Hummel and Puchalski developed the Neonatal Pain, Agitation and Sedation Scale (N-PASS) to evaluate the level of sedation and pain in a neonate in the intensive care unit (ICU). This can help to identify an infant who may require therapy and as a guide to therapy once started. The authors are from Loyola University Medical Center in Maywood, Illinois, and Elmhurst Memorial Healthcare in Elmhurst, Illinois.
NOTE: The authors should be contacted for permission to use the scale. Their email addresses are phummel@lumc.edu and marypuch@comcast.net
Parameters:
(1) crying and irritability
(2) behavior state
(3) facial expression
(4) extremities and tone
(5) vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation)
(6) gestational age (corrected age) if premature
|
Parameter |
Finding |
Points |
|
crying and irritability |
no cry to painful stimulus |
-2 |
|
|
moans or cries minimally with painful stimuli |
-1 |
|
|
appropriate crying; not irritable |
0 |
|
|
irritable; crying at intervals but consolable |
+1 |
|
|
high-pitched or silent continuous cry; inconsolable |
+2 |
|
behavior state |
no arousal to any stimulus; no spontaneous movement |
-2 |
|
|
arouses minimally to stimulus; little spontaneous movement |
-1 |
|
|
appropriate for gestational age |
0 |
|
|
restless; squirming; awakens frequently |
+1 |
|
|
arching, kicking; constantly awake; not sedated and arouses minimally with no movement |
+2 |
|
facial expression |
mouth is lax; no expression |
-2 |
|
|
minimal expression with stimuli |
-1 |
|
|
relaxed; appropriate |
0 |
|
|
intermittent expression of any sign for pain |
+1 |
|
|
continual expression of pain |
+2 |
|
extremities and tone |
no grasp reflex; flaccid tone |
-2 |
|
|
weak grasp reflex; decreased muscle tone |
-1 |
|
|
relaxed hands and feed; normal tone |
0 |
|
|
intermittent clenched toes, fists or finger splay; body is not tense |
+1 |
|
|
continual clenching of toes, fists or finger splay; body is tense |
+2 |
|
vital signs |
no variability with stimuli; hypoventilation or apnea |
-2 |
|
|
< 10% variability from baseline with stimuli |
-1 |
|
|
within baseline or normal for gestational age |
0 |
|
|
10-20% from baseline; oxygen saturation 76-85% with stimulation; quick recovery |
+1 |
|
|
> 20% from baseline; oxygen saturation <= 75% with simulation; slow recovery; out of synchrony with ventilator |
+2 |
|
gestational age |
>= 36 weeks |
0 |
|
|
32 to 35 weeks |
+1 |
|
|
28 to 31 weeks |
+2 |
|
|
< 28 weeks |
+3 |
where:
• The scoring criteria are given at the web site (see references).
sedation score =
= SUM(points for the first 5 parameters, with any score > 0 set to 0)
pain score =
= SUM(points for the 6 parameters, with any score < 0 set to 0)
Interpretation of the sedation score:
• minimum sedation score: -10
• maximum sedation score: 0
• Light sedation is indicated by a sedation score of -2 to -5. Deep sedation is indicated a score from -5 to -10.
• The presence of a negative score in the absence of sedative or opioid therapy may indicate neurologic depression, sepsis, or other disorder. A premature infant may show a negative score in response to chronic pain.
Interpretation of the pain score:
• minimum pain score: 0
• maximum pain score: 10 if term, 13 if premature
• A pain score > 3 indicates a need for therapeutic intervention.
• The pain score cannot be used as a guide in a paralyzed infant. Monitoring of vital signs such as heart rate and blood pressure may be the only indicators of the pain response.
Specialty: Pedatrics
ICD-10: ,
