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Sakthivel M, Su V, Nataraja RM, Pacilli M. Newborn and Infant Parasympathetic Evaluation (NIPE™) Monitor for Assessing Pain During Surgery and Interventional Procedures: A Systematic Review. J Pediatr Surg 2024; 59:672-677. [PMID: 38158253 DOI: 10.1016/j.jpedsurg.2023.12.008] [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: 11/22/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) monitor has been designed to be an objective, non-invasive tool for the assessment of pain and discomfort in children under 2 years of age. The aim of this systematic review was to evaluate the ability of NIPE to assess pain in neonates and infants during surgical and/or painful procedures. METHODS A systematic review (2010-2023) was conducted using PRISMA guidelines. Studies containing children above 2-years-old were excluded. The ROBINS-I (Risk of Bias in Non-randomised Studies of Interventions) tool was used to assess the quality of included studies. RESULTS 9 databases were searched identifying 470 articles, 460 did not meet the inclusion criteria and were excluded; therefore, 10 studies with 548 participants were included. NIPE was used to assess intraoperative and postoperative pain for surgery under general anaesthesia (5 studies), as well as acute and prolonged pain from other interventional procedures (5 studies). For surgery under general anaesthesia: NIPE has shown to detect nociceptive events (e.g., skin incision, intubation), insufficient analgesia intraoperatively and to predict early postoperative pain. For painful interventional procedures: NIPE has shown to detect acute pain with a high sensitivity and negative predictive value. CONCLUSION NIPE has been used to assess pain in surgery and for various painful procedures. NIPE can detect intraoperative pain and reflect early postoperative pain. NIPE may be useful in evaluating procedural pain, however with heterogenous outcomes, more studies are required to confirm its efficacy. TYPE OF STUDY Systematic Review. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Mahesh Sakthivel
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Virginia Su
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, Faculty of Medicine, Nursing and Health Sciences., Monash University, Melbourne, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, Faculty of Medicine, Nursing and Health Sciences., Monash University, Melbourne, Australia.
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Pacilli M, Nataraja RM. Response to the Letter to the Editor by Manzar S. J Pediatr Surg 2023; 58:1853-1854. [PMID: 37321939 DOI: 10.1016/j.jpedsurg.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Bertolizio G, Molliex S, Richebé P. Evaluation of nociception: if one parameter can do so little, can multiple parameters do so much? Anaesth Crit Care Pain Med 2023; 42:101236. [PMID: 37116863 DOI: 10.1016/j.accpm.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Gianluca Bertolizio
- Department of Pediatric Anesthesiology, Montreal Children's Hospital, Montreal, QC H4A 3J1, Canada; Research Institute, McGill University Health Centre, Montreal, QC H4A 3J1, Canada; Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada.
| | - Serge Molliex
- Université Saint Etienne, Département d'Anesthésie-Réanimation CHU Saint Etienne, Inserm Sainbiose U1059, F-42023, Saint Etienne, France
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, Montreal, QC, H1T 2M4, Canada; Research Center of Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, Montreal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, H3T 1J4
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Ivanic S, Tong LS, Laird A, Malhotra A, Nataraja RM, Lang C, Pacilli M. The Newborn Infant Parasympathetic Evaluation (NIPE™) monitor predicts post-operative pain in children undergoing day-procedures: A prospective observational study. J Pediatr Surg 2023; 58:684-688. [PMID: 36646541 DOI: 10.1016/j.jpedsurg.2022.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pain assessment is essential for the administration of appropriate analgesia. Currently, clinicians use surrogate methods, such as heart rate or behavioural pain scales, to estimate pain in neonates and infants. The Newborn and Infant Parasympathetic Evaluation (NIPE™) monitor aims to provide an objective numeric value (NIPE index) of pain through a continuous assessment of the patient's parasympathetic activity. The aim of this study was to determine if the intraoperative NIPE index monitoring could predict postoperative pain in neonates and infants. METHODS This prospective observational pilot study included neonates and infants undergoing elective day-surgical procedures (n = 50). Intraoperatively, NIPE indices at 0 (NIPE0), 10 (NIPE10), 20 (NIPE20), 30 (NIPE30) minutes and at completion of surgery (NIPEe), were recorded; the median NIPE index (NIPEm) was calculated for the entire procedure. Postoperative Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were calculated by the nursing staff blinded to the intraoperative NIPE indices. RESULTS Linear regression documented an association between the NIPEm and postoperative FLACC score at 0 (r = 0.31, p = 0.03) and 10 min (r = 0.36, p = 0.01). No significant associations were observed for FLACC scores at 20 (r = 0.21, p = 0.2) and 30 min (r = 0.36, p > 0.9). Multiple regression analysis revealed that intraoperative NIPE10, NIPE20, NIPE30 and NIPEe also predicted the FLACC score at 0 min (p = 0.003). CONCLUSION The intraoperative NIPE index is predictive of pain in the immediate postoperative period. This association was lost at 20 min likely due to nursing intervention to administer analgesia. NIPE monitoring could be useful in facilitating postoperative pain management in infants. LEVEL OF EVIDENCE II. TYPE OF STUDY Study of Diagnostic Test.
