Sedation and analgesia practices at Italian neonatal intensive care units: results from the EUROPAIN study

Abstract

Background: We aimed to examine current bedside analgesia/sedation (A/S) and pain assessment (PA) practices in Italian neonatal intensive care units (NICUs) in relation to the findings of an epidemiological European study and recently-introduced national guidelines.

Methods: We analyzed the Italian data from the EUROPAIN (EUROpean-Pain-Audit-In-Neonates) prospective observational study on A/S practices that involved 6680 newborns admitted to tertiary-level NICUs in 18 European countries. Demographics, type of assisted ventilation, type and mode of A/S administration and PA were analyzed. Multivariate linear regression models were used to identify factors predicting A/S and PA practices.

Results: From October 1^st, 2012 to June 30^th, 2013, thirty Italian NICUs gathered data on 422 newborn: 131 on invasive ventilation (IV); 150 on noninvasive ventilation (NIV); and 141 on spontaneous ventilation (SV). A/S was documented for 35.3% of all infants admitted (86.3% IV; 17.3% NIV; 7.1% SV [p = 0.0001]), and varied considerably between NICUs (as reported in other European countries). Strong analgesics were used in 32.5% of cases, sedatives in 10.2%, mild analgesics in 3.8%. Fentanyl was used in 78.6% of cases, morphine in 8.4%, neuromuscular blockers in 5.3%, midazolam in 22.1%. The performance of PA was documented in 67.5% of all newborn (85.5% IV; 67.3% NIV; 51.1% SV [p = 0.001]). Illness severity, type of ventilation, bedside PA, and number of NICU beds were all factors associated with A/S use on multivariate analysis, while gestational age ≤ 32 weeks, and type of ventilation and presence of a pain team were associated with PA.

Conclusions: We documented a generally widespread, but still highly variable use of A/S and PA at Italian NICUs, despite the diffusion of national guidelines. There is an urgent need to improve routine PA to enable customized pain and stress control (and prevention) in all infants.

Trial registration: Clinical Trials.gov # NCT01694745 .

Keywords: Analgesic; Newborn and preterm; Opioids; Pain; Pain assessment; Sedative.

Fig. 1

Study flowchart

Fig. 2

Analgesia and sedation in Italy and in all participating countries in Europe by type of ventilation. EU include: Austria, Belgium, Cyprus, Estonia, Finland, France, Germany, Greece, Lithuania, Malta, Netherlands, Norway, Poland, Portugal, Spain, Sweden, United Kingdom. Chi-square test p < 0.001

Fig. 3

Pain assessment in Italy and all participating countries in Europe. EU include: Austria, Belgium, Cyprus, Estonia, Finland, France, Germany, Greece, Lithuania, Malta, Netherlands, Norway, Poland, Portugal, Spain, Sweden, United Kingdom. ITA = pain assessment in Italian NICU admissions, PA_EU = pain assessment in other European NICU admissions, IV = pain assessment in invasive ventilation group, NIV = pain assessment in non-invasive ventilation group, SR = pain assessment in spontaneous ventilation group. Chi-square test p < 0.001