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Akkaya-Gül A, Özyazıcıoğlu N. Effect of pacifier and pacifier with dextrose in reducing pain during orogastric tube insertion in newborns: a randomized controlled trial. J Perinatol 2024; 44:717-723. [PMID: 38553602 DOI: 10.1038/s41372-024-01948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 03/07/2024] [Accepted: 03/19/2024] [Indexed: 05/15/2024]
Abstract
OBJECTIVE This study aimed to assess the efficacy of pacifier use, with and without 25% dextrose, in reducing pain during orogastric tube insertion in newborns. STUDY DESIGN In a randomized controlled trial involving 60 newborns at a public hospital from April to December 2019, participants were divided into three groups: pacifier (n = 20), pacifier with 25% dextrose (n = 20), and control (n = 20). A pacifier, with and without dextrose, was used for the experimental groups, while the control group performed a routine procedure. Neonatal infant pain scale, crying duration, heart rate (HR), and oxygen saturation (SpO2) were evaluated. RESULTS Results indicated that the control group experienced significantly higher pain levels, elevated HRs, decreased SpO2, and prolonged crying. Conversely, the pacifier with 25% dextrose group showed a notable reduction in crying duration. CONCLUSION A pacifier, with and without 25% dextrose, effectively reduces pain and improves physiological and behavioral parameters during orogastric tube insertion. CLINICAL TRIAL NUMBER NCT05462964 CLINICAL TRIAL REGISTRATION: The protocol for this randomized controlled experimental trial is registered on ClinicalTrials.gov. The clinical trial registration number is https://clinicaltrials.gov ; NCT05462964.
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Affiliation(s)
- Ayşenur Akkaya-Gül
- Department of Child Health and Diseases Nursing, Health Sciences Institute, Bursa Uludağ University, Bursa, Turkey.
- Department of First and Emergency Aid, Vocational School of Health Services, Fenerbahçe University, Istanbul, Turkey.
| | - Nurcan Özyazıcıoğlu
- Department of Child Health and Diseases Nursing, Faculty of Health Sciences, Bursa Uludağ University, Bursa, Turkey
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Kavurt S, Arslan Z, Unal S, Bas AY, Demirel N. The effect of oscillometric blood pressure measurement on pain response in preterm infants. J Paediatr Child Health 2023; 59:1251-1255. [PMID: 37694507 DOI: 10.1111/jpc.16490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/01/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
AIM Preterm neonates are exposed to many painful procedures in neonatal intensive care units. This study aims to evaluate the effect of oscillometric blood pressure (BP) measurement on pain response in preterm infants. METHODS This prospective study was performed over 4 months in a level III neonatal intensive care unit. Premature neonates whose gestational age was <34 weeks and postmenstrual age <36 weeks were included if they had no systemic diseases. BP measurement was performed on the right arm. The Premature Infant Pain Profile-Revised (PIPP-R) scores were evaluated three times before, during, and 10 min after BP measurement. RESULTS During the 5-month period, 100 preterm neonates (53 male infants) were included in the study. Median birth weight and gestational age of the infants were 1148 (IQR: 1015-1300) g and 28 (IQR: 27-30) weeks, respectively. PIPP-R scores were found to be ≥7 in 34% of neonates. PIPP-R scores increased during BP measurement and decreased after. CONCLUSION Our results demonstrated that oscillometric BP measurement which is generally accepted as a non-invasive tool for monitoring can produce mild pain in premature neonates of postmenstrual age <36 weeks.
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Affiliation(s)
- Sumru Kavurt
- Department of Neonatology, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Zehra Arslan
- Department of Neonatology, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Sezin Unal
- Department of Neonatology, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ahmet Yagmur Bas
- Department of Neonatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Nihal Demirel
- Department of Neonatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Kara N, Arman D, Seymen Z, Gül A, Cömert S. Effects of fentanyl and sucrose on pain in retinopathy examinations with pain scale, near-infrared spectroscopy, and ultrasonography: a randomized trial. World J Pediatr 2023; 19:873-882. [PMID: 36976515 DOI: 10.1007/s12519-023-00705-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/12/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy of intravenous, intranasal fentanyl and oral sucrose in reducing the pain response during retinopathy of prematurity examinations using premature infant pain profile (PIPP) scores. METHOD The study included 42 infants who underwent retinopathy screening examinations. The infants were divided into three groups: oral sucrose, intranasal fentanyl, and intravenous fentanyl. Vital signs (heart rate, arterial oxygen saturation, and mean arterial pressure) were recorded. The PIPP was used to determine pain severity. Cerebral oxygenation and middle cerebral artery blood flow were evaluated using near-infrared spectroscopy and Doppler ultrasonography, respectively. The data obtained were compared between groups. RESULTS There was no significant difference between the three groups regarding postconceptional and postnatal ages or birth weights and weight at the time of examination. All babies had moderate pain during the examination. No correlation was observed between analgesia method and pain scores (P = 0.159). In all three groups, heart rate and mean arterial pressure increased, whereas oxygen saturation decreased during the exam compared with pre-examination values. However, heart rate (HR), mean arterial pressure (MAP) and arterial oxygen saturation (sPO2) values did not differ between groups (HR, P = 0.150; MAP, P = 0.245; sPO2, P = 0.140). The cerebral oxygenation (rSO2) values between the three groups were found to be similar [rSO2: P = 0.545, P = 0.247, P = 0.803; fractional tissue oxygen extraction (FTOE): P = 0.553, P = 0.278]. Regarding cerebral blood flow values, we also did not find any difference between the three groups [mean blood flow velocity (Vmean): P = 0.569, P = 0.975; maximum flow velocity (Vmax): P = 0.820, P = 0.997]. CONCLUSIONS Intravenous and intranasal fentanyl and oral sucrose were not superior to each other in preventing pain during the examination for retinopathy of prematurity (ROP). Sucrose may be a good alternative for pain control during ROP examination. Our findings suggest that ROP exam may not affect cerebral oxygenation or cerebral blood flow. Larger scale studies are needed to determine the best pharmacological option to reduce pain during ROP exams and evaluate the effects of this procedure on cerebral oxygenation and blood flow.
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Affiliation(s)
- Nursu Kara
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey.
| | - Didem Arman
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Zeynep Seymen
- Department of Opthalmology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Adem Gül
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Serdar Cömert
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
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Gkikas S, Tsiknakis M. Automatic assessment of pain based on deep learning methods: A systematic review. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 231:107365. [PMID: 36764062 DOI: 10.1016/j.cmpb.2023.107365] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 01/06/2023] [Accepted: 01/21/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND OBJECTIVE The automatic assessment of pain is vital in designing optimal pain management interventions focused on reducing suffering and preventing the functional decline of patients. In recent years, there has been a surge in the adoption of deep learning algorithms by researchers attempting to encode the multidimensional nature of pain into meaningful features. This systematic review aims to discuss the models, the methods, and the types of data employed in establishing the foundation of a deep learning-based automatic pain assessment system. METHODS The systematic review was conducted by identifying original studies searching digital libraries, namely Scopus, IEEE Xplore, and ACM Digital Library. Inclusion and exclusion criteria were applied to retrieve and select those of interest, published until December 2021. RESULTS A total of one hundred and ten publications were identified and categorized by the number of information channels used (unimodal versus multimodal approaches) and whether the temporal dimension was also used. CONCLUSIONS This review demonstrates the importance of multimodal approaches for automatic pain estimation, especially in clinical settings, and also reveals that significant improvements are observed when the temporal exploitation of modalities is included. It provides suggestions regarding better-performing deep architectures and learning methods. Also, it provides suggestions for adopting robust evaluation protocols and interpretation methods to provide objective and comprehensible results. Furthermore, the review presents the limitations of the available pain databases for optimally supporting deep learning model development, validation, and application as decision-support tools in real-life scenarios.
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Affiliation(s)
- Stefanos Gkikas
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, Estavromenos, Heraklion, 71410, Greece; Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research & Technology-Hellas, Vassilika Vouton, Heraklion, 70013, Greece.
| | - Manolis Tsiknakis
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, Estavromenos, Heraklion, 71410, Greece; Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research & Technology-Hellas, Vassilika Vouton, Heraklion, 70013, Greece.
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5
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Meesters NJ, Dilles T, van Rosmalen J, van den Bosch GE, Simons SHP, van Dijk M. COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates? J Perinatol 2023; 43:595-600. [PMID: 36746985 DOI: 10.1038/s41372-023-01628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We studied the reliability and validity of the COMFORTneo scale, designed to measure neonatal prolonged pain. STUDY DESIGN This prospective observational study evaluated four clinimetric properties of the COMFORTneo scale from NICU nurses' assessments of neonates' pain. Intra-rater reliability was determined from three video fragments at two time points. Inter-rater reliability and construct validity were determined in five neonates per nurse with the COMFORTneo and numeric rating scales (NRS) for pain and distress. Pain scores using N-PASS were correlated with COMFORTneo scores to further evaluate construct validity. RESULT Intra-rater reliability: Twenty-two nurses assessed pain twice with an intraclass correlation coefficient (ICC) of 0.70. Inter-rater reliability: The ICC for 310 COMFORTneo scores together with 62 nurses was 0.93. Construct validity: Correlation between COMFORTneo and NRS pain, distress, and N-PASS was 0.34, 0.72, and 0.70, respectively. CONCLUSION The COMFORTneo can be used to reliably and validly assess pain in NICU patients.
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Affiliation(s)
- Naomi J Meesters
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Tinne Dilles
- Nursing and Midwifery Sciences, Centre for Research and Innovation in Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Monique van Dijk
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
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Skelton H, Psaila K, Schmied V, Foster J. Systematic Review of the Effects of Positioning on Nonautonomic Outcomes in Preterm Infants. J Obstet Gynecol Neonatal Nurs 2023; 52:9-20. [PMID: 36309067 DOI: 10.1016/j.jogn.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm infants admitted to the NICU. DATA SOURCES We searched the CINAHL, MEDLINE, Scopus, and Cochrane databases for reports of primary research studies using a three-step strategy. We also searched for gray literature and reviewed the reference lists of retrieved articles. STUDY SELECTION We included reports of quantitative studies published in English from database inception through February 2022 that focused on positioning and nonautonomic outcomes (pain, comfort, skin integrity, behavioral state, and sleep quality and duration) for preterm infants in the NICU. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria. DATA EXTRACTION Two authors independently extracted the data from the full-text articles using a standardized data extraction tool. We synthesized the data narratively because of the different designs and outcome measures among the included studies. DATA SYNTHESIS From a total of 550 records initially screened, we included 17 articles in our review. In the included articles, prone positioning improved sleep quality and duration, whereas supine positioning was associated with increased awakenings and activity. Infants demonstrated fewer self-regulatory behaviors in the prone position compared to supine or side-lying and were less stressed in the prone position. We found minimal evidence on the effect of positioning on skin integrity or pain. CONCLUSION There is limited good-quality evidence on the effect of positioning on nonautonomic outcomes in preterm infants. To inform clinical practice, high-quality randomized controlled trials focused on the positioning of premature infants are warranted.