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Affiliation(s)
- Svetlana Ivanic
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Lauren S Tong
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Ashleigh Laird
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Atul Malhotra
- Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, Faculty of Medicine, Nursing and Health Sciences., Monash University, Melbourne, Australia
| | - Cassandra Lang
- Department of Anaesthesia, Monash Medical Centre, Melbourne, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, Faculty of Medicine, Nursing and Health Sciences., Monash University, Melbourne, Australia.
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Bertolizio G, Garbin M, Ingelmo PM. Evaluation of Nociception during Pediatric Surgery: A Topical Review. J Pers Med 2023; 13:260. [PMID: 36836492 PMCID: PMC9964458 DOI: 10.3390/jpm13020260] [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: 01/02/2023] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
The association between intraoperative nociception and increased patient's morbidity is well established. However, hemodynamic parameters, such as heart rate and blood pressure, may result in an inadequate monitor of nociception during surgery. Over the last two decades, different devices have been marketed to "reliably" detect intraoperative nociception. Since the direct measure of nociception is impractical during surgery, these monitors measures nociception surrogates such as sympathetic and parasympathetic nervous systems responses (heart rate variability, pupillometry, skin conductance), electroencephalographic changes, and muscular reflex arc. Each monitor carries its own advantages and disadvantages. The manuscript aims to give an overview of the most up-to-date information available in the literature on current nociceptor monitors available in clinical practice, with particular focus on their applications in pediatrics.
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Affiliation(s)
- Gianluca Bertolizio
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
| | - Marta Garbin
- Department of Clinical Sciences, Université de Montréal, St-Hyacinthe, QC J2S 2M2, Canada
| | - Pablo M. Ingelmo
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Alan Edwards Center for Research on Pain, McGill University, Montreal, QC H3A 2B4, Canada
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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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Lebrun S, Boccara J, Cailliau E, Herbet M, Tavernier B, Constant I, Sabourdin N. Quantitative assessment of a pediatric nociception monitor in children under sevoflurane anesthesia. Reg Anesth Pain Med 2022; 47:rapm-2022-103547. [PMID: 35654480 DOI: 10.1136/rapm-2022-103547] [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: 02/03/2022] [Accepted: 04/26/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Intraoperative monitoring of nociception has recently made substantial progress in adult anesthesia. In contrast, pediatric data are scarce. Newborn-Infant Parasympathetic Evaluation (NIPE index, Mdoloris Medical Systems, Loos, France) is the first nociception index specifically designed for young children. It is a dimensionless index comprised between 0 and 100. Two previous studies suggested that NIPE could indeed 'detect' nociception in anesthetized children. The objective of our study was to investigate if NIPE allowed to detect and to provide a quantitative assessment of nociception in children. METHODS Children were anesthetized with sevoflurane, and received a bolus of alfentanil (10 µg/kg before intubation). Before surgical incision, each participant received three tetanic stimulations (5 s, 100 Hertz) with a 5 min interval, in a randomized order: 10, 30 and 60 milliamps. NIPE and heart rate variations were assessed after each stimulation. RESULTS Thirty children (2.4±1.6 years) were included. Mean delay between alfentanil and the first stimulation was 19±4 min. Mean baseline NIPE was 75±10. NIPE variation after the stimulations was significant at 10, 30 and 60 mA (linear mixed regression model, p<0.001). The intensity of stimulation significantly influenced the amplitude of NIPE variation (linear mixed regression model p<0.001), but had no statistically significant effect on heart rate variation (p=0.52). DISCUSSION NIPE might allow a quantitative assessment of nociception in young children in these anesthetic conditions. This study provides a basis for future research investigating the potential benefits of NIPE-guided intraoperative analgesia in pediatric anesthesia. TRIAL REGISTRATION NUMBER NCT04381637.
