NICU Procedural Pain Management Guidelines


  1. Indications: To prevent, or relieve, pain associated with specific NICU procedures.


  1. Procedures:
    1. Peripheral arterial line placement (PAL)
    2. Lumbar puncture (LP)
    3. IM Vitamin A injections
    4. IM Vitamin K injection
    5. IM Immunizations & RSV prophylaxis
    6. Percutaneous intravenous central catheter (PICC) line placemen


  1. Preparation
    1. Notify bedside nurse of intended procedure
    2. Order medications & necessary equipment
    3. Document N-PASS score (pre & post procedure)
    4. Notify parent(s); secure informed consent if indicated


  1. Action
    1. Place infant in correct position

i.      Use developmentally supportive bedding, posture, boundaries

ii.      Consider swaddling infant with exposed extremity free

    1. Clean skin surface over area that the procedure will be performed upon
    2. Apply 0.5gm of topical mixture of lidocaine/prilocaine (generic EMLA) in a 1 x 1 cm square (dime-sized) surface over the anticipated puncture site (maximum of 3 sites)
    3. Cover with an occlusive dressing for 45 minutes (maximum 60 minutes)
    4. Remove dressing
    5. Wipe/wash away topical medication
    6. Prep skin in sterile manner with povidone iodine or chlorhexidine
    7. Use sucrose pacifier or administer po sucrose 2 minutes before puncturing skin
    8. Administer IM injection, place PAL, perform LP
    9. For PICC Line: Administer IV Fentanyl 0.5 mcg/kg/dose to patient

i.      Consider higher dose in:

1.       patient already receiving Fentanyl infusion (should be equivalent to a “prn” dose or 1 hour’s infusion dose)

2.       patient on assisted ventilation

ii.      Be cautious of potential apnea or chest wall rigidity (Narcan at bedside)

iii.      Use sucrose pacifier or administer 0.2ml po sucrose 2 minutes before puncturing skin

iv.      Perform percutaneous puncture with introducer

v.      Repeat Fentanyl dose after 45 minutes or if patient is agitated (document N-PASS score).

    1. Limit attempts at LP, PAL, or PICC to 3 (use only premedicated sites).


  1. Thoracostomy tube placement by trained operator (MD or NNP)
    1. This is an urgent/emergent procedure not allowing for preparation of the site with topical anesthetic agents. (Document pre-procedural N-PASS score).
    2. Administer 1-2 mcg/kg IV Fentanyl (note cautions above; Narcan at bedside)
    3. Use subcutaneous lidocaine 0.5% for local infiltration at the site of puncture
    4. Make skin incision; place tube; connect to suction/water seal; secure with suture, and occlusive dressing
    5. Repeat Fentanyl dose as indicated for pain control (document N-PASS score).

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