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Menegol NA, Ribeiro SNS, de Paula AC, Montemezzo D, Sanada LS. A Cross-Cultural Adaptation and Content Validity of COMFORTneo Scale into Brazilian Portuguese. J Pain Symptom Manage 2022; 64:e323-e330. [PMID: 35985550 DOI: 10.1016/j.jpainsymman.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT The instrument used to assess neonatal pain must be adequate regarding the type of pain, population, country, and language to provide the best evidence-based clinical strategies; however, few neonatal pain instruments have been translated and validated for the Brazilian population. OBJECTIVE The aim was to perform a cross-cultural adaptation of the COMFORTneo scale into Brazilian Portuguese and to evaluate the content validity of the adapted scale. METHODS The cross-cultural adaptation process followed six main steps: translation, synthesis of the translations, back-translation, submission to the expert committee, final version pretest, being that 65 individuals participated in this stage, including both healthcare professionals and students, and submission to the committee for process appraisal. Additionally, an equivalence form composed of a four-point Likert scale was sent to each committee participant to calculate the content validity index (CVI). The CVI was obtained as the sum of the items ranked as three or four by the experts divided by the total number of experts. RESULTS No difficulties were reported in the production of translated versions. The CVI for the final version of the translated instrument was 0.99. The final version was reviewed to correct any possible grammatical errors. The layout was modified as necessary, and instructions on scale scoring were added to facilitate the application, resulting in the COMFORTneo Brazil scale. CONCLUSION The COMFORTneo scale was properly and cross-culturally adapted into Brazilian Portuguese, reaching semantic, idiomatic, experimental, and conceptual equivalence with the original instrument, and a good CVI.
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Affiliation(s)
- Natália Alves Menegol
- Department of Physical Therapy (N.A.M., D.M., L.S.S.), Universidade do Estado de Santa Catarina, Florianópolis, SC, Brazil
| | - Simone Nascimento Santos Ribeiro
- Faculdade Ciências Médicas de Minas Gerais (S.N.S.R.), Instituto de Previdência dos Servidores do Estado de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Dayane Montemezzo
- Department of Physical Therapy (N.A.M., D.M., L.S.S.), Universidade do Estado de Santa Catarina, Florianópolis, SC, Brazil
| | - Luciana Sayuri Sanada
- Department of Physical Therapy (N.A.M., D.M., L.S.S.), Universidade do Estado de Santa Catarina, Florianópolis, SC, Brazil.
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Onuagu V, Gardner F, Soni A, Doheny KK. Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations. FRONTIERS IN PAIN RESEARCH 2022; 3:1032513. [PMID: 36483945 PMCID: PMC9722726 DOI: 10.3389/fpain.2022.1032513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/07/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Retinopathy of prematurity (ROP) ophthalmologic examinations cause stress and pain. Infants' stress and pain can be measured non-invasively using skin conductance (SC) and high frequency heart rate variability (HF-HRV), reflecting sympathetic-mediated sweating and parasympathetic activity, respectively. OBJECTIVES To test the utility of SC to detect sympathetic activation during ROP examination, and the contribution of HF-HRV to predict stability post-examination. METHODS In this prospective, single center study, we measured SC continuously pre-, during, and post-examination, and HRV at 24 h pre-ROP examination. Clinical data included stability [apneas, bradycardias, and desaturations (A/B/Ds)], and interventions post-examination. RESULTS SC increased 56% above baseline during ROP examination (p = 0.001) and remained elevated post-examination (p = 0.02). Post-hoc analysis showed higher illness acuity, represented by need for respiratory support, was associated with lower HF-HRV at 24 h pre-ROP examination (p = 0.001). Linear regression indicated lower HF-HRV at 24 h pre-examination contributed to the need for higher intervention (i.e., stimulation to breathe, oxygen support) particularly among infants with higher illness acuity [F(1, 15) = 5.05, p = 0.04; β = -1.33, p = 0.04]. CONCLUSION ROP examination induced a 2-fold increase in sympathetic activation which remained above baseline in recovery. Also, we propose that the low parasympathetic tone associated with autonomic imbalance contributes to instability and need for higher intervention to assure stabilization with A/B/D events. Our findings provide insight into the underestimation of adverse events associated with ROP examination and identification of infants who may be more vulnerable to potential sequelae following ROP examinations.
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Affiliation(s)
- Vivian Onuagu
- Department of Neonatology, Mountain View Hospital Las Vegas, Las Vegas, NV, United States
| | - Fumiyuki Gardner
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, United States
| | - Ajay Soni
- Department of Ophthalmology, Penn State College of Medicine, Hershey, PA, United States
| | - Kim K Doheny
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, United States
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, United States
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Neumann C, Babasiz T, Straßberger-Nerschbach N, Schindler E, Reuter C, Weinhold L, Wittmann M, Hilbert T, Klaschik S. Comparison of the Newborn Infant Parasympathetic Evaluation (NIPE™) index to changes in heart rate to detect intraoperative nociceptive stimuli in healthy and critically ill children below 2 years: An observational study. Paediatr Anaesth 2022; 32:815-824. [PMID: 35332622 DOI: 10.1111/pan.14446] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/24/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The validity of current tools for intraoperative objective assessment of nociception/antinociception balance during anesthesia in young and very young surgery children is unknown. AIM Primary aim of the study was to test the hypothesis that the Newborn Infant Parasympathetic Evaluation (NIPE) index performs better in indicating nociception in anesthetized children below 2 years than changes in heart rate. Secondary aims were to evaluate associations between intraoperative changes in NIPE index values and postoperative pain and emergence delirium. METHODS Fifty-one children aged <2 years who underwent surgery were included in this prospective observational study. Patients were assigned to either group 1 (healthy children, n = 31) or group 2 (critically ill, ventilated premature infants and neonates, n = 20). The NIPE index and heart rate in response to three defined nociceptive stimuli were continuously recorded. Two different scales, Kindliche Unbehagens- und Schmerzskala (KUS) and Pediatric Anesthesia Emergence Delirium (PAED) as well as a Pain Questionnaire were used to assess postoperative pain levels and emergence delirium. RESULTS In total, 110 nociceptive events were evaluated. The analysis revealed a statistically significant association between a decrease in the NIPE index and all nociceptive stimuli, with a sensitivity of 92% and a specificity of 96%. The mean percentage decrease ranged from approx. 15%-30% and was highly statistically significant in both groups and for each of the nociceptive events except for venous puncture (p = .004). In contrast, no consistent change in heart rate was demonstrated. The KUS and PAED scale scores were significantly associated with the duration of anesthesia (p = .04), but not with intraoperative NIPE depression. CONCLUSION The NIPE index was reliable for assessing intraoperative nociception in children aged <2 years and was more reproducible for detecting specific nociceptive stimuli during general anesthesia than heart rate. An effect on postoperative outcome is still elusive.
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Affiliation(s)
- Claudia Neumann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tamara Babasiz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Reuter
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Leonie Weinhold
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Sven Klaschik
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Walas W, Latka-Grot J, Szczapa T, Maroszyńska I, Rutkowska M, Bartkowska-Śniatkowska A, Piotrowski A. Usefulness of two types of pain monitors in newborns treated in NICU, in the opinion of experts: Results of the survey. JOURNAL OF MOTHER AND CHILD 2022; 25:72-76. [PMID: 34842396 PMCID: PMC8976587 DOI: 10.34763/jmotherandchild.20212502.d-21-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/17/2021] [Indexed: 11/30/2022]
Abstract
Pain experienced in the neonatal period has been shown to have serious short- and long-term consequences. It is also known that painkillers have side effects and should not be abused. The basis of proper pain management is assessment of pain, which in newborns is very difficult due to the lack of verbal communication. In these patients, behavioural scales are used to assess pain, but they have numerous shortcomings. For this reason, many newborns treated in the ICU are at risk of pain, so instrumental methods of detecting and assessing the severity of pain are being sought. During three months, seven Polish NICUs conducted research with the use of NIPE and SCA monitors. After this time, the heads of these departments filled in questionnaires regarding their individual opinions on the usefulness of these devices. All respondents found pain monitors useful in the NICU. The NIPE monitor was rated slightly higher, as its usefulness in assessing the effectiveness of analgosedation and in the management of patients in the postoperative period was better rated. The high acceptance of both devices by legal guardians of newborns is noteworthy. It should be stated that in newborns, any way to improve pain monitoring is valuable. In the opinion of Polish experts, pain monitors are useful in NICU. The NIPE monitor was assessed a little higher and was considered useful in the assessment of analgosedation and in postoperative treatment. Pain monitors can provide valuable support for pain assessment in newborns treated in the NICU.
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Affiliation(s)
- Wojciech Walas
- Institute of Medical Sciences, University of Opole, Opole, Poland,Paediatric and Neonatal Intensive Care Unit, University Hospital in Opole, Opole, Poland, E-mail:
| | - Julita Latka-Grot
- Department of Neonatology, Children’s Memorial Health Institute, Warszawa, Poland
| | - Tomasz Szczapa
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznań University of Medical Sciences, Poznań, Poland
| | - Iwona Maroszyńska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother’s Memorial Hospital Research Institute in Łódź, Łódź, Poland
| | - Magdalena Rutkowska
- Clinic of Neonatology and Intensive Care (Department of Neonatology), Institute of Mother and Child, Warszawa, Poland
| | - Alicja Bartkowska-Śniatkowska
- Department of Paediatric Anaesthesiology and Intensive Therapy, Poznań University of Medical Sciences, Poznań, Poland
| | - Andrzej Piotrowski
- Department of Anaesthesiology and Intensive Care, Children’s Memorial Health Institute, Warszawa, Poland
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Yuan I, Nelson O, Barr GA, Zhang B, Topjian AA, DiMaggio TJ, Lang SS, Christ LA, Izzetoglu K, Greco CC, Kurth CD, Ganesh A. Functional near-infrared spectroscopy to assess pain in neonatal circumcisions. Paediatr Anaesth 2022; 32:404-412. [PMID: 34747096 DOI: 10.1111/pan.14326] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pain assessment is challenging in neonates. Behavioral and physiological pain scales do not assess neocortical nociception, essential to pain encoding and central pain pathway development. Functional near-infrared spectroscopy (fNIRS) can assess neocortical activation to noxious stimuli from changes in oxy-(HbO) and total-hemoglobin concentrations (HbT). This study aims to assess fNIRS nociceptive functional activation in the prefrontal cortex of neonates undergoing circumcision through changes in HbO and HbT, and the correlation between changes in fNIRS and Neonatal Infant Pain Scale (NIPS), a behavioral pain assessment scale. METHODS In healthy term neonates, HbO, HbT, and NIPS were recorded during sequential circumcision events 1-Prep before local anesthetic injection; 2-Local anesthetic injection; 3-Prep before incision; 4-Oral sucrose; 5-Incision; 6-Gomco (hemostatic device) attached; 7-Gomco twisted on; and 8-Gomco removed. fNIRS and NIPS changes after each event were assessed with Wilcoxon signed-rank test and summarized as median and interquartile range (IQR). Changes in fNIRS vs. NIPS were correlated with Spearman coefficient. RESULTS In 31 neonates fNIRS increased (median [IQR] µmol/L) with noxious events: Local injection (HbO: 1.1 [0.5, 3.1], p < .001; HbT: 2.3 [0.2, 7.6], p < .001), Gomco attached (HbO: 0.7 [0.1, 1.7], p = .002; HbT: 0.7 [-0.2, 2.9], p = .02), and Gomco twisted on (HbO: 0.5 [-0.2, 1.7], p = .03; HbT: 0.8 [-0.1, 3.3], p = .02). fNIRS decreased with non-noxious event: Prep before incision (HbO: -0.6 [-1.2, -0.2] p < .001; HbT: -1 [-1.8, -0.4], p < .001). Local anesthetic attenuated fNIRS increases to subsequent sharp stimuli. NIPS increased with subsequent sharp stimuli despite local anesthetic. Although fNIRS and NIPS changed in the same direction, there was not a strong correlation between them. CONCLUSIONS During neonatal circumcision, changes in fNIRS differed between different types of painful stimuli, which was not the case for NIPS, suggesting that fNIRS may complement NIPS to assess the quality of pain.
