J. Pediatr. (Rio J.) vol.92 número1

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www.jped.com.br

ORIGINAL

ARTICLE

Painful

procedures

and

analgesia

in

the

NICU:

what

has

changed

in

the

medical

perception

and

practice

in

a

ten-year

period?

夽

,

夽夽

Ana

Claudia

Yoshikumi

Prestes

a

_,

_Rita

_de

_Cássia

_Xavier

_Balda

a

_,

Gianni

Mara

Silva

dos

Santos

b

_,

_Ligia

_Maria

_Suppo

_de

_Souza

_Rugolo

c

_,

Maria

Regina

Bentlin

c

_,

_Mauricio

_Magalhães

d,e

,

Paulo

Roberto

Pachi

d

,

Sergio

Tadeu

Martins

Marba

f

_,

_Jamil

_Pedro

_de

_Siqueira

_Caldas

g

_,

_Ruth

_Guinsburg

a,∗

a_Division_of_Neonatal_Medicine,_Escola_Paulista_de_Medicina_(EPM),_Universidade_Federal_de_São_Paulo_(UNIFESP),_São_Paulo,

SP,Brazil

b_Universidade_Federal_de_São_Paulo_(UNIFESP),_São_Paulo,_SP,_Brazil

c_Department_of_Pediatrics,_Faculdade_de_Medicina_de_Botucatu_(FMB),_Universidade_Estadual_Paulista_Júlio_de_Mesquita_Filho

(UNESP),Botucatu,SP,Brazil

d_Department_of_Pediatrics,_Faculdade_de_Ciências_Médicas_da_Santa_Casa_de_São_Paulo_(FCMSCSP),_São_Paulo,_SP,_Brazil e_Service_of_Neonatology,_Faculdade_de_Ciências_Médicas_da_Santa_Casa_de_São_Paulo_(FCMSCSP),_São_Paulo,_SP,_Brazil f_Department_of_Pediatrics,_Universidade_Estadual_de_Campinas_(UNICAMP),_Campinas,_SP,_Brazil

g_Division_of_Neonatology,_Hospital_da_Mulher_Prof._Dr._José_Aristodemo_Pinotti,_Centro_de_Atenc¸ão_Integral_à_Saúde_da_Mulher

(CAISM),UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil

Received12March2015;accepted27April2015 Availableonline9October2015

KEYWORDS

Painmeasurement; Painperception; Painmanagement;

Abstract

Objective: Tocomparetheuseofanalgesiaversusneonatologists’perceptionregarding

anal-gesicuseinpainfulproceduresintheyears2001,2006,and2011.

Methods: This was a prospective cohort study of all newborns admitted to four university

neonatalintensive careunits duringonemonth in2001, 2006,and 2011.The frequencyof

夽 _Please_cite_this_article_as:_Prestes_AC,_Balda_RC,_dos_Santos_GM,_Rugolo_LM,_Bentlin_MR,_Magalhães_M,_et_al._Painful_procedures_and

analgesiaintheNICU:whathaschangedinthemedicalperceptionandpracticeinaten-yearperiod?JPediatr(RioJ).2016;92:88---95. 夽夽_Study_conducted_at_Faculdade_de_Ciências_Médicas_da_Santa_Casa_de_São_Paulo_(FCMSCSP),_São_Paulo,_SP,_Brazil;_Universidade_Estadual

deCampinas(UNICAMP),Campinas,SP,Brazil;FaculdadedeMedicinadeBotucatu(FMB),UniversidadeEstadualPaulistaJúliodeMesquita Filho(UNESP),Botucatu,SP,Brazil;andEscolaPaulistadeMedicina(EPM),UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP, Brazil.

∗_{Corresponding}_author.

E-mail:[email protected](R.Guinsburg).

http://dx.doi.org/10.1016/j.jped.2015.04.009

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Neonatalintensive careunits; Newborn

analgesic prescription forpainfulprocedureswas evaluated.Ofthe202 neonatologists,188 answeredaquestionnairegivingtheiropinionontheintensityofpainduringlumbarpuncture, tracheal intubation, mechanicalventilation, and postoperative period using a10-cm visual analogicscale(VAS;pain>3cm).

