What is the recommended agitation and sedation scale for assessing and managing neonates under 2 months, particularly in the Neonatal Intensive Care Unit (NICU)?

Agitation and Sedation Assessment in Neonates Under 2 Months

For neonates under 2 months of age in the NICU, use the Neonatal Pain, Agitation and Sedation Scale (N-PASS) to assess both agitation and sedation levels. 1

Recommended Assessment Tool

The N-PASS is the validated instrument specifically designed for the neonatal population from birth through 100 days after birth, making it ideal for infants under 2 months. 2, 3

Key Features of N-PASS

• Dual assessment capability: N-PASS uniquely measures both pain/agitation AND sedation on a single scale, which is critical in neonates who may experience either extreme. 1, 4

• Score range and interpretation: 1, 4

  • Positive scores indicate pain/agitation
  • Negative scores indicate sedation
  • Score of 0 represents an awake and calm state
  • Scores range from -10 (deep sedation) to +10 (severe pain/agitation)

• Assessment parameters: The scale evaluates crying/irritability, behavior/state, facial expression, extremity tone, and vital signs (heart rate, respiratory rate, oxygen saturation). 2, 5

Psychometric Properties

• Excellent reliability: N-PASS demonstrates good to excellent interrater reliability (ICC = 0.83-0.94) between bedside nurses and independent assessors. 3

• Strong validity: The scale shows moderate agreement with nurses' clinical assessments for pain (κ = 0.52) and very strong agreement for sedation (κ = 0.99). 3

• Clinical utility: 93% of bedside nurses report that N-PASS reflects infant sedation levels well or very well, and 96.7% found neonates to be better pain-relieved after N-PASS implementation. 5, 3

Assessment Frequency

Document N-PASS scores every 4-8 hours alongside vital signs, or more frequently based on clinical condition and sedation goals. 1

• Increase assessment frequency during:
  • Active titration of sedatives or analgesics 1
  • Weaning from mechanical ventilation 1
  • Therapeutic hypothermia protocols 5
  • Any clinical deterioration or agitation 1

Clinical Application Algorithm

Step 1: Baseline Assessment

• Score the neonate using N-PASS before initiating sedation or analgesia 2, 5
• Establish target sedation range based on clinical needs (e.g., mechanical ventilation, post-surgical, therapeutic hypothermia) 5

Step 2: Medication Adjustment

• For positive scores (agitation/pain): Consider increasing analgesics or sedatives 5
• For excessive negative scores (oversedation): Consider reducing sedative doses 1
• For scores near zero: Maintain current regimen 4

Step 3: Reassessment

• Reassess 30-60 minutes after medication changes 5
• Continue monitoring at regular intervals per protocol 1

Important Clinical Caveats

Limitations to Recognize

• Acute postoperative pain: N-PASS lacks robust validation data for measuring acute pain in postoperative neonates of any gestational age—use additional clinical judgment in this population. 2

• Non-ventilated infants: Limited evidence supports N-PASS reliability for prolonged pain and sedation assessment in non-mechanically ventilated neonates—consider supplementing with other clinical indicators. 2

• Deep sedation detection: When used alone, N-PASS cannot reliably differentiate between light and deep sedation states. 4

Enhanced Assessment Strategy

For neonates requiring precise sedation depth monitoring (e.g., during therapeutic hypothermia), combine N-PASS with amplitude-integrated EEG (aEEG) using the Burdjalov scoring system. 4

• This combination provides the best accuracy for distinguishing light from deep sedation 4
• aEEG Burdjalov scores differentiate no sedation (median score 12) from deep sedation (median score 9) 4
• The combined approach addresses N-PASS limitations in detecting sedation depth 4

Common Pitfalls to Avoid

• Delayed pain recognition: Do not wait for extreme N-PASS scores before intervening—scores consistently above +3 warrant medication adjustment. 5

• Oversedation during hypothermia: Neonates undergoing therapeutic hypothermia often remain inadequately sedated until day 3 of treatment despite medication—reassess frequently and adjust aggressively. 5

• Ignoring sedation scores: Negative N-PASS scores indicating oversedation predict prolonged mechanical ventilation and ICU stay—actively reduce sedation when scores fall below -5. 1

• Inconsistent documentation: Failure to document N-PASS scores with each assessment leads to inconsistent medication dosing across nursing shifts—standardize documentation practices. 1