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Affiliation(s)
- Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon A Barr
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bingqing Zhang
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theresa J DiMaggio
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shih-Shan Lang
- Division of Neurosurgery, Department of Neurosurgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lori A Christ
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kurtulus Izzetoglu
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Christine C Greco
- Department of Neonatology, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Charles D Kurth
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arjunan Ganesh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rop S, Matheri JM, Tawa N. Knowledge, attitudes and practice of clinicians managing chronic pain in a tertiary care facility. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2022; 78:1597. [PMID: 35169653 PMCID: PMC8831966 DOI: 10.4102/sajp.v78i1.1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/13/2021] [Indexed: 11/01/2022] Open
Affiliation(s)
- Solomon Rop
- Department of Rehabilitation Science, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Joseph M. Matheri
- Department of Rehabilitation Science, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nassib Tawa
- Department of Rehabilitation Science, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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13
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Exploration and Validation of Behavioral Pain Measures and Physiological Pain Measures Factor Structure Extracted From the Pain Assessment Tool Item Scores for Infants Admitted to Neonatal Intensive Care. Clin J Pain 2021; 37:397-403. [PMID: 33734145 DOI: 10.1097/ajp.0000000000000931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/26/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of the study was to explore and then validate the factor structure of the Pain Assessment Tool (PAT). MATERIALS AND METHODS A retrospective medical record review was performed of all infants who were admitted to a neonatal intensive care unit between 2008 and 2018 and had 1 PAT assessment (n=2111). Scores on items of the PAT were collected. Infants were randomized to either the principal component analysis (n=1100) to explore the factor structure or confirmatory factor analysis (n=1011). RESULTS Infants in the 2 samples were demographically comparable. A 2-factor model, consisting of factors Behavioral and Physiological Pain Measures, was extracted, explaining 39.8% of the total variance. There was a low interfactor correlation (r=0.12), and both Behavioral (r=0.59) and Physiological Pain (r=0.37) Measures factor scores were correlated with nurses' perception of pain scores. When the frequencies in the gestational age at birth categories were compared between upper and lower quartile score infants, there was more with pain at preterm than at term (χ2(3)=44.9, P<0.001) for the Physiological Pain Measures factor, whereas Behavioral Pain Measures frequency was higher at term than at preterm (χ2(3)=8.1, P<0.043). A similar pattern was observed for postmenstrual age at assessment categories: Behavioral Pain Measures (χ2(3)=41.8, P<0.001) Physiological Pain Measures (χ2(3)=46.1, P<0.001). The 2-factor correlated model performed better at explaining the observed variances: (χ2(13)=41.6, P<0.001) compared with rival models. DISCUSSION The PAT assesses both Behavioral Pain and Physiological Pain Measures, and these dimensions need to be considered separately when assessing pain in infants in the neonatal intensive care unit. Behavioral item scores may be insufficient for detecting pain in premature infants if used alone.
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Baxter L, Moultrie F, Fitzgibbon S, Aspbury M, Mansfield R, Bastiani M, Rogers R, Jbabdi S, Duff E, Slater R. Functional and diffusion MRI reveal the neurophysiological basis of neonates' noxious-stimulus evoked brain activity. Nat Commun 2021; 12:2744. [PMID: 33980860 PMCID: PMC8115252 DOI: 10.1038/s41467-021-22960-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/05/2021] [Indexed: 11/20/2022] Open
Abstract
Understanding the neurophysiology underlying neonatal responses to noxious stimulation is central to improving early life pain management. In this neonatal multimodal MRI study, we use resting-state and diffusion MRI to investigate inter-individual variability in noxious-stimulus evoked brain activity. We observe that cerebral haemodynamic responses to experimental noxious stimulation can be predicted from separately acquired resting-state brain activity (n = 18). Applying this prediction model to independent Developing Human Connectome Project data (n = 215), we identify negative associations between predicted noxious-stimulus evoked responses and white matter mean diffusivity. These associations are subsequently confirmed in the original noxious stimulation paradigm dataset, validating the prediction model. Here, we observe that noxious-stimulus evoked brain activity in healthy neonates is coupled to resting-state activity and white matter microstructure, that neural features can be used to predict responses to noxious stimulation, and that the dHCP dataset could be utilised for future exploratory research of early life pain system neurophysiology.
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Affiliation(s)
- Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sean Fitzgibbon
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | | | | | - Matteo Bastiani
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Saad Jbabdi
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Eugene Duff
- Department of Paediatrics, University of Oxford, Oxford, UK
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
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15
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Gendras J, Lavenant P, Sicard-Cras I, Consigny M, Misery L, Anand KJS, Sizun J, Roué JM. The newborn infant parasympathetic evaluation index for acute procedural pain assessment in preterm infants. Pediatr Res 2021; 89:1840-1847. [PMID: 32961546 DOI: 10.1038/s41390-020-01152-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Accurate assessments of pain in hospitalized preterm infants present a major challenge in improving the short- and long-term consequences associated with painful experiences. We evaluated the ability of the newborn infant parasympathetic evaluation (NIPE) index to detect acute procedural pain in preterm infants. METHODS Different painful and stressful interventions were prospectively observed in preterm infants born at 25 + 0 to 35 + 6 weeks gestation. Pain responses were measured using the composite Premature Infant Pain Profile Revised (PIPP-R) scale, the NIPE index, and skin conductance responses (SCR). Outcome measures were correlations between the NIPE index, the PIPP-R score, and the SCR. Sensitivity/specificity analyses tested the accuracy of the NIPE index and SCR. RESULTS Two hundred and fifty-four procedures were recorded in 90 preterm infants. No significant correlation was found between PIPP-R and the NIPE index. PIPP-R and SCR were positively correlated (r = 0.27, P < 0.001), with stronger correlations for painful procedures (r = 0.68, P < 0.001) and especially for skin-breaking procedures (r = 0.82, P < 0.001). The NIPE index and SCR had high sensitivity and high negative predictive values to predict PIPP-R > 10, especially for skin-breaking painful procedures. CONCLUSIONS We found no significant correlation between the NIPE index and PIPP-R during routine painful or stressful procedures in preterm infants. IMPACT Exposure to repetitive pain can lead to neurodevelopmental sequelae. Behavior-based pain scales have limited clinical utility, especially for preterm infants. New devices for monitoring physiological responses to pain have not been validated sufficiently in preterm infants. This study found that the NIPE index was not significantly correlated to the validated PIPP-R scale during acute procedural pain. Secondary analysis of this study showed that NIPE index and SCRs may help to exclude severe pain in preterm infants. In clinical practice, measurements of physiological parameters should be combined with behavior-based scales for multidimensional pain assessments.
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Affiliation(s)
- Julie Gendras
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Pauline Lavenant
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Iona Sicard-Cras
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Maëlys Consigny
- Centre d'Investigation Clinique 0502, Inserm, Brest, 29200, France
| | - Laurent Misery
- Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Kanwaljeet J S Anand
- Pain/Stress Neurobiology Lab, Maternal and Child Health Research Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Jacques Sizun
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Jean-Michel Roué
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France. .,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France. .,Pain/Stress Neurobiology Lab, Maternal and Child Health Research Institute, Stanford University School of Medicine, Stanford, CA, USA.
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16
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Ilhan E, Pacey V, Brown L, Spence K, Gray K, Rowland JE, White K, Hush JM. Neonates as intrinsically worthy recipients of pain management in neonatal intensive care. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:65-72. [PMID: 33034802 DOI: 10.1007/s11019-020-09982-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.
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Affiliation(s)
- Emre Ilhan
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia.
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Ground Floor, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Verity Pacey
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Laura Brown
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Kaye Spence
- Children's Hospital at Westmead, Grace Centre for Newborn Intensive Care, Sydney, NSW, Australia
- School of Nursing and Midwifery, Western Sydney University, Parramatta, NSW, Australia
| | - Kelly Gray
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Jennifer E Rowland
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Karolyn White
- Research Ethics and Integrity, Macquarie University, Sydney, NSW, Australia
| | - Julia M Hush
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
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Relland LM, Neel ML, Gehred A, Maitre NL. Regional anesthesia in neonates and infants outside the immediate perioperative period: A systematic review of studies with efficacy and safety considerations. Paediatr Anaesth 2021; 31:132-144. [PMID: 33070411 DOI: 10.1111/pan.14042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
This review examines the quality and quantity of literature regarding methods that measure efficacy in the context of reported safety of regional anesthesia techniques in preterm and term infants <1 year of age. Because the role of anesthesiologists continues to expand outside the operating room, we focused on all relevant settings with assessments that extend beyond 24 hours from the intraoperative period. All study designs were included from a search of MEDLINE, EMBASE, CINAHL, Scopus, and Cochrane databases from 1946 to the end of 2019. A total of 31 studies were included (n = 1038 participants), consisting of five randomized controlled trials and 26 observational studies. Twenty-three studies examined neuraxial procedures, seven studies examined peripheral procedures, and one study examined both. Efficacy measures included pain assessment tools, analgesic use, and factors pertaining to the recovery of patients. Safety was assessed in multiple systems (neurological, cardiovascular, respiratory, pathological) and with vital signs and/or measures of systemic toxicity. Evidence in this review establishes that neuraxial and peripheral anesthesia treatments may be applied to neonates and infants with a high degree of safety. However, large gaps in the consistency of methods used to assess pain in these studies underline the need for rigorous prospective efficacy studies of these techniques in this population. This systematic review was registered on PROSPERO (CRD42018114466).