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Affiliation(s)
- Sebastien Lebrun
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
- EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez L'enfant et la Femme Enceinte, University of Paris, Paris, France
| | - Johanna Boccara
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
| | | | | | - Benoit Tavernier
- Anesthesiology, CHU Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- ULR 2694 - METRICS: Évaluation des Technologies de santé et des Pratiques médicales, University of Lille, Lille, France
| | - Isabelle Constant
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
- EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez L'enfant et la Femme Enceinte, University of Paris, Paris, France
| | - Nada Sabourdin
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
- EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez L'enfant et la Femme Enceinte, University of Paris, Paris, France
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Abstract
PURPOSE OF REVIEW Monitoring of intraoperative nociception has made substantial progress in adult anesthesia during the last 10 years. Several monitors have been validated and their use has been associated with intraoperative or postoperative benefits in the adult population. In pediatric anesthesia, less data are available. However, several recent publications have assessed the performance of nociception monitors in children, and investigated their potential benefits in this context. This review will describe the main validated intraoperative nociception monitors, summarize adult findings and describe the available pediatric data. RECENT FINDINGS Six intraoperative nociception indices were included in this review. Among them, four have shown promising results in children: Surgical Pleth Index (GE-Healthcare, Helsinki, Finland), Analgesia-Nociception Index (Mdoloris Medical Systems, Loos, France), Newborn-Infant Parasympathetic Evaluation (Mdoloris Medical Systems), and Pupillometry (IDMED, Marseille, France). The relevance of Skin Conductance (MedStorm innovations, AS, Oslo, Norway) under general anesthesia could not be established. Finally, the Nociception Level (Medasense, Ramat Gan, Israel) still requires to be investigated in children. SUMMARY To date, four monitors may provide a relevant assessment of intraoperative nociception in children. However, the potential clinical benefits associated with their use to guide analgesia remain to be demonstrated.
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Dutriez-Casteloot I, Emmanuelli V, Wiart JF, Tavernier A, Besengez C, Storme L, Houfflin-Debarge V. Long-Lasting Analgesia With Transdermal Fentanyl: A New Approach in Rat Neonatal Research. Front Pharmacol 2022; 13:798011. [PMID: 35370716 PMCID: PMC8968727 DOI: 10.3389/fphar.2022.798011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background: With advances in neonatal care, management of prolonged pain in newborns is a daily concern. In addition to ethical considerations, pain in early life would have long-term effects and consequences. However, its treatment remains inadequate. It was therefore important to develop an experimental model of long-lasting analgesia for neonatal research. Materials and Methods: Experiments were performed in six groups of rats with transdermal fentanyl 0, 3, 12, 50, 100, or 200 μg/kg/h from second postnatal day (P2) until weaning. Assessment of analgesia was carried out at P21, with behavioral scores (ranging from 0 to 3) using a 4% formalin test. Plasma levels of fentanyl were determined by UPLC/TQD at P22. Growth rate was investigated. Results: Fentanyl 100 and 200 μg/kg/h reduced scores of formalin-evoked behavioral pain. They increased time spent in pain score 0 (8 min 55 s and 6 min 34 s versus 23 s in controls) as in low pain scores 1 and 2, and decreased time in the most severe pain score 3 (19 min 56 s and 17 min 39 s versus 44 min 15 s). Fentanylemia increased in a dose-dependent manner from 50 μg/kg/h (2.36 ± 0.64 ng/ml) to 200 μg/kg/h (8.66 ± 1.80 ng/ml). Concerning growth, no difference was observed except weaker growth from P17 to P22 with 200 μg/kg/h. Clinically, we noticed no visible side effect from 3 to 100 μg/kg/h. Concomitantly, 200 μg/kg/h was responsible for ophthalmological side effects with appearance of corneal bilateral clouding in 90% pups. No difference was observed between male and female rats. Conclusion: Altogether, results indicate that transdermal fentanyl 100 μg/kg/h is an efficient therapeutic for long-lasting analgesia in lactating pups. This new model provides a useful tool for protection and welfare, and future opportunity for studying long-term health consequences of sustainable neonatal analgesia.