Results: Forlumbarpuncture,12%(2001),43%(2006),and36%(2011)wereperformedusing

analgesia.Amongtheneonatologists,40---50%reportedVAS>3forlumbarpunctureinallstudy periods.Forintubation,30%receivedanalgesiainthestudyperiods,and35%(2001),55%(2006), and73%(2011)oftheneonatologistsreportedVAS>3 andwouldprescribeanalgesiafor this procedure.Asformechanicalventilation,45%(2001),64%(2006),and48%(2011)of patient-dayswereunderanalgesia;56%(2001),57%(2006),and26%(2011)ofneonatologistsreported VAS>3 andsaidtheywoulduse analgesiaduringmechanicalventilation.For thefirst three post-operativedays,37%(2001),78%(2006),and89%(2011)ofthepatientsreceivedanalgesia andmorethan90%ofneonatologistsreportedVAS>3formajorsurgeries.

Conclusions: Despiteanincreaseinthemedicalperceptionofneonatalpainandinanalgesic

useduringpainfulprocedures,thegapbetweenclinicalpracticeandneonatologistperception ofanalgesianeeddidnotchangeduringtheten-yearperiod.

PALAVRAS-CHAVE

Medic¸ãodador; Percepc¸ãodador; Manejodador; Unidadesdeterapia intensivaneonatal; Recém-nascido

ProcedimentosdolorososeanalgesiaemUTINeonatal:oquemudounaopinião enapráticaprofissionalemdezanos?

Resumo

Objetivo: Confrontar o uso de analgesia versus a percepc¸ão de neonatologistas quanto ao

empregodeanalgésicosparaprocedimentosdolorososnosanosde2001,2006e2011.

Métodos: Coorteprospectivadetodosrecém-nascidosinternadosemquatrounidades

univer-sitárias.Avaliou-seafrequênciadoempregodeanalgésicosparaprocedimentosdolorosospor um mêsdos anosde estudo.Dos202neonatologistasatuantes nasunidades nostrês perío-dos, 188assinalaramem escala analógicavisual de 10cm(dor >3cm) aintensidadeda dor sentida pelo recém-nascido na punção lombar, intubação traqueal, ventilação mecânica e pós-operatório.

Resultados: ParaPL,12%,43%e36%foramrealizadascomanalgesiaem2001,2006e2011e

40-50%dosneonatologistasreferiamindicaranalgésicosnapunçãolombarnostrêsperíodos. Naintubação,30%foramrealizadassobanalgesianostrêsperíodose35%(2001),55%(2006)e 73%(2011)dosmédicosdiziamindicaranalgésicos.Quantoàventilaçãomecânica,45-64%dos ventilados-diaestavamsobanalgesianostrêsperíodose56%(2001),57%(2006)e26%(2011) dosneonatologistasdiziamusaranalgésicos.Dospacientes-dianostrêsprimeirosdiasde pós-operatório,37%(2001),78%(2006)e89%(2011)receberamalgumadosedeanalgésico,sendo quemaisde90%dosmédicosreferiamusaranalgesiaparaessasituação.

Conclusões: Entre2001e2011,ocorreuaumentonousodeanalgésicos paraprocedimentos

dolorososnasunidadesneonataiseumapercepçãomaisacentuadaporpartedosmédicosde queorecém-nascidosentedor,masolapsoentreapráticaclínicaeapercepçãomédicaquanto àpresençadedorpersistiu.

Introduction

Painfuleventsarecommoninnewbornswhorequire inten-sivecare.Simonsetal.1_observed₁₅₁_newborns_in_the_first

14 daysof admission tothe intensive care unit (ICU) and eachwassubmittedtoanaverageof14painfulprocedures aday.Prestesetal.2_verified_that_three_to_five_potentially

painfulprocedureswereperformedperpatient/dayin uni-versityneonatalunitsinSãoPaulo.Carbajaletal.3_assessed

430 newborns in the Paris region in the first 14 days of life and observed, on average, ten painful procedures a

day. Cignacco et al.4 _studied ₁₂₀ _infants _on _mechanical

ventilationduringthefirst14daysoflifeintwoSwissunits andfound23painfulprocedures/dayperpatient.