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Affiliation(s)
- Lance M Relland
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mary Lauren Neel
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alison Gehred
- Grant Morrow III Library, Nationwide Children's Hospital, Columbus, OH, USA
| | - Nathalie L Maitre
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
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18
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Knowledge and Practices in Neonatal Pain Management of Nurses Employed in Hospitals with Different Levels of Referral-Multicenter Study. Healthcare (Basel) 2021; 9:healthcare9010048. [PMID: 33466529 PMCID: PMC7824971 DOI: 10.3390/healthcare9010048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
Background: One of the key elements of patient care is the relief and prevention of pain sensations. The importance of pain prevention and treatment has been emphasized by many international organizations. Despite the recommendations and guidelines based on evidence, contemporary research shows that the problem of pain among patients in neonatal intensive care units (NICUs) in various centers is still an important and neglected problem. Aim: The aim of this study was to assess the level of knowledge of the medical personnel and their perception of the issue of pain in neonatal patients. Methods: A quantitative descriptive study carried out in 2019. The study used a nurses’ perceptions of neonatal pain questionnaire. Results: A total of 43 Polish hospitals and 558 respondents participated in the project. 60.9% (n = 340) and 39.1% (n = 218) of respondents were employed in secondary and tertiary referral departments, respectively. Conclusion: Our analyses indicate that despite the availability of pain assessment tools for neonatal patients, only a few centers use standardized tools. The introduction of strategies to promote and extend the personnel’s awareness of neonatal pain monitoring scales is necessary.
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Bosch-Alcaraz A, Jordan I, Guàrdia Olmos J, Falcó-Pegueroles A. Adaptación transcultural y características de la versión española de la escala COMFORT Behavior Scale en el paciente crítico pediátrico. Med Intensiva 2020; 44:542-550. [DOI: 10.1016/j.medin.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/07/2019] [Accepted: 07/02/2019] [Indexed: 11/26/2022]
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20
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Devsam BU, Kinney S. The clinical utility of the pain assessment tool in ventilated, sedated, and muscle-relaxed neonates. Aust Crit Care 2020; 34:333-339. [PMID: 33223388 DOI: 10.1016/j.aucc.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The neonatal Pain Assessment Tool (PAT) is considered a reliable and valid tool for assessing neonatal pain. No research has been conducted on the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. OBJECTIVE The objective of the study was to determine the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. METHODS Neonatal nurses from the Royal Children's Hospital completed online surveys to assess the clinical utility of the PAT. Three focus groups were then conducted to further explore the variation of pain scores from the survey and clarify the challenges in interpreting the pain score. RESULTS Nurses perceived the PAT clinically useful in neonates who were ventilated and minimally sedated. However, the PAT was not clinically useful in neonates who were ventilated and heavily sedated or muscle-relaxed. Further exploration via focus groups highlighted two themes related to the 'variation in the timing of the pain score' and the 'integration of critical thinking and judgement' used when assessing pain in neonates. CONCLUSIONS The clinical utility of the PAT is acceptable for minimally sedated neonates; however, it decreases the more sedated a neonate becomes, and the PAT's usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate's clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability, and clinical utility research, particularly in critically ill and muscle-relaxed neonates.
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Affiliation(s)
- Bianca U Devsam
- Neonatal Intensive Care Unit (Butterfly Ward), The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia; Nursing Research Department, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia; Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Victoria, 3010, Australia.
| | - Sharon Kinney
- Nursing Research Department, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia; Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Victoria, 3010, Australia
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Dietrich S, Bürger F, Kugler C. Implementierung eines neonatalen Schmerzassessmentinstruments auf einer neonatologischen Intensivstation - Ein Qualitätsentwicklungsprojekt. Pflege 2020; 33:385-395. [PMID: 33086942 DOI: 10.1024/1012-5302/a000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Implementation of a Neonatal Pain Assessment Instrument at a Neonatal Intensive Care Unit - A Quality Improvement Project Abstract. Background: Optimal pain management is necessary in order to not jeopardize the development of preterm neonates. Aim: Implementation and evaluation of systematic and best possible pain assessment with the Bernese Pain Scale for Neonates for all preterm and sick neonates of a neonatal intensive care unit by nursing staff. Methods: The educational concept is based on three key strategies: knowledge translation (group- and one-on-one training), reflection (case conferences) and clinical training. The frequency of the use of the Pain Score was recorded before (T0) and after implementation (T1) and six months after completion of the project (T2). Results: Before the implementation (T0) the use of the Bernese Pain Scale was regulated by an internal guideline but its application could not be verified during the baseline period (fulfillment rate of 0 %). After implementation (T1) at least one assessment per shift per neonate could be achieved in 99.1 % of the cases. Nurses conducted 210 assessments on 38 neonates in T1. In follow-up (T2) six months after implementation fulfillment rate of 100 % in 34 neonates was achieved with 188 pain assessments. Conclusions: This implementation strategy was successful in establishing the assessment instrument in clinical practice.
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Affiliation(s)
| | - Florian Bürger
- Charité Universitätsmedizin Berlin, Core Teams des Geschäftsbereichs Pflegedirektion
| | - Christiane Kugler
- Albert-Ludwigs-Universität Freiburg, Medizinische Fakultät, Institut für Pflegewissenschaft
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Wade C, Frazer JS, Qian E, Davidson LM, Dash S, Te Water Naudé A, Ramakrishan R, Aluvaala J, Lakhoo K, English M. Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysis. THE LANCET. CHILD & ADOLESCENT HEALTH 2020; 4:750-760. [PMID: 32735783 PMCID: PMC7507957 DOI: 10.1016/s2352-4642(20)30182-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 01/30/2023]
Abstract
Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings. METHODS We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO2), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aiguë du nouveau-né scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620. FINDINGS Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were -1·40 [95% CI -1·96 to -0·84] in PIPP score and -2·20 [-2·91 to -1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were -0·38 [-0·61 to -0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO2). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were -0·46 [95% CI -0·87 to -0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO2). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1-2 mL of expressed breastmilk should be given as first-line analgesic, or 1-2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible. INTERPRETATION We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings. FUNDING Wellcome Trust Research Programme, and the Africa-Oxford Initiative.
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Affiliation(s)
- Cian Wade
- Medical Sciences Division, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | | | - Evelyn Qian
- Medical Sciences Division, University of Oxford, Oxford, UK
| | | | - Suzanne Dash
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Rema Ramakrishan
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; University of New South Wales, Faculty of Medicine, Sydney, NSW, Australia
| | - Jalemba Aluvaala
- KEMRI Wellcome Trust, Nairobi, Kenya; Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Kokila Lakhoo
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Mike English
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; KEMRI Wellcome Trust, Nairobi, Kenya
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Jones L, Laudiano-Dray MP, Whitehead K, Meek J, Fitzgerald M, Fabrizi L, Pillai Riddell R. The impact of parental contact upon cortical noxious-related activity in human neonates. Eur J Pain 2020; 25:149-159. [PMID: 32965725 PMCID: PMC8436758 DOI: 10.1002/ejp.1656] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/13/2020] [Accepted: 08/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neonates display strong behavioural, physiological and cortical responses to tissue-damaging procedures. Parental contact can successfully regulate general behavioural and physiological reactivity of the infant, but it is not known whether it can influence noxious-related activity in the brain. Brain activity is highly dependent upon maternal presence in animal models, and therefore this could be an important contextual factor in human infant pain-related brain activity. METHODS Global topographic analysis was used to identify the presence and inter-group differences in noxious-related activity in three separate parental contexts. EEG was recorded during a clinically required heel lance in three age and sex-matched groups of neonates (a) while held by a parent in skin-to-skin (n = 9), (b) while held by a parent with clothing (n = 9) or (c) not held at all, but in individualized care (n = 9). RESULTS The lance elicited a sequence of 4-5 event-related potentials (ERPs), including the noxious ERP (nERP), which was smallest for infants held skin-to-skin and largest for infants held with clothing (p=0.016). The nERP was then followed by additional and divergent long-latency ERPs (> 750 ms post-lance), not previously described, in each of the groups, suggesting the engagement of different higher level cortical processes depending on parental contact. CONCLUSIONS These results show the importance of considering contextual factors in determining infant brain activity and reveal the powerful influence of parental contact upon noxious-related activity across the developing human brain. SIGNIFICANCE This observational study found that the way in which the neonatal brain processes a noxious stimulus is altered by the type of contact the infant has with their mother. Specifically, being held in skin-to-skin reduces the magnitude of noxious-related cortical activity. This work has also shown that different neural mechanisms are engaged depending on the mother/infant context, suggesting maternal contact can change how a baby's brain processes a noxious stimulus.
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Affiliation(s)
- Laura Jones
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
| | | | - Kimberley Whitehead
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing, University College London Hospitals, London, UK
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
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24
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Lavanga M, Smets L, Bollen B, Jansen K, Ortibus E, Huffel SV, Naulaers G, Caicedo A. A perinatal stress calculator for the neonatal intensive care unit: an unobtrusive approach. Physiol Meas 2020; 41:075012. [PMID: 32521528 DOI: 10.1088/1361-6579/ab9b66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Early experience of pain and stress in the neonatal intensive care unit is known to have an effect on the neurodevelopment of the infant. However, an automated method to quantify the procedural pain or perinatal stress in premature patients does not exist. APPROACH In the current study, EEG and ECG data were collected for more than 3 hours from 136 patients in order to quantify stress exposure. Specifically, features extracted from the EEG and heart-rate variability in both quiet and non-quiet sleep segments were used to develop a subspace linear-discriminant analysis stress classifier. MAIN RESULTS The main novelty of the study lies in the absence of intrusive methods or pain elicitation protocols to develop the stress classifier. Three main findings can be reported. First, we developed different stress classifiers for the different age groups and stress intensities, obtaining an area under the curve in the range [0.78-0.93] for non-quiet sleep and [0.77-0.96] for quiet sleep. Second, a dysmature EEG was found in patients under stress. Third, an enhanced cortical connectivity and increased brain-heart communication was correlated with a higher stress load, while the autonomic activity did not seem to be associated to stress exposure. SIGNIFICANCE The results shed a light on the pain and stress processing in preterm neonates, suggesting that software tools to investigate dysmature EEG might be helpful to assess stress load in premature patients. These results could be the foundation to assess the impact of stress on infants' development and to tune preventive care.
