LINDSEY GRACE ADAMS
HONORS COLLEGE FELLOW
UNIVERSITY 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
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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
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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
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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
Pre-procedure, During, and Post-procedure NIPS Scores
1.6
1.4
1.2
1
0.8
Series1
Series2
0.6
0.4
0.2
0
Pre NIPS Score
Highest Pain Score
Post NIPS Score
Types and Frequency of Pain Management
Interventions Used
Types and Frequency of Pain Management Interventions Used
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Pain Management Interventions Used in Relation
to other Pain Management Interventions
Pain Management Interventions Used in Relation to Other Pain Management
Interventions
Oxygen Administration
Repositioning
3%
EMLA Cream
SQ Lidocaine
Oxygen
Administration
15%
Containment
14%
Nerve Blocks
Acetaminophen
IV Opioids
Sucrose
11%
Facilitated Tucking
11%
General Anesthesia
Sucrose
Neutral Thermal Environment
Neutral Thermal
Environment
18%
Swaddling
17%
Remove Wet Diaper
Distraction
Pacifier
Swaddling
Pacifier
12%
Facilitated Tucking
Remove Wet Diaper
1%
Containment
Repositioning
Number of Non-pharmacological Interventions
Implemented
Average
5.33
Standard
Deviation
1.75
Range
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
NPAL
Assess used
ed and
Docum
ented
NPAL
Step 1
NPAL
Step 2
NPAL
Step 3
NPAL
Step 4
NPAL
Step 5
NPAL
Step 6
100%
100%
0%
0%
0%
0%
0%
100%
•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 review
 Standardize cluster care and work towards
decreasing touch time pre- and post-procedure with
every entry time-dated
 Standardize nursing documentation with 10 nonpharmacologic 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
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convenient ways to decrease pain during procedures
Stimulates endorphin release in CNS
Found to reduce procedural pain better than EMLA
in neonates (Gradin et al., 2002)
Immediate effect > Used in emergent situations
Sucrose 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
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Several neonate studies
support EMLA use to
decrease venipuncture
pain when applied 30
minutes prior to insertion
Provides pain relief nonpharmacologic
interventions alone cannot
provide
Possible additive pain
relief effect when used
with sucrose
 Cons
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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
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including pharmacologic interventions in Steps 2-6
Step 2- EMLA cream, SQ lidocaine
Step 3- Oral or rectal acetaminophen administration
Step 4- IV Fentanyl used with particularly irritable
infants for PICC insertions
Step 5-6- Nerve blocks and general anesthesia rarely
necessary for PICC insertions
No 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
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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
Any Questions or Comments?
 Regarding neonate pain
 Non-pharmacologic pain management
 Pharmacologic pain management
 Differing interpretations of the data
 Further research suggestions
 Other observed limitations
 Anything else?
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