Despitethisscenario,theuseofmeasurestorelievethe painduringpotentially painful proceduresis unusual,and it is estimated that only 3% of newborns receive specific analgesiafortheprocedureandthat,in30%,adjuvant tech-niquesareappliedtominimizepain.1---3 _In_Italy,_five_years

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units for tracheal intubation,47% for mechanical ventila-tion,33% for lumbarpuncture, and 64%for postoperative pain.5

Therefore,aparadoxisobservedbetweenthefrequency ofconditionsthatcause painincritically illneonatesand theuseofanalgesiainneonatalunits.Themostoftencited causesfor thisparadox aretheseveralmyths surrounding thepainfulexperienceintheneonatalpopulation, particu-larlytheperceptionthatthenewbornistooimmaturetofeel pain.6---8_It_is_known_that_the_knowledge_about_the_presence

ofpaininnewbornshasgreatlyincreasedamonghealth pro-fessionalsresponsibleforneonatalcare,9_but_it_is_not_known

howeachprofessionalputssuchknowledgeintopractice. The aim of this study was to compare the perception ofphysiciansworkinginuniversityneonatalintensivecare units(NICUs)regardingthepainfulproceduresandthe anal-gesia versus the use of analgesics for potentially painful procedures performed in critically ill newborns in these units,inthreedifferenttimesoveraten-yearperiod.

Methods

This was a multicenter observational study consisting of threeprospectivecohortsofallnewbornsadmittedtofour university NICUs and the neonatologists working in these unitswithintheperiodofOctober1stto31stoftheyears 2001,2006,and2011.Thechoiceofmonthandtheyear2001 wasfor convenience, and the repetition every five years wasconsideredbecausecloseto100%ofmedicalknowledge isrenewed every tenyears,with an obsolescence rateof medicaljournalsofabout50%everyfiveyears.

The following neonatalunits wereassessed: Faculdade deCiênciasMédicasdaSantaCasadeSãoPaulo, Universi-dadeEstadualdeCampinas,UniversidadeEstadualPaulista Júliode Mesquita Filho, and Universidade Federal de São Paulo---Escola Paulista de Medicina. The research protocol wasapproved by the Research Ethics Committee of each institution.Theneedforinformedconsentfromnewborns’ familymembers waswaived. Each participating physician signedaninformedconsentform.

Allneonates admittedtothefourunits wereincluded, according tothe criteriaof the intensive care of each of them.Inordertoanswerthepainperceptionquestionnaire, theinclusioncriterionwastobeaphysicianatoneofthe participatingunits,withpowertomakeclinical decisions. Residentsfromthe pediatricsandneonatology units were notincluded.

The head of the neonatal intensive care unit of each institutionfilledoutaquestionnairewithinformationabout thegeneralcharacteristicsoftheunit,presenceofroutine assessment,treatment,andeducationonpainandanalgesia intheneonatalperiod.

Datacollectionofthehospitalizednewbornswascarried outbya neonatologist ofeach institution. Information on thetotalnumberofpatientsandpatient-daysineachunit wereobtained.Theperformedpainfulprocedureswere reg-isteredinamedicalfileatthebedside,filledbydoctorsand nurseswhocared for thepatients. Forthe present study, the following procedures were considered: lumbar punc-ture,tracheal intubation,time ofmechanical ventilation,

and postoperative period.The same team of researchers collecteddatainthethreestudyperiods.

To evaluate the use of analgesics in newborns in the threeperiodsofthestudy,thefollowingdatawereanalyzed: patient-daysonanalgesia(sumofallpatientswhoreceived at leastone doseof analgesic for eachday ofthe study); numberoflumbarpunctureandtrachealintubation proce-duresunderanalgesiaforeachdayoftheevaluatedmonth andyear;postoperativeperiodunderanalgesia(itwas veri-fied,ateachdayofthestudy,whichpatientswerereceiving any dose of analgesia on the three first days after some surgical procedure),and ventilation-days(sumof patients undergoingmechanicalventilationineverydayofthestudy, whetherunderanalgesiaornot).