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Affiliation(s)
- M Lavanga
- Department of Electrical Engineering (ESAT), STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Kasteelpark Arenberg 10, box 2446, 3001, Leuven, Belgium. Authors contributed equally to this work
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25
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Ahmad MU, Farrell RM, Weise KL. Neonatal organ donation: Ethical insights and policy implications. J Neonatal Perinatal Med 2020; 12:369-377. [PMID: 31256079 DOI: 10.3233/npm-1850] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the realm of clinical ethics as well as in health policy and organizational ethics, the onus of our work as ethicists is to optimize the medical care and experience of the patient to better target ethical dilemmas that develop in the course of care delivery. The role of ethics is critical in all aspects of medicine, but particularly so in the difficult and often challenging cases that arise in the care of pregnant women and newborns. One exemplary situation is that when a pregnant woman and her partner consider neonatal organ donation after receiving news of a terminal diagnosis and expected death of the newborn. While a newer, less practiced form of organ donation, this approach is gaining greater visibility as an option for parents facing this terminal outcome. The aim of our paper is to highlight some of the key ethical issues associated with neonatal organ donation and identify clinical and logistical aspects of implementing such an approach to facilitate organ donation.
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Affiliation(s)
- M U Ahmad
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA
| | - R M Farrell
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA.,Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - K L Weise
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA.,Pediatric Institute, Cleveland Clinic Children's, Cleveland, OH, USA
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26
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Ercan N, Bostanci I, Şenel G, Özmen S. A More Comfortable Method of Skin Prick Testing in Children Ages 0-2 to Decrease Symptoms of Pain. Pain Manag Nurs 2020; 22:220-224. [PMID: 32624443 DOI: 10.1016/j.pmn.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/08/2020] [Accepted: 05/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Skin prick testing (SPT) is the best initial diagnostic method for individuals of all ages who have potential allergies. AIM We aimed to investigate if recent breastfeeding has any effect on reducing the pain of children before SPT. DESIGN Prospective, randomized, single-blinded study. SETTINGS Academic hospital specialized in pediatrics. PARTICIPANTS/SUBJECTS Sixty-four out of seventy-five children requiring SPT within ages 0-2 were included. METHODS All participants in this study were breastfed children, and that group assignment randomized them to the control group (n = 32) if children breastfed 30-90 min. prior to arriving for SPT, and study group of children (n = 32) who were also breastfed 30-90 minutes prior to arriving for SPT who were then breastfed again just prior to the beginning of the SPT. The FLACC pain scale was used to test the sensitivity of all children for pain before, during, and 15 minutes after the SPT. The effect of breastfeeding on the pain score and the duration of crying were compared among groups. RESULTS Both groups were similar according to age, gender, and other socio-demographic characteristics (p > .05). The percentage of children that cried during SPT was significantly higher in the control group than the study group (p = .002). The FLACC pain scale values were significantly lower in the study group (p < .001). CONCLUSION Recent breastfeeding before SPT is correlated with less crying by possibly reducing the perceived pain of children ages 0-2.
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Affiliation(s)
- Nazli Ercan
- University of Health Sciences, Ankara, Turkey.
| | | | - Gülay Şenel
- University of Health Sciences, Ankara, Turkey
| | - Serap Özmen
- University of Health Sciences, Ankara, Turkey
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27
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Schenk K, Stoffel L, Bürgin R, Stevens B, Bassler D, Schulzke S, Nelle M, Cignacco E. Acute pain measured with the modified Bernese Pain Scale for Neonates is influenced by individual contextual factors. Eur J Pain 2020; 24:1107-1118. [PMID: 32170786 DOI: 10.1002/ejp.1555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 02/28/2020] [Accepted: 03/11/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Individual contextual factors like gestational age (GA) or previous painful experiences have an influence on neonates' pain responses and may lead to inaccurate pain assessment when not appropriately considered. OBJECTIVES We set out to determine the influence of individual contextual factors on variability in pain response in neonates, measured with the modified Bernese Pain Scale for Neonates (BPSN), and, if necessary, to incorporate relevant individual factors into a revised version of the BPSN. METHODS We videotaped 154 full-term and preterm neonates of different GAs during 1-5 capillary heel sticks in their first 14 days of life. For each heel stick, we produced three video sequences: baseline, heel stick, and recovery. The randomized sequences were rated on the BPSN by five blinded nurses. Individual contextual factors were retrospectively extracted from patient charts and from the video recordings. We analysed the data in single and multiple linear mixed models. RESULTS Premature birth (b = -0.721), caffeine (b = -0.302), and the behavioural states quiet and awake (b = -0.283), active and asleep (b = -0.158), and quiet and asleep (b = -0.498) were associated with changes in behavioural pain scores. Premature birth (b = -0.232), mechanical ventilation (b = -0.196), and duration of the heel stick procedure (b = 0.0004) were associated with changes in physiological pain scores. Premature birth (b = -0.907), Caffeine (b = -0.402), the behavioural states quiet and awake (b = -0.274), and quiet and asleep (b = -0.459), and duration of the heel stick procedure (b = 0.001) were associated with changes in the modified BPSN total scores. CONCLUSIONS Postmenstrual age, behavioural state, caffeine, and ventilation status have an influence on neonates' pain response and should be incorporated in the revised BPSN to enhance clinical pain assessment in neonates with different GAs. SIGNIFICANCE We identified individual contextual factors associated with dampened pain response in neonates and will incorporate them into a revised version of the Bernese Pain Scale for Neonates to provide clinicians with a tool they can use to more accurately assess and manage pain in this vulnerable population.
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Affiliation(s)
- Karin Schenk
- Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Lilian Stoffel
- Neonatalogy, Children's Hospital, University Hospital of Bern, Bern, Switzerland
| | - Reto Bürgin
- Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Bonnie Stevens
- Lawrence S. Bloomberg Faculty of Nursing and Faculties of Medicine and Dentistry, University of Toronto, Toronto, Canada
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Sven Schulzke
- Department of Neonatology, University Children's Hospital Basel UKBB, Basel, Switzerland
| | - Mathias Nelle
- Department of Neonatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Eva Cignacco
- Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
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28
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McPherson C, Miller SP, El-Dib M, Massaro AN, Inder TE. The influence of pain, agitation, and their management on the immature brain. Pediatr Res 2020; 88:168-175. [PMID: 31896130 PMCID: PMC7223850 DOI: 10.1038/s41390-019-0744-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/11/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU). The adverse neurobiological impact of pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Although many tools have been validated to assess acute pain, few methods are available to assess chronic pain or agitation (a clinical manifestation of neonatal stress). Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of pain and agitation in the preterm infant, with concerns emerging over the adverse effects of analgesia and sedatives. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat pain. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures. Sucrose may be utilized judiciously as an adjunctive therapy for minor painful procedures. Rapidly acting opioids (fentanyl or remifentanil) form the backbone of analgesia for moderately painful procedures. Chronic sedation during invasive mechanical ventilation represents an ongoing challenge; appropriate containment and an optimal environment should be standard; when indicated, low-dose morphine infusion may be utilized cautiously and dexmedetomidine infusion may be considered as an emerging adjunct.
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Affiliation(s)
- Christopher McPherson
- 0000 0000 9953 7617grid.416775.6Department of Pharmacy, St. Louis Children’s Hospital, St. Louis, MO USA ,0000 0001 2355 7002grid.4367.6Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA
| | - Steven P. Miller
- 0000 0004 0473 9646grid.42327.30Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON Canada
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - An N. Massaro
- 0000 0004 1936 9510grid.253615.6Department of Pediatrics—Neonatology Division, The George Washington University School of Medicine and Children’s National Health System, Washington, DC USA
| | - Terrie E. Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
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29
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Abstract
Preterm and term neonate pain assessment in neonatal intensive care units is vitally important because of the prevalence of procedural and postoperative pain. Of the 40 plus tools available, a few should be chosen for different populations and contexts (2 have been validated in premature infants). Preterm neonates do not display pain behaviors and physiologic indicators as reliably and specifically as full-term infants, and are vulnerable to long-term sequelae of painful experiences. Brain-oriented approaches may become available in the future; meanwhile, neonatal pain assessment tools must be taught, implemented, and their use optimized for consistent, reproducible, safe, and effective treatment.
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Affiliation(s)
- Lynne G Maxwell
- Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood 6021, Philadelphia, PA 19104, USA.
| | - María V Fraga
- Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Carrie P Malavolta
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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30
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Völler S, Flint RB, Andriessen P, Allegaert K, Zimmermann LJI, Liem KD, Koch BCP, Simons SHP, Knibbe CAJ. Rapidly maturing fentanyl clearance in preterm neonates. Arch Dis Child Fetal Neonatal Ed 2019; 104:F598-F603. [PMID: 31498775 DOI: 10.1136/archdischild-2018-315920] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fentanyl is frequently used off-label in preterm newborns. Due to very limited pharmacokinetic and pharmacodynamic data, fentanyl dosing is mostly based on bodyweight. This study describes the maturation of the pharmacokinetics in preterm neonates born before 32 weeks of gestation. METHODS 442 plasma samples from 98 preterm neonates (median gestational age: 26.9 (range 23.9-31.9) weeks, postnatal age: 3 (range 0-68) days, bodyweight 1.00 (range 0.39-2.37) kg) were collected in an opportunistic trial and fentanyl plasma levels were determined. NONMEM V.7.3 was used to develop a population pharmacokinetic model and to perform simulations. RESULTS Fentanyl pharmacokinetics was best described by a two-compartment model. A pronounced non-linear influence of postnatal and gestational age on clearance was identified. Clearance (L/hour/kg) increased threefold, 1.3-fold and 1.01-fold in the first, second and third weeks of life, respectively. In addition, clearance (L/hour/kg) was 1.4-fold and 1.7-fold higher in case of a gestational age of 28 and 31 weeks, respectively, compared with 25 weeks. Volume of distribution changed linearly with bodyweight and was 8.7 L/kg. To achieve similar exposure across the entire population, a continuous infusion (µg/kg/hour) dose should be reduced by 50% and 25% in preterm neonates with a postnatal age of 0-4 days and 5-9 days in comparison to 10 days and older. CONCLUSION Because of low clearance, bodyweight-based dosages may result in fentanyl accumulation in neonates with the lowest postnatal and gestational ages which may require dose reduction. Together with additional information on the pharmacodynamics, the results of this study can be used to guide dosing.
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Affiliation(s)
- Swantje Völler
- Division of Pharmacology, Division Systems Pharmacology and Biomedicine, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Robert B Flint
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Andriessen
- Division of Neonatology, Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Karel Allegaert
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Luc J I Zimmermann
- Department of Pediatrics, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kian D Liem
- Division of Neonatology, Department of Pediatrics, Radboudumc, Nijmegen, The Netherlands
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Division of Pharmacology, Division Systems Pharmacology and Biomedicine, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
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31
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The Indonesian version of the Premature Infant Pain Profile-Revised: Translation and adaptation of a neonatal pain assessment. Int J Nurs Sci 2019; 6:439-444. [PMID: 31728398 PMCID: PMC6838999 DOI: 10.1016/j.ijnss.2019.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/12/2019] [Accepted: 06/26/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose Pain assessment is a key component of good pain management in hospitalized infants. This study aimed to translate and adapt a version of pain measurement in infants, the Premature Infant Pain Profile Revised (PIPP-R) into Indonesian. Method The adaptation process of the measuring instrument used a modified Brislin method which included forward translation, back translation 1, group discussion 1, back translation 2, group discussion 2, and pilot testing on neonatal nurses: feasibility test, inter-rater reliability using intraclass correlation (ICC), and internal consistency using Cronbach's α coefficient. Results The PIPP-R version in English has been translated into Indonesian. In general, nurses assessed this measuring instrument as feasible. The inter-rater reliability showed a high agreement (ICC = 0.968, P = 0.001) and this measuring instrument had good internal consistency (Cronbach's α = 0.856). Conclusion The Indonesian version of PIPP-R is easy to use and shows good psychometric properties. The use of this measuring instrument will help nurses and researchers obtain accurate infant pain intensity measurement values.