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Affiliation(s)
- Isabelle Dutriez-Casteloot
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France.,Department of Biology, Faculty of Sciences and Technology, University of Lille, Lille, France
| | - Virginie Emmanuelli
- Department of Obstetrics, Jeanne de Flandre Hospital, University Hospital Center of Lille, Lille, France
| | - Jean-François Wiart
- Department of Toxicology, University Hospital Center of Lille, Lille, France
| | - Annabelle Tavernier
- Department of Biology, Faculty of Sciences and Technology, University of Lille, Lille, France
| | - Capucine Besengez
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
| | - Laurent Storme
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
| | - Véronique Houfflin-Debarge
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France.,Department of Obstetrics, Jeanne de Flandre Hospital, University Hospital Center of Lille, Lille, France
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Walas W, Halaba Z, Latka-Grot J, Piotrowski A. Available Instruments to Assess Pain in Infants. Neoreviews 2021; 22:e644-e652. [PMID: 34599062 DOI: 10.1542/neo.22-10-e644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pain assessment in newborns and infants is challenging for clinicians. Although behavioral and behavioral-physiological scales are validated pain assessment instruments, their use in this age group has significant limitations. In this review, we summarize the methods currently available for assessing pain in neonates and infants. It is possible that these pain detection methods are also useful for assessing the quality of anesthesia and analgosedation in these populations. Further research should be aimed at confirming the usefulness of these tools in infants and identifying additional pain assessment options for clinical practice.
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Affiliation(s)
- Wojciech Walas
- Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Zenon Halaba
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Julita Latka-Grot
- Neonatal Department, Children's Memorial Health Institute, Warszawa, Poland
| | - Andrzej Piotrowski
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
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Walas W, Latka-Grot J, Maroszyńska I, Malinowska E, Rutkowska M, Piotrowski A, Wrońska M, Szczapa T, Kubiaczyk A, Skrzypek M, De Jonckheere J, Halaba ZP. Newborn Infant Parasympathetic Evaluation Index for the Assessment of Procedural Pain in Nonanesthetized Infants: A Multicenter Pilot Study. Am J Perinatol 2021; 38:e224-e230. [PMID: 32276281 DOI: 10.1055/s-0040-1709458] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the ability of the Newborn Infant Parasympathetic Evaluation (NIPE) index to detect the response to nociceptive stimuli in nonanesthetized infants and to compare these results to simultaneous scoring by behavioral scales. STUDY DESIGN Thirty-six nonanesthetized infants admitted to neonatal/pediatric intensive care unit (N/PICUs) were enrolled to the study. Due to faulty records of the data, three patients had to be excluded. To detect pain caused by noxious stimuli, the heart-rate-variability-derived NIPE index and behavioral pain scales designed for measuring procedural pain in nonverbal children were used. RESULTS Forty-one painful events were available for analysis. We observed in the whole group a statistically significant decrease in NIPE values at 1, 2, and 3 minutes after a painful stimulus, in comparison to the NIPE value at rest and the statistically significant differences between the minimum NIPE value within 3 minutes after the stimulus in comparison to NIPE value at rest in the whole group, as well as in the subgroups of moderate and severe pain. Receiver operating characteristic (ROC) analysis has shown the strong sensitivity and specificity of the NIPE in detecting the noxious stimuli (ROC AUC: 0.767). We also found that the stronger the sensation of pain was, the more rapidly NIPE reached its lowest value. DISCUSSION Our study indicates that the painful procedures are associated with a significant decrease in the NIPE value within 3 minutes after a noxious stimulus. Based on our observation, the minimum value within 3 minutes from the painful procedure seems to be the most distinctive value.