Allphysicianswhoworkedattheuniversityneonatalunits answeredan anonymousquestionnaire,which consistedof personalcharacteristics, knowledge regardingpain assess-ment, and personal opinion about the aspects related to pain in invasive procedures.In this regard, the physician wasaskedregardingwhethernewbornsfeelpainduring lum-bar puncture, intubation, mechanical ventilation, and in the postoperativeperiodof minor(inguinal hernia repair) andmajor(laparotomy)surgeries. Ifthe answerwas posi-tive,theprofessionalwasaskedtostatehowmuchpainhe thoughtthenewbornfeltineach procedureusinga10-cm horizontalvisual analogicscale(VAS).Suchascale ranged fromnopain(zero)toseverepain(10cm);painwas consid-eredtobepresentwhenthemarkeddistancewasgreater than3.0cm.10_Each_physician_was_also_asked_whether_he/she

thoughtitwasadequatetoprescribeanalgesiafortheabove procedures;theonlypossibleanswerswereyesorno.

Data were compared in the three study periods by descriptiveanalysis,usingPearson’spartitioningchi-squared testforcategoricalvariables,orFisher’sexacttest.Forthe quantitativevariables,comparisonwasmadebyanalysisof variancewithTukey’sposthoctest.Asallpatientsadmitted tothefourunitsandallphysiciansfromeachoftheunitsin threeperiodsofthestudywereanalyzed,thesamplepost hocpowerwasverifiedonlyforthenumberofpainful pro-ceduresperformedunderanalgesia.TheSPSSsoftwarefor Windows,version19(StatisticalPackageforSocialSciences, Chicago,IL,USA)wasusedforthestatisticalanalysis.

Results

The characteristics of the four units in the three study periods areshown inTable 1.Allof them werereference units for high-risk pregnancies and included residents in Pediatrics and Neonatology. Regarding teaching on pain and analgesia in the neonatal period, only one institu-tionreportedhavingaformaltheoreticalprogramin2001, althoughtheheadsoftheNICUsreportedhavingdiscussed painandanalgesiaatbedsideinallunits.In2006and2011, allunitsreportedtheoreticallecturesandpractical discuss-ionsonthetopic.

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Table1 Characteristicsoftheunitsregardingthetotalnumberofbeds,physicalarea,monthlymeannumberofbirthsand admissions,personnelinvolvedeverydayinneonatalcareintheneonatalICUs(numberofundergraduatestudents,residentsin pediatricsandneonatology,graduatestudents,anddoctors),educationregardingpainandanalgesiaintheneonatalperiod.

InstitutionA InstitutionB InstitutionC InstitutionD

2001 2006 2011 2001 2006 2011 2001 2006 2011 2001 2006 2011

Birth/month 300 300 300 100 95 95 120 120 170 270 200 200

Totalofavailablebeds 60 59 59 37 29 29 44 66 56 59 50 50

NeonatalICUbed 12 15 15 11 8 8 15 17 17 6 18 18

NeonatalICUarea(m2₎ ₂₄₀ ₅₀₀ ₅₀₀ ₉₆ ₉₆ ₉₆ ₆₀₀ ₇₀₀ ₆₅₀ ₁₂₀ ₁₈₀ ₁₈₀

ICUadmissions/month 50---60 50---60 50---60 20---30 20---30 20 30 30 30 20 20 20

PhysiciansinICU/shift 3 2 2 1 1 1 4 6 4 1 2 2

Postgraduatestudentin

ICU/shift

0 0 0 2 2 2 0 0 0 0 0 0

RinneonatologyinICU/shift 2 1 1 4 4 4 2---4 4 3 1 4 4

RinpediatricsinICU/shift 2 1 1 1 1 1 1 1---2 1 2 2 2

Undergraduatestudentin

ICU/shift

1 1 1 0 0 0 1 1 0 1 1 1

Educationrelatedtopain

-Theoreticallectures No Yes Yes Yes Yes Yes No Yes Yes No Yes Yes

-Duration(hours) - 1 1 6 6 6 - 1 2 - 2 2

-Annualfrequency - 4 4 2 2 2 - 1 1 - 1 1

-Discussionsatthebedside Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

ICU,intensivecareunit;R,residents.