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Vaart M, Duff E, Raafat N, Rogers R, Hartley C, Slater R. Multimodal pain assessment improves discrimination between noxious and non‐noxious stimuli in infants. ACTA ACUST UNITED AC 2019; 1:21-30. [PMID: 35546868 PMCID: PMC8974881 DOI: 10.1002/pne2.12007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/25/2019] [Accepted: 08/07/2019] [Indexed: 11/30/2022]
Abstract
Infants in neonatal intensive care units frequently experience clinically necessary painful procedures, which elicit a range of behavioral, physiological, and neurophysiological responses. However, the measurement of pain in this population is a challenge and no gold standard exists. The aim of this study was to investigate how noxious‐evoked changes in facial expression, reflex withdrawal, brain activity, heart rate, and oxygen saturation are related and to examine their accuracy in discriminating between noxious and non‐noxious stimuli. In 109 infants who received a clinically required heel lance and a control non‐noxious stimulus, we investigated whether combining responses across each modality, or including multiple measures from within each modality improves our ability to discriminate the noxious and non‐noxious stimuli. A random forest algorithm was used to build data‐driven models to discriminate between the noxious and non‐noxious stimuli in a training set which were then validated in a test set of independent infants. Measures within each modality were highly correlated, while different modalities showed less association. The model combining information across all modalities had good discriminative ability (accuracy of 0.81 in identifying noxious and non‐noxious stimuli), which was higher than the discriminative power of the models built from individual modalities. This demonstrates the importance of including multiple modalities in the assessment of infant pain.
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Affiliation(s)
- Marianne Vaart
- Department of Paediatrics University of Oxford Oxford UK
| | - Eugene Duff
- Department of Paediatrics University of Oxford Oxford UK
| | - Nader Raafat
- Department of Paediatrics University of Oxford Oxford UK
| | - Richard Rogers
- Nuffield Department of Anaesthesia John Radcliffe Hospital Oxford UK
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Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach. Clin Ther 2019; 41:1701-1713. [PMID: 31431300 DOI: 10.1016/j.clinthera.2019.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain. FINDINGS After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking. IMPLICATIONS The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.
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Abstract
Hospitalized newborn infants experience pain that can have negative short- and long-term consequences and thus should be prevented and treated. National and international guidelines state that adequate pain management requires valid pain assessment. Nociceptive signals cause a cascade of physical and behavioral reactions that alone or in combination can be observed and used to assess the presence and intensity of pain. Units that are caring for newborn infants must adopt sufficient pain assessment tools to cover the gestational ages and pain types that occurs in their setting. Pain assessment should be performed on a regular basis and any detection of pain should be acted on. Future research should focus on developing and validating pain assessment tools for specific situations.
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Affiliation(s)
- Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, S-701 85, Örebro, Sweden.
| | - Marsha Campbell-Yeo
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, S-701 85, Örebro, Sweden; School of Nursing, Faculty of Health, Departments of Pediatrics, Psychology & Neuroscience, Dalhousie University, 5850/5890 University Ave, Halifax, NS, B3K 6R8, Canada; Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada.
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Meesters N, Dilles T, Simons S, van Dijk M. Do Pain Measurement Instruments Detect the Effect of Pain-Reducing Interventions in Neonates? A Systematic Review on Responsiveness. THE JOURNAL OF PAIN 2019; 20:760-770. [DOI: 10.1016/j.jpain.2018.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/25/2018] [Accepted: 12/08/2018] [Indexed: 01/05/2023]
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Green G, Hartley C, Hoskin A, Duff E, Shriver A, Wilkinson D, Adams E, Rogers R, Moultrie F, Slater R. Behavioural discrimination of noxious stimuli in infants is dependent on brain maturation. Pain 2019; 160:493-500. [PMID: 30422872 PMCID: PMC6343955 DOI: 10.1097/j.pain.0000000000001425] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 11/26/2022]
Abstract
Changes in facial expression are an essential form of social communication and in nonverbal infants are often used to alert care providers to pain-related distress. However, studies of early human brain development suggest that premature infants aged less than 34 weeks' gestation do not display discriminative brain activity patterns to equally salient noxious and innocuous events. Here we examine the development of facial expression in 105 infants, aged between 28 and 42 weeks' gestation. We show that the presence of facial expression change after noxious and innocuous stimulation is age-dependent and that discriminative facial expressions emerge from approximately 33 weeks' gestation. In a subset of 49 infants, we also recorded EEG brain activity and demonstrated that the temporal emergence of facial discrimination mirrors the developmental profile of the brain's ability to generate discriminative responses. Furthermore, within individual infants, the ability to display discriminative facial expressions is significantly related to brain response maturity. These data demonstrate that the emergence of behavioural discrimination in early human life corresponds to our brain's ability to discriminate noxious and innocuous events and raises fundamental questions as to how best to interpret infant behaviours when measuring and treating pain in premature infants.
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Affiliation(s)
- Gabrielle Green
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Eugene Duff
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Adam Shriver
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom
| | - Dominic Wilkinson
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Richard Rogers
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, United Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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The influence of gestational age in the psychometric testing of the Bernese Pain Scale for Neonates. BMC Pediatr 2019; 19:20. [PMID: 30646872 PMCID: PMC6334397 DOI: 10.1186/s12887-018-1380-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 12/20/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Assessing pain in neonates is challenging because full-term and preterm neonates of different gestational ages (GAs) have widely varied reactions to pain. We validated the Bernese Pain Scale for Neonates (BPSN) by testing its use among a large sample of neonates that represented all GAs. METHODS In this prospective multisite validation study, we assessed 154 neonates between 24 2/7 and 41 4/7 weeks GA, based on the results of 1-5 capillary heel sticks in their first 14 days of life. From each heel stick, we produced three video sequences: baseline; heel stick; and, recovery. Five blinded nurses rated neonates' pain responses according to the BPSN. The underlying factor structure of the BPSN, interrater reliability, concurrent validity with the Premature Infant Pain Profile-Revised (PIPP-R), construct validity, sensitivity and specificity, and the relationship between behavioural and physiological indicators were explored. We considered GA and gender as individual contextual factors. RESULTS The factor analyses resulted in a model where the following behaviours best fit the data: crying; facial expression; and, posture. Pain scores for these behavioural items increased on average more than 1 point during the heel stick phases compared to the baseline and recovery phases (p < 0.001). Among physiological items, heart rate was more sensitive to pain than oxygen saturation. Heart rate averaged 0.646 points higher during the heel stick than the recovery phases (p < 0.001). GA increased along with pain scores: for every additional week of gestation, the average increase of behavioural pain score was 0.063 points (SE = 0.01, t = 5.49); average heart rate increased 0.042 points (SE = 0.01, t = 6.15). Sensitivity and specificity analyses indicated that the cut-off should increase with GA. Modified BPSN showed good concurrent validity with the PIPP-R (r = 0.600-0.758, p < 0.001). Correlations between the modified behavioural subscale and the item heart rate were low (r = 0.102-0.379). CONCLUSIONS The modified BPSN that includes facial expression, crying, posture, and heart rate is a reliable and valid tool for assessing acute pain in full-term and preterm neonates, but our results suggest that adding different cut-off points for different GA-groups will improve the BPSN's clinical usefulness. TRIAL REGISTRATION The study was retrospectively registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461 . Registration date: 12 April 2016.
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Toye JM, Yang J, Sankaran K. Narcotics and sedatives use in the mechanical ventilation in preterm infants: Predictors and outcome. J Neonatal Perinatal Med 2019; 12:135-141. [PMID: 30614810 DOI: 10.3233/npm-17157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mechanical ventilation (MV) causes discomfort but whether it causes pain remains controversial. Around the world neonatal intensive care units (NICU) often utilize narcotics and/or sedatives during MV of vulnerable infants yet the association with adverse neonatal outcomes has not been adequately addressed. OBJECTIVE Test for associations between the use of narcotics/sedatives during MV and mortality/morbidity in preterm infants in a large infant cohort in Canada. DESIGN/METHODS Preterm infants born <35 weeks gestational age (GA) requiring MV for >24 hrs were identified retrospectively from the Canadian Neonatal Network database, 2010-12. Infants were categorized according to whether they received narcotics/sedatives for greater than 24 hours concurrently with MV. Infants were excluded if moribund on admission, had major congenital anomalies, diagnoses where narcotic administration is routine and suspected seizures. Multivariable logistic and linear regression analysis tested for association of narcotics/sedatives use during MV with mortality/morbidity (nosocomial infections, BPD, ROP, IVH) and length of MV. RESULTS After exclusions the cohort included 2672 infants; 467(17%) exposed only to narcotics 101(4%) only to sedatives and 299(11%) to both. All models were adjusted for GA, gender, small for GA, SNAP-II score >20, multiple births, delivery mode, outborn, PDA status, MV type, use of high flow, muscle relaxant use, indwelling lines, caffeine and surfactant therapy. The composite mortality/morbidity, and MV days were significantly higher for MV infants exposed to narcotics, sedatives or both compared to infants not exposed. CONCLUSION Mounting evidence of the adverse short and long-term impacts of narcotics/sedatives during MV supports the need for further work in alternative therapies.
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Affiliation(s)
- J M Toye
- University of Alberta, Division of Neonatology, Department of Pediatrics, Alberta, Canada
| | - J Yang
- Mount Sinai Hospital, Maternal-Infant Care Research Centre, Ontario, Canada
| | - K Sankaran
- Department of Pediatrics, University of Saskatchewan, Division of Neonatology, SK, Canada
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Relland LM, Gehred A, Maitre NL. Behavioral and Physiological Signs for Pain Assessment in Preterm and Term Neonates During a Nociception-Specific Response: A Systematic Review. Pediatr Neurol 2019; 90:13-23. [PMID: 30449602 DOI: 10.1016/j.pediatrneurol.2018.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/26/2018] [Accepted: 10/03/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND/GOAL Assessment and treatment of neonatal pain is difficult because current scales are rarely validated against brain-based evidence. We sought to systematically evaluate published evidence to extract validation of the most promising markers of neonatal pain. METHODS We searched four databases using germane MeSH terms. We focused on assessments of pain and/or nociception that had at least two measures among behavioral, physiological, or cortical components in preterm and/or term neonates. We evaluated studies for quality of evidence and strength of recommendations using standardized tools. RESULTS Fifteen articles met our inclusion criteria. Among the behavioral components uncovered in this review, the withdrawal reflex and changes in facial expression are the most strongly associated with nociception-specific brain activity. These associations may be influenced by gestational age and change over time. Physiological signs, such heart rate and oxygen saturation, have little to no association with this type of response. CONCLUSIONS Current assessments of neonatal pain include behavioral components that are associated with nociceptive processing, but also other less valid components, while omitting newer measures based on neuroscientific research.