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Affiliation(s)
- Wojciech Walas
- Paediatric and Neonatal Intensive Care Unit, University Hospital in Opole, Opole, Poland
| | - Julita Latka-Grot
- Department of Neonatal, Children's Memorial Health Institute, Warszawa, Poland
| | - Iwona Maroszyńska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Ewelina Malinowska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | | | - Andrzej Piotrowski
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
| | - Monika Wrońska
- Department of Anaesthesiology and Intensive Care, 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, Poznań, Poland
| | - Agata Kubiaczyk
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznań University of Medical Sciences, Poznań, Poznań, Poland
| | - Michał Skrzypek
- Department of Biostatistics, School of Public Health in Bytom, Medical University of Silesia, Bytom, Poland
| | - Julien De Jonckheere
- Clinical Investigation Center-Technological Innovation (CIC-IT) 1403, University Hospital Center (UHC) Lille, Lille, France
| | - Zenon P Halaba
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
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Verweij LM, Kivits JTS, Weber F. The performance of the heart rate variability-derived Newborn Infant Parasympathetic Evaluation Index as a measure of early postoperative pain and discomfort in infants-A prospective observational study. Paediatr Anaesth 2021; 31:787-793. [PMID: 33811710 PMCID: PMC8251861 DOI: 10.1111/pan.14188] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/19/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE™) Index is a continuous noninvasive tool for the assessment of pain and discomfort in infants. Little is known about its performance in the early postoperative setting, where assessment of pain/discomfort is usually based on discontinuous observational scoring systems or personal experience of medical staff. AIMS To investigate the performance of the NIPE as a measure of early postoperative pain and/or discomfort in infants. METHODS The potential of the NIPE to detect pain/discomfort, as assessed by two clinical scoring systems (FLACC and COMFORT-B scale), was investigated in postoperative infants (0-2 years). RESULTS Receiver operating curve (ROC) analyses investigating the power of the NIPE to distinguish between comfort and pain/discomfort, revealed areas under the curve (AUC) of 0.77 for the FLACC, 0.81 for the COMFORT-B score, and 0.77 for a combination of FLACC & COMFORT-B. Logistic regression analysis provided initial evidence that the NIPE is an independent predictor of a FLACC score ≥4 and/or a COMFORT-B score ≥17, though R2 values were below .2. NIPE values associated with a FLACC ≥4 (48 [45-56]), a COMFORT-B score ≥17 (47 [42-53]), and a FLACC ≥4 & COMFORT-B ≥17 (47 [42-57]) were lower than NIPE values associated with a FLACC <4 (60 [53-68], 95% CI of difference -14 to -8, p < .0001), a COMFORT-B score <17 (61 [54-68], 95% CI of difference -16 to -10, p < .0001), and a FLACC <4 & COMFORT-B score <17 (60 [53-68], 95% CI of difference -15 to -8, p < .0001). We found no evidence of a predictive value of the NIPE regarding the occurrence of pain. CONCLUSIONS The NIPE detected pain and discomfort in infants after general anesthesia with reasonable areas under the ROC curve (±0.8), whereas it was not predictive of clinically detectable pain or discomfort.