in 2006,andin 2011, 125newborns totaled1366 patient-days. As for the four assessed painful situations (lumbar puncture,trachealintubation,mechanicalventilation,and thefirstthreepostoperativedays),therewasanincreaseof analgesic usein 2006when comparedwith2001.In2011,

compared with 2006, there was a reduction of analgesia prescribedtopatientsreceivingmechanicalventilationand lumbarpuncture andtherewerenomodifications for tra-cheal intubation. As for the postoperative period (three days),therewasasignificantandprogressiveincreaseinthe

Table2 Clinicalcharacteristicsofnewbornsassessedinthefourneonatalintensivecareunitsforamonth,withafive-year

interval.

2001(n=91) 2006(n=114) 2011(n=125) p

Birthweight(g) 0.347a

Mean±SD 1889±879 2058±977 1915±909

Median 1880 1920 1740

Range 590---4090 590---4255 574---3975

Weightatstudyentry(g) 0.426a

Mean±SD 1985±1016 2145±966 2010±945

Median(range) 1925 1987 1800

Range 590---6700 495---4445 575---4060

Daysoflifeattheenrollment 0.862b

Mean±SD 15±30 12±23 14±31

Median 1 1 1

Range 0---218 1---152 1---224

Malegender 50(56%) 67(59%) 65(52%) 0.568c

Morbidities

Respiratorydisease,n(%) 47(52%) 46(40%) 68(54%) 0.077c

Infection,n(%) 33(36%) 31(27%) 30(24%) 0.133c

Cardiovasculardisease,n(%) 13(15%) 07(06%) 22(18%) 0.025c

Malformation,n(%) 20(22%) 24(21%) 25(20%) 0.939c

Death,n(%) 16(18%) 08(07%) 09(07%) 0.018c

a _ANOVA_with_fixed_factor. b _{Kruskal---Wallis.}

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Table3 Numberofpatient-days,patient-daysundergoingpainfulprocedures,andpatient-daysthatwereunderanalgesiain thefourneonatalintensivecareunitsintheassessedyears.

2001(n=91) 2006(n=114) 2011(n=125) p-Value Samplepower

Patient-days

Number 1025 1112 1366

Patient-daysunderanalgesia 255(25%) 312(28%) 294(22%) 0.002a _0.887

Lumbarpuncture(LP)

Lumbarpunctures 34 51 45

LPunderanalgesia 4(12%) 22(43%) 16(36%) 0.009a _0.795

Trachealintubation(TI)

Trachealintubations 109 62 74

TIunderanalgesia 28(26%) 20(32%) 24(32%) 0.523a _0.159

Mechanicalventilation(MV)

PatientsinMV 440 362 376

Ventilated-days/patient-days 43% 33% 27%

MVunderanalgesia 200(45%) 233(64%) 180(48%) <0.001a _0.999

Threedayspostoperatively(PO)

NBsubmittedtosurgery 18 14 36

Patient-daysuptothirdPO 16 45 55

POunderanalgesia 6(37%) 35(78%) 49(89%) <0.001a _0.980

a_Pearson’s_Chi-squared_test,_Fisher’s_exact_test_or_its_extension.

useofanalgesiaovertheyears(Table3).Foralltheanalyzed situations,thesamplepowerwasgreaterthan80%,except fortrachealintubationunderanalgesia.

Regardingthe medicalopinion, 68(96%)neonatologists answeredthequestionnairein2001,58(91%)in2006,and62 (91%)in2011.Therewasnosignificantdifferenceregarding the demographicdata of the professionals in these three periods(Table4).Overtime,therewasanincreaseinthe numberofprofessionalswhostatedtheyknewtheunitpain routineandusedtheNeonatalFacialCodingSystem(NFCS) and/orNeonatalInfantPainScale(NIPS)painscales.

