Observational study of newborn infant parasympathetic evaluation as a comfort system in awake patients admitted to a pediatric intensive care unit

Tools used to assess comfort among patients undergoing high flow nasal cannula: A scoping review

OBJECTIVE

The aims were twofold: (a) to map tools documented in the literature to evaluate comfort among patients undergoing high flow nasal cannula (HFNC) treatment; and (b) to assess if the retrieved tools have been validated for this purpose.

METHODS

A scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). In July 2023, PubMed, Scopus, CINAHL and Cochrane Library were consulted. Studies assessing comfort in adult, paediatric, and neonatal patients undergoing HFNC were included.

RESULTS

Seventy-four articles were included, among which nine (12.2 %) investigated comfort as the primary aim. Twenty-five different tools were found, classifiable into 14 types, mostly unidimensional and originating from those measuring pain. The most widely used was the Visual Analogic Scale (n = 27, 35.6 %) followed by the Numerical Rating Scale (n = 11, 14.5 %) and less defined generic tools (n = 10, 13.2 %) with different metrics (e.g. 0-5, 0-10, 0-100). Only the General Comfort Questionnaire and the Comfort Scale were specifically validated for the assessment of comfort among adults and children, respectively.

CONCLUSION

Although the comfort of patients undergoing HFNC is widely investigated in the literature, there is a scarcity of tools specifically validated in this field. Those used have been validated mainly to assess pain, suggesting the need to inform patients to prevent confusion while measuring comfort during HFNC and to develop more research in the field.

IMPLICATIONS FOR CLINICAL PRACTICE

Comfort assessment is an important aspect of nursing care. Given the lack of validation studies in the field, efforts in research are recommended.

Dexmedetomidine: An Alternative to Pain Treatment in Neonatology

Infants might be exposed to pain during their admissions in the neonatal intensive care unit [NICU], both from their underlying conditions and several invasive procedures required during their stay. Considering the particularities of this population, recognition and adequate management of pain continues to be a challenge for neonatologists and investigators. Diverse therapies are available for treatment, including non-pharmacological pain management measures and pharmacological agents (sucrose, opioids, midazolam, acetaminophen, topical agents…) and research continues. In recent years one of the most promising drugs for analgesia has been dexmedetomidine, an alpha-2 adrenergic receptor agonist. It has shown a promising efficacy and safety profile as it produces anxiolysis, sedation and analgesia without respiratory depression. Moreover, studies have shown a neuroprotective role in animal models which could be beneficial to neonatal population, especially in preterm newborns. Side effects of this therapy are mainly cardiovascular, but in most studies published, those were not severe and did not require specific therapeutic measures for their resolution. The main objective of this article is to summarize the existing literature on neonatal pain management strategies available and review the efficacy of dexmedetomidine as a new therapy with increasing use in the NICU.

Clinical Promotion of Comfort Nursing Combined with Comprehensive Nursing in the Treatment of Severe Stroke Patients with Diabetes in ICU

Objective

To investigate the application value of comprehensive nursing combined with comfort nursing for severe stroke patients with diabetes in the intensive care unit (ICU), as well as its effect on the incidence of pressure ulcers and aspiration.

Methods

Between March 2019 and March 2021, 123 severe stroke patients with diabetes who were treated at our hospital were randomly assigned to one of two groups: the control group (n = 61) or the study group (n = 62). The control group received normal care, but the research group received comprehensive nursing as well as comfort nursing. The two patient groups were compared in terms of the effects of the clinical application.

Results

The two groups did not differ significantly in general data (P > 0.05). The shorter ICU monitoring and extubation times, the lower incidence of pressure ulcers, aspiration, and nosocomial infections, and higher self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores and a lower MOS 36-item short-form health survey (SF-36) score were all observed in the research group when compared to the control group (P < 0.05).

Conclusion

For severe stroke patients with diabetes in the ICU, comprehensive nursing combined with comfort nursing has a promising effect, significantly, lowering the risk of pressure ulcers, aspiration, and nosocomial infections, accelerating physical recovery, enhancing mental state, and ensuring a better prognosis, deserving general clinical promotion.

Parasympathetic evaluation for procedural pain assessment in neonatology

INTRODUCTION

The Newborn Infant Parasympathetic Evaluation (NIPE) index is an instrument that enables continuous, fast and objective assessment of neonatal discomfort. The aim of the study was to analyse changes in NIPE values after performance of blood draws and the factors involved in this variation.