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Affiliation(s)
- Lance M Relland
- Center for Clinical and Translational Research at Nationwide Children's Hospital, Columbus, Ohio; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio.
| | - Alison Gehred
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Nathalie L Maitre
- Center for Perinatal Research at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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Hartley C, Moultrie F, Hoskin A, Green G, Monk V, Bell JL, King AR, Buckle M, van der Vaart M, Gursul D, Goksan S, Juszczak E, Norman JE, Rogers R, Patel C, Adams E, Slater R. Analgesic efficacy and safety of morphine in the Procedural Pain in Premature Infants (Poppi) study: randomised placebo-controlled trial. Lancet 2018; 392:2595-2605. [PMID: 30509743 PMCID: PMC6294828 DOI: 10.1016/s0140-6736(18)31813-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/16/2018] [Accepted: 08/01/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Infant pain has immediate and long-term effects but is undertreated because of a paucity of evidence-based analgesics. Although morphine is often used to sedate ventilated infants, its analgesic efficacy is unclear. We aimed to establish whether oral morphine could provide effective and safe analgesia in non-ventilated premature infants for acute procedural pain. METHODS In this single-centre masked trial, 31 infants at the John Radcliffe Hospital, Oxford, UK, were randomly allocated using a web-based facility with a minimisation algorithm to either 100 μg/kg oral morphine sulphate or placebo 1 h before a clinically required heel lance and retinopathy of prematurity screening examination, on the same occasion. Eligible infants were born prematurely at less than 32 weeks' gestation or with a birthweight lower than 1501 g and had a gestational age of 34-42 weeks at the time of the study. The co-primary outcome measures were the Premature Infant Pain Profile-Revised (PIPP-R) score after retinopathy of prematurity screening and the magnitude of noxious-evoked brain activity after heel lancing. Secondary outcome measures assessed physiological stability and safety. This trial is registered with the European Clinical Trials Database (number 2014-003237-25). FINDINGS Between Oct 30, 2016, and Nov 17, 2017, 15 infants were randomly allocated to morphine and 16 to placebo; one infant assigned placebo was withdrawn from the study before monitoring began. The predefined stopping boundary was crossed, and trial recruitment stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. None of the co-primary outcome measures differed significantly between groups. PIPP-R score after retinopathy of prematurity screening was mean 11·1 (SD 3·2) with morphine and 10·5 (3·4) with placebo (mean difference 0·5, 95% CI -2·0 to 3·0; p=0·66). Noxious-evoked brain activity after heel lancing was median 0·99 (IQR 0·40-1·56) with morphine and 0·75 (0·33-1·22) with placebo (median difference 0·25, 95% CI -0·16 to 0·80; p=0·25). INTERPRETATION Administration of oral morphine (100 μg/kg) to non-ventilated premature infants has the potential for harm without analgesic efficacy. We do not recommend oral morphine for retinopathy of prematurity screening and strongly advise caution if considering its use for other acute painful procedures in non-ventilated premature infants. FUNDING Wellcome Trust and National Institute for Health Research.
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Affiliation(s)
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew R King
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Miranda Buckle
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Deniz Gursul
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sezgi Goksan
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane E Norman
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Richard Rogers
- Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Chetan Patel
- Department of Ophthalmology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
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Azevedo-Santos IF, DeSantana JM. Pain measurement techniques: spotlight on mechanically ventilated patients. J Pain Res 2018; 11:2969-2980. [PMID: 30538536 PMCID: PMC6255280 DOI: 10.2147/jpr.s151169] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background Procedural pain is a frequent problem in intensive care units (ICUs). For that, pain assessment has been increasingly introduced to the ICU professional’s routine, and studies have been developed to show the relevance of measuring pain in critically ill patients. Objective This review aimed to describe pain measurement techniques for mechanically ventilated adult patients based on evidence and already published. Method Systematic literature search was performed on PubMed and Google Scholar. Keywords “pain”, “pain measurement”, “intensive care units” and “respiration, artificial” were combined to the Boolean operator AND. No language or publication year was limited in this search. The purpose and method of all papers were analyzed and only studies which described pain assessment in mechanically ventilated patients were included in this review. Results Objective methods were found in the literature to assess pain in mechanically ventilated adults. Behavioral scales were the most used method for pain measurement in noncommunicative patients. Vital signs were used, but the reliability of this method was questioned. Pupillometry, bispectral index and skin conductance were found and described as pain assessment methods. Conclusion This review showed that objective measures, as behavioral scales, are the gold standard tools to measure pain intensity in noncommunicative subjects. These data contribute to professionals’ knowledge about ICU pain measurement and emphasize its importance and consequences for adequate pain management.
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Affiliation(s)
- Isabela Freire Azevedo-Santos
- Neuroscience Research Laboratory (LAPENE), Department of Physical Therapy, Graduate Program of Health Science, Graduate Program of Physiological Science, Federal University of Sergipe, Aracaju, Sergipe, Brazil,
| | - Josimari Melo DeSantana
- Neuroscience Research Laboratory (LAPENE), Department of Physical Therapy, Graduate Program of Health Science, Graduate Program of Physiological Science, Federal University of Sergipe, Aracaju, Sergipe, Brazil,
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Hartley C, Duff EP, Green G, Mellado GS, Worley A, Rogers R, Slater R. Nociceptive brain activity as a measure of analgesic efficacy in infants. Sci Transl Med 2018; 9:9/388/eaah6122. [PMID: 28469039 DOI: 10.1126/scitranslmed.aah6122] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/30/2016] [Accepted: 03/21/2017] [Indexed: 01/08/2023]
Abstract
Pain in infants is undertreated and poorly understood, representing a major clinical problem. In part, this is due to our inability to objectively measure pain in nonverbal populations. We present and validate an electroencephalography-based measure of infant nociceptive brain activity that is evoked by acute noxious stimulation and is sensitive to analgesic modulation. This measure should be valuable both for mechanistic investigations and for testing analgesic efficacy in the infant population.
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Affiliation(s)
- Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Eugene P Duff
- Functional Magnetic Resonance Imaging of the Brain Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Gabrielle Green
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | | | - Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Richard Rogers
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK.
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Does Topical Lidocaine Reduce the Pain Associated With the Insertion of Nasal Continuous Positive Airway Pressure Prongs in Preterm Infants?: A Randomized, Controlled Pilot Trial. Clin J Pain 2017; 32:948-954. [PMID: 26710224 DOI: 10.1097/ajp.0000000000000341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy of topical lidocaine 2% gel in reducing the pain associated with the insertion of nasal continuous positive airway pressure (nCPAP) prongs in preterm infants. MATERIALS AND METHODS A pilot randomized controlled trial. Sixty preterm infants, categorized into lidocaine (n=30) and control groups (n=30). The primary outcome was Premature Infant Pain Profile (PIPP) score, secondary outcomes included salivary cortisol, presence of cry, the duration of first cry, and adverse effects of lidocaine. RESULTS There were no statistically significant differences between lidocaine and control groups regarding PIPP scores (mean±SD: 7.2±2.3 vs. 9.3±3.0, respectively, P=0.086). None of the infants in the lidocaine group had severe pain defined as a PIPP score>12, compared with 3 (10%) infants in the control group (P=0.056). Salivary cortisol concentrations were not significantly different between the lidocaine and control groups (mean±SD: 2.57±1.79 vs. 4.82±1.61 μg/dL, respectively, P=0.11). Standardized effect sizes for topical lidocaine were medium to large for reduction in PIPP scores and large for reduction in salivary cortisol (Cohen d=-0.78 and -1.32, respectively). No adverse effects were reported in infants receiving lidocaine. DISCUSSION Our data suggest that topical lidocaine did not reduce the pain associated with the insertion of nCPAP prongs in preterm infants. However, the trends for lower PIPP scores in the lidocaine group and the effect sizes for lidocaine on PIPP scores and salivary cortisol were large enough so that a large-scale randomized clinical trial is warranted to confirm or refute our results. Such a study should compare 2 or more active pain interventions during nCPAP application, rather than evaluating a single intervention versus placebo or no treatment.
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Anand KJS, Eriksson M, Boyle EM, Avila-Alvarez A, Andersen RD, Sarafidis K, Polkki T, Matos C, Lago P, Papadouri T, Attard-Montalto S, Ilmoja ML, Simons S, Tameliene R, van Overmeire B, Berger A, Dobrzanska A, Schroth M, Bergqvist L, Courtois E, Rousseau J, Carbajal R. Assessment of continuous pain in newborns admitted to NICUs in 18 European countries. Acta Paediatr 2017; 106:1248-1259. [PMID: 28257153 DOI: 10.1111/apa.13810] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 02/06/2017] [Accepted: 02/21/2017] [Indexed: 12/25/2022]
Abstract
AIM Continuous pain occurs routinely, even after invasive procedures, or inflammation and surgery, but clinical practices associated with assessments of continuous pain remain unknown. METHODS A prospective cohort study in 243 neonatal intensive care units (NICUs) from 18 European countries recorded the frequency of pain assessments, use of mechanical ventilation, sedation, analgesia or neuromuscular blockade for each neonate for up to 28 days after NICU admission. RESULTS Only 2113 of 6648 (31.8%) of neonates received assessments of continuous pain, occurring variably among tracheal ventilation (TrV, 46.0%), noninvasive ventilation (NiV, 35.0%) and no ventilation (NoV, 20.1%) groups (p < 0.001). Daily assessments for continuous pain occurred in only 10.4% of all neonates (TrV: 14.0%, NiV: 10.7%, NoV: 7.6%; p < 0.001). More frequent assessments of continuous pain occurred in NICUs with pain guidelines, nursing champions and surgical admissions (all p < 0.01), and for newborns <32 weeks gestational age, those requiring ventilation, or opioids, sedatives-hypnotics, general anaesthetics (O-SH-GA) (all p < 0.001), or surgery (p = 0.028). Use of O-SH-GA drugs increased the odds for pain assessment in the TrV (OR:1.60, p < 0.001) and NiV groups (OR:1.40, p < 0.001). CONCLUSION Assessments of continuous pain occurred in less than one-third of NICU admissions and daily in only 10% of neonates. NICU clinical practices should consider including routine assessments of continuous pain in newborns.