Asfor theintensity ofpainattributedtopainful proce-dures,therewasnodifferencebetween thethreeperiods forlumbarpunctureandintubation.Therewasareduction intheintensityofpainattributedtomechanicalventilation between2001/2006and2011andtheoppositeoccurredfor majorsurgery(Table4).

Regardingthe practiceofanalgesiain thethree evalu-ated periods,only 12% of lumbar puncturesin 2001 were performed under adequate analgesia for the procedure. After five years (2006), there wasan increase in analge-sia indicationin the units, witha slight decreasein 2011 (Table 3). In the three studied periods, 40---50% of physi-ciansthoughtthatthepaincausedbylumbarpuncturewas atleastmoderate(VAS>3)andstatedthatintheory, they indicatedtheanalgesiafortheprocedure(Table4).

Regarding tracheal intubation, nearly 30% of the pro-cedureswere performed underanalgesia in threeperiods ofthestudy (Table3).Ofthe respondents,35%,55%,and 73% in 2001, 2006, and 2011, respectively, reported VAS >3andstatedtheyusedanalgesicsfortrachealintubation (p<0.001;Table4).

For patients on mechanical ventilation, 45% of

ventilated-dayswereunderanalgesiain2001,64%in2006, and 48% in 2011 (p<0.001; Table 3). For this situation,

there was a significant decrease in neonatologists that reported VAS >3 and stated they used analgesia between 2001---2006and2011(p=0.002;Table4).

Finally,inthefirstthreepostoperativedays,37%, 78%, and89%ofpatientsreceivedanalgesicsrespectivelyin2001, 2006, and 2011 (p=0.013; Table 3). Regarding the physi-cians, for a smallsurgery, 73% in 2001, 67% in 2006, and 73% in 2011, considered the postoperativepain moderate to severe and said they prescribed analgesics (p<0.001;

Table 4). For major surgeries, 91% in 2001, and 100% in 2006 and 2011 considered the postoperative pain moder-atetosevereandsaidtheyprescribedanalgesics(p<0.001;

Table4).

Discussion

The present study demonstrated, for almost all analyzed painful situations,adistance between theneonatologists’ theoreticalattitudeandtherealpracticeinneonatalunits, although there has been an increase in the awareness aboutthepresenceofpainincriticallyillnewbornsmainly between2001and2006,accompaniedbymorefrequentuse of analgesics in clinical practice for some of the painful procedures.Thestudyfindingsconfirmtheliterature3,4_and

indicatethatcriticallyillnewbornsaresubmittedtoseveral potentiallypainfulprocedures,andthattheirmanagement remainsinadequate.Themostfrequentperceptionofpain byprofessionalsandthegreateruseofanalgesiaforpainful procedures in clinical practice between 2001 and 2006 appeartoreflecttheknowledgeimprovementinthisarea.11

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Table4 Characteristicsofprofessionalsworkinginfourunitsassessedtogether,theirknowledgeofthepainroutineintheir unitsandtheiropinionsaboutthepotentiallypainfulprocedures(lumbarpuncture,intubation,mechanicalventilation, and minorandmajorpostoperative).

2001 2006 2011 p

ProfessionalsthatansweredtheQ 68(96%) 58(91%) 62(91%)

Age(years)a ₃₈_±₈_(27---67) ₃₉_±₇_(27---54) ₄₀_±₈_(29---60) _0.345b

Female 49(72%) 46(79%) 49(79%) 0.542c

Yearssincegraduationa ₁₃_±₈_(4---42) ₁₄_±₇_(4---28) ₁₅_±₉_(4---35) _0.286b

YearsinNICU 10±6(1---28) 11±7(2---25) 12±7(2---25) 0.197b

Professionalsthatknowpainroutine 54(79%) 40(69%) 57(92%) 0.007c

UseNFCStoassesspain 19(28%) 23(40%) 40(64%) <0.001c

UseNIPStoassesspain 21(31%) 31(53%) 45(73%) <0.001c

Procedures---Lumbarpuncture(LP)

PainintensityattributedtoLP 5±2 5±2 5±2 0.894b

ProfessionalsthinkLPispainfulandindicateanalgesia 27(40%) 28(48%) 29(47%) 0.579c

Procedures---Trachealintubation(TI)