MATERIAL AND METHODS

We conducted a prospective observational study. We included infants admitted to the neonatal intensive care unit between June and December 2021 who underwent blood draws. We recorded demographic data, aspects related to the procedure, the NIPE index and the heart rate at baseline and 1, 2, 3, 4, 5, 10 and 15 min after the procedure.

RESULTS

The study included 86 records for 49 patients. In the first 4 min after the procedure, there was a significant decrease in the NIPE index, with a maximum decrease of 22.8% relative to baseline and the nadir at 2.79 min. The decrease in NIPE values was greater in infants born preterm, male, with lower 5-min Apgar scores and following procedures that had been performed previously, after caesarean section or in the morning. There were no differences when the blood draw was obtained during kangaroo care. The correlation between the NIPE index and the heart rate was weak.

CONCLUSIONS

After a painful procedure, such as a blood draw, the NIPE monitor showed a significant decrease in the first 4 min, which was more pronounced in preterm infants, in repeated procedures or after caesarean delivery. The NIPE index could help identify infants experiencing acute procedural pain, complementing clinical rating scales.

Effects and Satisfaction of Comfort Nursing plus Psychological Nursing in the Clinical Nursing of Neurology Patients: A Comparative Study

Objective

To explore the effects and satisfaction of comfort nursing plus psychological nursing in the clinical nursing of neurology patients.

Methods

In this prospective study, 90 neurology patients admitted to our hospital from January 2019 to January 2020 were recruited and randomized into a control group and an experimental group with 45 cases in each group. The control group received routine care, and the experimental group received comfort care plus psychological care. The comfort scores and nursing satisfaction of the two groups were compared. The Hospital Anxiety and Depression Scale (HAD) was used to assess the emotional state of patients before and after the intervention. The Exercise of Self-care Agency Scale (ESCA) was used to assess the patient's self-care ability after the intervention.

Results

The comfort scores of the experimental group were higher than those of the control group (P < 0.05). The experimental group showed significantly higher satisfaction than the control group (P < 0.05). Patients in the experimental group had lower HAD scores after intervention than those in the control group (P < 0.05). After the intervention, the experimental group had higher ESCA scores and a higher Barthel index than the control group (P < 0.05).

Conclusion

Comfort nursing plus psychological care improves nursing satisfaction and self-care ability of neurology patients and relieves their negative emotions.

Monitoring of analgesia level during general anesthesia in children

PURPOSE OF REVIEW

Monitoring of intraoperative nociception has made substantial progress in adult anesthesia during the last 10 years. Several monitors have been validated and their use has been associated with intraoperative or postoperative benefits in the adult population. In pediatric anesthesia, less data are available. However, several recent publications have assessed the performance of nociception monitors in children, and investigated their potential benefits in this context. This review will describe the main validated intraoperative nociception monitors, summarize adult findings and describe the available pediatric data.

RECENT FINDINGS

Six intraoperative nociception indices were included in this review. Among them, four have shown promising results in children: Surgical Pleth Index (GE-Healthcare, Helsinki, Finland), Analgesia-Nociception Index (Mdoloris Medical Systems, Loos, France), Newborn-Infant Parasympathetic Evaluation (Mdoloris Medical Systems), and Pupillometry (IDMED, Marseille, France). The relevance of Skin Conductance (MedStorm innovations, AS, Oslo, Norway) under general anesthesia could not be established. Finally, the Nociception Level (Medasense, Ramat Gan, Israel) still requires to be investigated in children.

SUMMARY

To date, four monitors may provide a relevant assessment of intraoperative nociception in children. However, the potential clinical benefits associated with their use to guide analgesia remain to be demonstrated.

Available Instruments to Assess Pain in Infants

Pain assessment in newborns and infants is challenging for clinicians. Although behavioral and behavioral-physiological scales are validated pain assessment instruments, their use in this age group has significant limitations. In this review, we summarize the methods currently available for assessing pain in neonates and infants. It is possible that these pain detection methods are also useful for assessing the quality of anesthesia and analgosedation in these populations. Further research should be aimed at confirming the usefulness of these tools in infants and identifying additional pain assessment options for clinical practice.