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Affiliation(s)
- Kanwaljeet J. S. Anand
- Departments of Pediatrics, Anesthesiology, Perioperative & Pain Medicine; Stanford University School of Medicine; Stanford CA USA
| | - Mats Eriksson
- School of Health Sciences; Faculty of Medicine and Health; Örebro University; Örebro Sweden
| | - Elaine M. Boyle
- Department of Health Sciences; University of Leicester; Leicester UK
| | | | | | - Kosmas Sarafidis
- 1st Department of Neonatology; ‘Hippokrateion’ General Hospital; Aristotle University of Thessaloniki; Thessalokiki Greece
| | - Tarja Polkki
- Children and Women Department; Oulu University Hospital; Oulu Finland
| | | | - Paola Lago
- Department of Woman's and Child's Health; University of Padua; Padua Italy
| | - Thalia Papadouri
- Department of Paediatrics; Arch. Makarios III Hospital; Nicosia Cyprus
| | | | - Mari-Liis Ilmoja
- Department of Paediatrics; Tallinn Children's Hospital; Tallinn Estonia
| | - Sinno Simons
- Department of Pediatrics; Erasmus MC-Sophia Kinderziekenhuis; Rotterdam The Netherlands
| | - Rasa Tameliene
- Department of Neonatology; Kaunas Perinatal Center; Lithuanian University of Health Sciences; Kaunas Lithuania
| | - Bart van Overmeire
- Cliniques Universitaires de Bruxelles; Erasme Hospital; Bruxelles Belgium
| | - Angelika Berger
- Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
| | - Anna Dobrzanska
- Department of Neonatology; Children's Memorial Health Institute Warsaw; Warszawa Poland
| | - Michael Schroth
- Department of Paediatrics; Cnopf'sche Kinderklinik; Nürnberg Children's Hospital; Nürenberg Germany
| | - Lena Bergqvist
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; Solna Sweden
| | - Emilie Courtois
- Urgences Pédiatriques; Hôpital Armand Trousseau; INSERM U1153; Université Pierre et Marie Curie Paris VI; Paris VI Paris France
| | - Jessica Rousseau
- Urgences Pédiatriques; Hôpital Armand Trousseau; INSERM U1153; Université Pierre et Marie Curie Paris VI; Paris VI Paris France
| | - Ricardo Carbajal
- Urgences Pédiatriques; Hôpital Armand Trousseau; INSERM U1153; Université Pierre et Marie Curie Paris VI; Paris VI Paris France
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Sorrentino G, Fumagalli M, Milani S, Cortinovis I, Zorz A, Cavallaro G, Mosca F, Plevani L. The impact of automatic devices for capillary blood collection on efficiency and pain response in newborns: A randomized controlled trial. Int J Nurs Stud 2017; 72:24-29. [DOI: 10.1016/j.ijnurstu.2017.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 03/29/2017] [Accepted: 04/04/2017] [Indexed: 01/12/2023]
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Benoit B, Martin-Misener R, Newman A, Latimer M, Campbell-Yeo M. Neurophysiological assessment of acute pain in infants: a scoping review of research methods. Acta Paediatr 2017; 106:1053-1066. [PMID: 28326623 DOI: 10.1111/apa.13839] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
Abstract
A systematic scoping search to describe the neurophysiological methods used in infant acute pain assessment research was conducted. Of the 2411 abstracts screened, 19 articles were retained. Nine studies utilised near-infrared spectroscopy (NIRS), two utilised functional magnetic resonance imaging (fMRI), and eight utilised electroencephalography (EEG). There was methodological variability in studies utilising NIRS, whereas EEG and fMRI studies reported consistent methods. Of the eight EEG studies, six identified a nociceptive-specific event-related potential. CONCLUSION While more methodologically rigorous studies are needed, ERPs appear to hold some promise as indicators of infant nociception during clinical procedures to supplement existing measures.
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Affiliation(s)
- B Benoit
- School of Nursing; Dalhousie University; Halifax Nova Scotia Canada
- Centre for Pediatric Pain Research; IWK Health Centre; Halifax NS Canada
- Maternal Newborn Program; IWK Health Centre; Halifax NS Canada
| | - R Martin-Misener
- School of Nursing; Dalhousie University; Halifax Nova Scotia Canada
| | - A Newman
- Department of Psychology and Neuroscience; Dalhousie University; Halifax NS Canada
- Department of Pediatrics; IWK Health Centre; Halifax NS Canada
| | - M Latimer
- School of Nursing; Dalhousie University; Halifax Nova Scotia Canada
- Centre for Pediatric Pain Research; IWK Health Centre; Halifax NS Canada
- Department of Pain, Anesthesia and Perioperative Medicine; Faculty of Medicine; Dalhousie University; Halifax NS Canada
| | - M Campbell-Yeo
- School of Nursing; Dalhousie University; Halifax Nova Scotia Canada
- Centre for Pediatric Pain Research; IWK Health Centre; Halifax NS Canada
- Maternal Newborn Program; IWK Health Centre; Halifax NS Canada
- Department of Psychology and Neuroscience; Dalhousie University; Halifax NS Canada
- Department of Pediatrics; IWK Health Centre; Halifax NS Canada
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Meyer-Frießem CH, Jess G, Pogatzki-Zahn EM, Zahn PK. Cerebral oxygenation for pain monitoring in adults is ineffective: A sequence-randomized, sham controlled study in volunteers. Scand J Pain 2017; 16:129-135. [PMID: 28850388 DOI: 10.1016/j.sjpain.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/01/2017] [Accepted: 05/02/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pain assessment by Numeric Rating Scale (NRS) is considered to be good clinical practice, but objective pain assessment is still a challenge. Near infrared spectroscopy (NIRS) measures cerebral tissue oxygen saturation (SctO2) that increases with cortical-neuronal activity and may provide point-of-care bedside pain monitoring. Analogous to promising studies in newborns, we hypothesize that different levels of SctO2 can probably quantify pain intensity. SctO2 may increase following painful in contrast to non-painful or sham stimuli and may correlate with pain intensity as assessed by NRS in volunteers. METHODS Twenty healthy male students (24.2±1.9 years), recruited via local advertising, were consecutively included in a sequence-randomized, sham-controlled, single-blinded study. SctO2 was recorded continuously with two NIRS sensors on the forehead. After resting, four stimuli were applied in a random order on the right forearm (unexpected and expected electrical pain, expected non-painful and sham stimuli). Blinded subjects were asked to rate each stimulus on NRS. STATISTICS RM-ANOVA; Wilcoxon or paired Student t-test; Spearman's rank correlation; P<.05. RESULTS Resting volunteers showed SctO2 of 72.65%±3.39. SctO2 significantly increased for about 60 to 70s until a maximum after unexpected painful (74.62%±3.9; P=.022) and sham stimuli (74.07%±3.23; P=.014). Expected painful (P=.139) and non-painful stimuli (P=.455) resulted in no changes in SctO2. NRS scores (median, IQR) were rated significantly higher after expected (5.25, 3.5 to 6.75) than after unexpected (4.5, 3 to 5; P=.008) pain. No strong correlation was found between NRS and SctO2. CONCLUSIONS AND IMPLICATIONS Contrary to our expectations, measuring SctO2 via a two-channel NIRS is not able to remediate the lack of objective bedside pain assessment under standardized experimental conditions in alert adults. TRIAL REGISTRATION DRKS 00011575 (retrospectively registered).
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Affiliation(s)
- Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care and Pain Management, BG-Universitätsklinikum Bergmannsheil GmbH Bochum, Medical Faculty of Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.
| | - Gunnar Jess
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care and Pain Management, BG-Universitätsklinikum Bergmannsheil GmbH Bochum, Medical Faculty of Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - Esther M Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1 (Building A1), 48149 Münster, Germany
| | - Peter K Zahn
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care and Pain Management, BG-Universitätsklinikum Bergmannsheil GmbH Bochum, Medical Faculty of Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
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49
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Pain and distress caused by endotracheal suctioning in neonates is better quantified by behavioural than physiological items: a comparison based on item response theory modelling. Pain 2017; 157:1611-1617. [PMID: 26761380 DOI: 10.1097/j.pain.0000000000000485] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pain cannot be directly measured in neonates. Therefore, scores based on indirect behavioural signals such as crying, or physiological signs such as blood pressure, are used to quantify neonatal pain both in clinical practice and in clinical studies. The aim of this study was to determine which of the physiological and behavioural items of 2 validated pain assessment scales (COMFORT and premature infant pain profile) are best able to detect pain during endotracheal and nasal suctioning in ventilated newborns. We analysed a total of 516 PIPP and COMFORT scores from 118 newborns. A graded response model was built to describe the data and item information was calculated for each of the behavioural and physiological items. We found that the graded response model was able to well describe the data, as judged by agreement between the observed data and model simulations. Furthermore, a good agreement was found between the pain estimated by the graded response model and the investigator-assessed visual analogue scale scores (Spearman rho correlation coefficient = 0.80). The information scores for the behavioural items ranged from 1.4 to 27.2 and from 0.0282 to 0.131 for physiological items. In these data with mild to moderate pain levels, behavioural items were vastly more informative of pain and distress than were physiological items. The items that were the most informative of pain are COMFORT items "calmness/agitation," "alertness," and "facial tension."
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50
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Välitalo PA, Krekels EH, van Dijk M, Simons S, Tibboel D, Knibbe CA. Morphine Pharmacodynamics in Mechanically Ventilated Preterm Neonates Undergoing Endotracheal Suctioning. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2017; 6:239-248. [PMID: 28109060 PMCID: PMC5397563 DOI: 10.1002/psp4.12156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 11/03/2016] [Indexed: 11/08/2022]
Abstract
To date, morphine pharmacokinetics (PKs) are well quantified in neonates, but results about its efficacy are ambiguous. This work presents an analysis of a previously published study on pain measurements in mechanically ventilated preterm neonates who received either morphine or placebo to improve comfort during invasive ventilation. The research question was whether morphine reduces the pain associated with endotracheal or nasal suctioning before, during, and after suctioning. Because these neonates cannot verbalize their pain levels, pain was assessed on the basis of several validated pain measurement instruments (i.e., COMFORT‐B, preterm infant pain profile [PIPP], Neonatal Infant Pain Scale (NIPS), and visual analogue scale (VAS)). The item response theory (IRT) was used to analyze the data in order for us to handle the data from multiple‐item pain scores. The analysis showed an intra‐individual relationship between morphine concentrations and pain reduction, as measured by COMFORT‐B and VAS. However, the small magnitude of the morphine effect was not considered clinically relevant for this intervention in preterm neonates.
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Affiliation(s)
- P A Välitalo
- Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - E H Krekels
- Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - M van Dijk
- Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Shp Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C A Knibbe
- Division of Pharmacology, Leiden University, Leiden, The Netherlands.,Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
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