PainintensityattributedtoTI 6±2 6±2 6±2 0.526b

ProfessionalsthinkTIispainfulandindicateanalgesia 24(35%) 32(55%) 45(73%) <0.001c

Mechanicalventilation(MV)

PainintensityattributedtoMV 4±2 4±3 2±2 0.001b

ProfessionalsthinkMVispainfulandindicateanalgesia 38(56%) 32(55%) 16(26%) 0.001c

Postoperative(PO)minorsurgery

PainintensityattributedtoPO 5±2 4±2 4±2 0.745b

ProfessionalsthinkPOispainfulandindicateanalgesia 50(73%) 39(67%) 45(73%) 0.711c

POmajorsurgery

PainintensityattributedtoPO 7±2 8±2 8±1 0.001c

ProfessionalsthinkPOispainfulandindicateanalgesia 62(91%) 58(100%) 62(100%) 0.004c

Q,questionnaire;NICU,neonatalintensivecareunit;NFCS,neonatalfacialcodingsystem;NIPS,neonatalinfantpainscale.

a _Mean_±_standard_deviation_(range). b _ANOVA_with_fixed_factor.

c _Pearson’s_Chi-squared_test,_Fisher’s_exact_test,_or_its_extension.

period,seem to bedue to thepublication of undesirable effectsofanalgesicsintheneonatalperiod.12,13

The procedures analyzed here were chosen as they are part of the daily routine of a NICU and also because they cause pain, according to consolidated data in the literature14---18_; _in _addition, _there _are _published _protocols

for drug analgesia in these procedures.11,18---21 _Regarding

tracheal intubation, Bonow et al.,22 _in _2004, _evaluated

297proceduresintwoneonatalintensivecareandtwo pedi-atric units for six months. Medications for sedation and analgesia were used in 89% of intubations performed in the Pediatric ICU, and 24% of those in the NICU. In the same year, Simon et al.23 _analyzed _the _use _of

premedi-cation for intubation in 75 French pediatric and neonatal unitsandshowedthat37%ofnewborns,67%ofinfants,and 92%ofolderchildrenreceivedanalgesicsand/orsedatives prior to the procedure. The evidence-basedinternational consensus11_concluded_that_tracheal_intubation_without_the

useofanalgesiaandsedationshouldbeperformedonlyin neonatal resuscitation in the delivery room or in urgency situations without available venous access; in 2010, the AmericanAcademyofPediatrics19_recommended_the_use_of

premedication for trachealintubation inneonates. In this study,itwasobservedthat,evenwithprogressiveincrease ofthephysician’sperceptionthatintubationcausespain,a

significantpercentageofpatientswerestillintubated with-outanypain relief.Oneexplanationfor this wouldbe its performanceinemergencysituations;however,outsidethe deliveryroom,suchsituationsarerareand,inmostcases, itispossiblethat,whileaprofessionalpreparesthe mate-rialforintubation,theothermanagestheanalgesics.24_The

beneficialeffectsofsedationandanalgesiaonintracranial pressure,airwayinjury,reduction ofprocedure time,and patientcomfortshouldbeconsidered.25

Asforlumbarpuncture,alocalinfiltrationoflidocainein neonatesis recommended.21 _Sabrine_and_Sinha26 _observed

theregular use of analgesics for lumbar puncture in only 9%ofthesurveyedEnglishNICU.Porteretal.27 _studied₁₄₀

lumbarpunctures,andonlyin4%specificanalgesic medica-tionwasprescribedfor theprocedure.Inthisstudy,inall years,lessthanhalfof thenewborns submittedtolumbar puncture received some type of analgesic for the proce-dure.Thisfindingistroublingwhencomparedtowhatoccurs inchildren andadults,in whomtheuse of local anesthe-siafor thepuncture is usual.28 _It _is_noteworthy _that _over

50%ofinterviewedphysiciansfeltthatthepaincausedby thelumbarpuncturewouldnotbeintenseenoughtojustify analgesia.