The performance of the heart rate variability-derived Newborn Infant Parasympathetic Evaluation Index as a measure of early postoperative pain and discomfort in infants-A prospective observational study

BACKGROUND

The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE™) Index is a continuous noninvasive tool for the assessment of pain and discomfort in infants. Little is known about its performance in the early postoperative setting, where assessment of pain/discomfort is usually based on discontinuous observational scoring systems or personal experience of medical staff.

AIMS

To investigate the performance of the NIPE as a measure of early postoperative pain and/or discomfort in infants.

METHODS

The potential of the NIPE to detect pain/discomfort, as assessed by two clinical scoring systems (FLACC and COMFORT-B scale), was investigated in postoperative infants (0-2 years).

RESULTS

Receiver operating curve (ROC) analyses investigating the power of the NIPE to distinguish between comfort and pain/discomfort, revealed areas under the curve (AUC) of 0.77 for the FLACC, 0.81 for the COMFORT-B score, and 0.77 for a combination of FLACC & COMFORT-B. Logistic regression analysis provided initial evidence that the NIPE is an independent predictor of a FLACC score ≥4 and/or a COMFORT-B score ≥17, though R² values were below .2. NIPE values associated with a FLACC ≥4 (48 [45-56]), a COMFORT-B score ≥17 (47 [42-53]), and a FLACC ≥4 & COMFORT-B ≥17 (47 [42-57]) were lower than NIPE values associated with a FLACC <4 (60 [53-68], 95% CI of difference -14 to -8, p < .0001), a COMFORT-B score <17 (61 [54-68], 95% CI of difference -16 to -10, p < .0001), and a FLACC <4 & COMFORT-B score <17 (60 [53-68], 95% CI of difference -15 to -8, p < .0001). We found no evidence of a predictive value of the NIPE regarding the occurrence of pain.

CONCLUSIONS

The NIPE detected pain and discomfort in infants after general anesthesia with reasonable areas under the ROC curve (±0.8), whereas it was not predictive of clinically detectable pain or discomfort.

The newborn infant parasympathetic evaluation in pediatric and neonatology: a literature review

PURPOSE

The Newborn Infant Parasympathetic Evaluation (NIPE) is a heart rate variability-based technology for assessing pain and comfort in neonates and infants under 2-years-old. This review aims to investigate the clinical utility of the NIPE.

METHODS

Two investigators screened Pubmed/Medline and Google Scholar for relevant studies, independently. One investigator extracted data, which were reviewed by a second investigator.

RESULTS

The NIPE was used during/after painful stimuli (6 studies), in the context of general anaesthesia (2 studies), and for comfort assessment (6 studies). A) Evaluation of procedural pain/distress: 2 studies reported that the mean-NIPE could be used for reliable monitoring of prolonged pain, and one study reported the association between instant-NIPE and pain after a stimulus but the instant-NIPE represents the NIPE average over 3 min. Two studies found no correlation between the NIPE and comfort behavior/pain scales, but they mainly differed in patients' gestational age and evaluation methodology. B) There are only 2 studies for the evaluation of nociception during surgery under general anaesthesia with contradictory results. C) Studies assessing neonates' comfort reported increased NIPE scores during skin-to-skin contact and during facilitated tucking associated with a human voice. No effect on NIPE scores of facilitated tucking during echocardiography was reported in preterm infants. One study reported significantly different NIPE scores with 2 surfactant therapy protocols. Overall, study populations were small and heterogeneous.

CONCLUSION

The results regarding NIPE's performances differ between studies. Given the limited number of studies and the heterogeneous outcomes, more studies are required to confirm the NIPE usefulness in the different clinical settings.

