Neonatal Pain Agitation and Sedation Scale
| Sedation | Sedation/pain | Pain/agitation | |||
|---|---|---|---|---|---|
| Assessment criteria | −2 | −1 | 0/0 | 1 | 2 |
| Crying irritability | No cry with painful stimuli | Moans or cries minimally with painful stimuli | No sedation/no pain signs | Irritable or crying at intervals Consolable | High-pitched or silent-continuous cry Inconsolable |
| Behaviour state | No arousal to any stimuli No spontaneous movement | Arouses minimally to stimuli Little spontaneous movement | No sedation/no pain signs | Restless, squirming Awakens frequently | Arching, kickingConstantly awake or arouses minimally/no movement (not sedated) |
| Facial expression | Mouth is lax No expression | Minimal expression with stimuli | No sedation/no pain signs | Any pain expression intermittent | Any pain expression continual |
| Extremities tone | No grasp reflex Flaccid tone | Weak grasp reflex ↓muscle tone | No sedation/no pain signs | Intermittent clenched toes, fist or fingers splay Body is not tense | Continual clenched toes, fists, or finger splay Body is tense |
| Vital signs HR, RR, BP, SaO2 | No variability with stimuli Hypoventilation or apnoea | <10% variability from baseline with stimuli | No sedation/no pain signs | ↑↑10–20% from baseline SaO2 76–85% with stimulation-quick recovery↑ | SaO2 <75% with stimulation-slow recovery↑ Out of sync with vent |
The pain score is adjusted in premature infants according to gestational age categories: add 3 to infants <28 weeks; add 2 to infants 28–31 weeks; add 1 to infants 32–35 weeks.
BP, blood pressure; HR, heart rate; RR, respiratory rate; SaO2, arterial oxygen saturation.