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worseneurologicaloutcomeinpreterminfantson mechani-calventilationwhoreceivedmorphinewithinthefirsthours oflife,forapproximately14days,withassociationbetween this unfavorable outcome and the presence of hypoten-sionpriortoopioidinfusion.12,13 _A_{meta-analysis}29 _did_not

showsufficientevidencetorecommendtheroutineuseof opioidsfornewbornsonmechanicalventilation.The incor-porationofthisknowledgeprobablyexplainsthehuge dis-crepancy of data between perception and practice of neonatologistsregardingpainandanalgesiaformechanical ventilationin 2011. It shouldbe notedthat, inthat year, neonatologistsattributedlesspaintomechanicalventilation thaninthepreviousyearsandstatedtheyindicated analge-sialessfrequently.However,inpractice,althoughtheuse ofanalgesia for ventilatedpatients hasdecreased, it was muchhigherthantheneonatologists’theoreticalintention touseit.

Finally, regarding the postoperative period, it wasthe undertreatment of pain in neonates undergoing surgical procedures that triggered the interest of the scientific communityonthesubject.30_There_is_no_doubt_that

postop-erativepainincreasesneonatalmorbidityandmortality.31,32

Thepresentstudydemonstratedthatmedicalknowledgein thisregard hasimproved; in2006 and2011, all neonatol-ogistsconsideredthepostoperativeperiodapainfulevent andstatedtheyprescribedanalgesia.Theclinicalpractice, however, can be analyzed fromtwo points of view:one, optimistic,observingthatthepostoperativeuseofanalgesia increasedfrom33%in2001to89%in2011,bringingthe theo-reticalknowledgeofneonatologistsclosertotheirpractice. Underthe pessimisticviewpoint,it canbe observedthat, althoughalltheneonatologistsfeelthatpostoperative new-bornsneedanalgesics,over10%ofhospitalizedpatientsin thefouruniversityunitsin2011didnotreceiveanyanalgesic doseinthefirstthreedayspostoperatively.Medical knowl-edge,especiallywithregardtotherapeuticproceduresand medicalposture,dependsmoreonwhatstudentsinferbased ontheperformanceoftheirmentors,thanonthe transmis-sionof theirtheoreticalknowledge.33 _In_this _context,_the

gapbetweenmedicalknowledgeandpracticeinuniversity hospitals,whereappropriateandupdatedtrainingofhuman resourcesisasmuchapriorityasthehighstandardcareto theirpatients,isofconcern.

Itis noteworthythat,tounderstand thepresent study, itisnecessarytocriticallyreviewitsmajorlimitation:the research compared neonatologists’ perceptions about thepresence,intensity,andneedtotreatpaintriggeredby procedures,withthefrequencyofanalgesicuseinnewborns undergoingsuchprocedures,anditwasnotpossibleto indi-viduallypointoutthediscrepancybetweenthetheoretical knowledge and practical performance of each responding healthcareprofessional.Thestudywaslimitedtoanalyzing the prescription of pharmacological analgesia, regardless ofnonpharmacologicalmeasures,whichcouldhelprelieve paininseveral procedures.Finally, whenconsidering only a month of each assessed year, the survey had limited statistical power to detect differences in the practice of analgesiafortrachealintubation.Nevertheless,thescenario shown here indicates the need to improvethe models of continuingeducationregarding neonatalpain,sothatthe universityneonatalunitshaveprofessionalsthatcanapply theirknowledgeatthebedsideandmodifysuchknowledge

inaccordancewiththedynamicacquisitionofinformation thatisbuiltfromthecriticalreadingofscientificliterature onthesubject.

Itcanbeconcludedthat,overaten-yearperiod,there was an increase in the use of analgesics for the assessed painful procedures andan increasedperception by physi-ciansthatnewbornsfeelpain.Thegapbetweentheactual use of analgesicsin clinical practice andmedical percep-tionabouttheneedforanalgesiaduringpainfulprocedures persistedinthefourassessedintensivecareunits.Itis essen-tialtoanalyzethefactorsthatinterfereinmedicalpractice anddevelopstrategiestotreatpainassociatedwithinvasive proceduresintheneonatalperiod.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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