blood flow.

• Infants have long-term disturbances in pain perception that persist well into childhood.

• An absence of behavioral or physiologic cues that might indicate pain does not indicate an absence of pain.

Behavioral Measures

• Swaddling: Keeping the extremities flexed and close to the trunk

• Pacifiers: Used for non-nutritive sucking

• “Kangaroo care”

• Developmentally appropriate care

• Minimize noise and light stimuli

Sucrose

• Sensory nerve terminals exist on all body surfaces by 22–29 wk of gestation.

• Pain assessment should be performed using validated tools in all patients upon admission and then at regularly defined intervals.
• Physiologic responses to pain include increased circulating levels of catecholamines, increased HR, and increased BP.

• Repeated or long-term painful stimuli result in long-term changes such as a lowered pain threshold.

• Response to painful stimuli contribute to physiologic disturbances such as hypoxia, hypercarbia, acidosis, and hyperglycemia; this may lead to alterations in oxygen delivery and cerebral blood flow.

• Infants have long-term disturbances in pain perception that persist well into childhood.

• An absence of behavioral or physiologic cues that might indicate pain does not indicate an absence of pain.

NOTE: See chapter 2 for additional information on side effects, dosing, and precautions.

Nonopioid Analgesic

• Acetaminophen
  • 1.5–1.9 kg: 20 mg PO Q12h
  • 2.0–2.9 kg: 30 mg PO Q8h
  • 3.0–3.9 kg: 40 mg PO Q8h
  • 4.0–5.2 kg: 60 mg PO Q6h
  • 5.3–7.9 kg: 80 mg PO Q4h (do not exceed 5 doses per day)

Opioid Analgesics

• Morphine
  • Intermittent IV dosing: 0.05–0.1 mg/kg/dose Q3–4h
  • Intermittent PO dosing: 0.2–0.5 mg/kg/dose Q4–6h
  • IV continuous infusion: Initial: 0.01–0.02 mg/kg/h
  • All dosing should be titrated to effect
• Fentanyl
  • Intermittent IV dosing: 1–2 mcg/kg/dose Q2h
  • IV continuous infusion: 1–5 mcg/kg/h
  • All dosing should be titrated to effect

See chapter 2.

• For minimally invasive procedures, combinations of a pacifier, swaddling, or sucrose can be used.
  • Arterial or venous puncture, or heelstick
  • Peripheral IV placement
  • Umbilical arterial or venous catheter placement
  • Endotracheal suctioning

• The above measures plus topical anesthetic (see chapter 2 for listing and precautions of ...