Procedural Pain Assessment in Infants Without Analgosedation: Comparison of Newborn Infant Parasympathetic Evaluation and Skin Conductance Activity - A Pilot Study

Objective: New technologies to measure pain responses, such as heart rate variability and skin conductance hold promise in the development of tools that can be reliable and quantifiable of detecting pain. The main objective of this study was to assess the capability of two monitors i.e., Newborn Infant Parasympathetic Evaluation (NIPE) and Skin Conductance Algesimeter for detecting procedural pain in non-anesthetized infants. Materials and Methods: Thirty-three non-anesthetized infants were enrolled to the study. To detect pain caused by heel stick, NIPE, and Skin Conductance monitors and behavioral pain scales were used. Three minutes before and just after heel stick, pain was evaluated by behavioral scales, and simultaneously over the whole period by NIPE and SCA. Results: A statistically significant decrease of NIPE Index and an increase of SCA values were found after the HS procedure. There were no statistically significant differences between the decrease in NIPEi values and the increase in PPS values between subgroups based on pain assessment by behavioral-scale scores. Conclusion: Both NIPE and SCA can be useful for detection of procedural pain and may constitue an additional valuable tool for better handling of pain among patients treated in NICUs. More studies on larger groups of patients are needed.

Assessment of Procedural Distress in Sedated/Intubated Children Under 3 Years Old Using the Newborn Infant Parasympathetic Evaluation: A Diagnostic Accuracy Pilot Study

OBJECTIVES

Newborn infant parasympathetic evaluation index is based on heart rate variability and is related to the autonomic response to pain or stress. The Comfort Behavior Scale is used to assess distress intensity in sedated intubated children. The objective of this study was to assess the validity and performance of newborn infant parasympathetic evaluation as a distress indicator during procedural distress.

DESIGN

Monocentric, prospective, noninterventional pilot study of diagnostic accuracy between October 1, 2017, and April 30, 2019.

SETTING

PICU in a tertiary care university hospital.

PATIENTS

Sedated intubated children under 3 years old.

INTERVENTIONS

We continuously obtained mean newborn infant parasympathetic evaluation and instantaneous newborn infant parasympathetic evaluation scores and compared them to Comfort Behavior scores obtained before (T1 period), during (T2 period), and after (T3 period) care procedures.

MEASUREMENTS AND MAIN RESULTS

We obtained 54 measurements from 32 patients. The median age was 4 months (23 d to 31 mo). Between T1 and T2, there was a significant decrease in the instantaneous newborn infant parasympathetic evaluation and mean newborn infant parasympathetic evaluation scores (64 ± 2 to 42 ± 1 [p 0.0001] and 64 ± 1 to 59 ± 1 [p = 0.007], respectively) and a significant increase in the Comfort Behavior scores (from 12 ± 0 to 16 ± 1; p 0.0001). Comfort Behavior scores and instantaneous newborn infant parasympathetic evaluation and mean newborn infant parasympathetic evaluation scores were significantly inversely correlated (r = -0.44, p 0.0001 and r = -0.19, p = 0.01, respectively). With a instantaneous newborn infant parasympathetic evaluation score threshold of 53, the sensitivity, specificity, positive predictive, and negative predictive values to predict a Comfort Behavior Scale up to 17 were 80.0%, 73.5%, 43.8%, and 93.5%, respectively.

CONCLUSIONS

Instantaneous newborn infant parasympathetic evaluation is valid for assessing distress in sedated/intubated children in the PICU. Further studies are needed to confirm these results and for newborn infant parasympathetic evaluation-based comparisons of sedation-analgesia protocols.

Nociception monitoring tools using autonomic tone changes for intraoperative analgesic guidance in pediatric patients

Nociception monitoring devices using changes in autonomic nervous system activity have been developed in numerous ways. Although there have been few studies conducted on children, compared to the relatively higher number of studies on adults, most of the nociception monitors in children, as in adults, appear to be more useful than the standard clinical practice that uses hemodynamic parameters in the evaluation and treatment of intraoperative nociception (pain) during general anesthesia. Particularly, when monitoring the surgical pleth index (SPI) in anesthetized children, the application of a new target range of SPI values (≤ 40) to the SPI monitoring criteria seems to be necessary for providing a more proper intraoperative analgesia. The analgesia nociception index (ANI) shows promising results in anesthetized adults, and recently, positive results along with cardiorespiratory coherence have been reported in pediatric patients. Newborn infant parasympathetic evaluation (NIPE) could be useful for providing adequate analgesia in newborns, infants, and children under 2 years of age in anesthetized or awake states. In cases of skin conductance and pupillometry, further studies are needed. Understanding the pros, cons, and limitations of these nociception monitoring tools will provide more effective and safe intraoperative analgesia to pediatric patients undergoing general anesthesia, and it may also help to plan and conduct promising research on the use of perioperative nociception monitoring in pediatric patients in the future.