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Affiliation(s)
- Laura M. Verweij
- Department of AnesthesiaErasmus University Medical Center ‐ Sophia Children's HospitalRotterdamThe Netherlands,Department of Intensive Care MedicineHaga HospitalThe HagueThe Netherlands
| | - Jaap T. S. Kivits
- Department of AnesthesiaErasmus University Medical Center ‐ Sophia Children's HospitalRotterdamThe Netherlands
| | - Frank Weber
- Department of AnesthesiaErasmus University Medical Center ‐ Sophia Children's HospitalRotterdamThe Netherlands
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13
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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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14
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Recher M, Boukhris MR, Jeanne M, Storme L, Leteurtre S, Sabourdin N, De Jonckheere J. The newborn infant parasympathetic evaluation in pediatric and neonatology: a literature review. J Clin Monit Comput 2021; 35:959-966. [PMID: 33590418 DOI: 10.1007/s10877-021-00670-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/03/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE The Newborn Infant Parasympathetic Evaluation (NIPE) is a heart rate variability-based technology for assessing pain and comfort in neonates and infants under 2-years-old. This review aims to investigate the clinical utility of the NIPE. METHODS Two investigators screened Pubmed/Medline and Google Scholar for relevant studies, independently. One investigator extracted data, which were reviewed by a second investigator. RESULTS The NIPE was used during/after painful stimuli (6 studies), in the context of general anaesthesia (2 studies), and for comfort assessment (6 studies). A) Evaluation of procedural pain/distress: 2 studies reported that the mean-NIPE could be used for reliable monitoring of prolonged pain, and one study reported the association between instant-NIPE and pain after a stimulus but the instant-NIPE represents the NIPE average over 3 min. Two studies found no correlation between the NIPE and comfort behavior/pain scales, but they mainly differed in patients' gestational age and evaluation methodology. B) There are only 2 studies for the evaluation of nociception during surgery under general anaesthesia with contradictory results. C) Studies assessing neonates' comfort reported increased NIPE scores during skin-to-skin contact and during facilitated tucking associated with a human voice. No effect on NIPE scores of facilitated tucking during echocardiography was reported in preterm infants. One study reported significantly different NIPE scores with 2 surfactant therapy protocols. Overall, study populations were small and heterogeneous. CONCLUSION The results regarding NIPE's performances differ between studies. Given the limited number of studies and the heterogeneous outcomes, more studies are required to confirm the NIPE usefulness in the different clinical settings.
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Affiliation(s)
- Morgan Recher
- ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, University of Lille, 59000, Lille, France. .,CHU Lille, Department of Pediatric Intensive Care, Jeanne de Flandre Hospital, 59000, Lille, France.
| | - Mohamed Riadh Boukhris
- ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, University of Lille, 59000, Lille, France.,CHU Lille, Department of Neonatology, Jeanne de Flandre Hospital, 59000, Lille, France
| | - Mathieu Jeanne
- CHU Lille, CIC-IT 1403, Centre D'Innovation Technologique, 59000, Lille, France.,CHU Lille, Anesthesia and Critical Care, 59000, Lille, France.,ULR 7365 Groupe de Recherches Sur Les Formes Injectables Et Les Technologies Associées, University of Lille, 59000, Lille, France
| | - Laurent Storme
- ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, University of Lille, 59000, Lille, France.,CHU Lille, Department of Neonatology, Jeanne de Flandre Hospital, 59000, Lille, France
| | - Stéphane Leteurtre
- ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, University of Lille, 59000, Lille, France.,CHU Lille, Department of Pediatric Intensive Care, Jeanne de Flandre Hospital, 59000, Lille, France
| | - Nada Sabourdin
- APHP, Hôpital Armand-Trousseau, Anesthesia Department, DMU Dream, 75012, Paris, France
| | - Julien De Jonckheere
- ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, University of Lille, 59000, Lille, France.,CHU Lille, CIC-IT 1403, Centre D'Innovation Technologique, 59000, Lille, France
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15
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Walas W, Halaba ZP, Szczapa T, Latka-Grot J, Maroszyńska I, Malinowska E, Rutkowska M, Kubiaczyk A, Wrońska M, Skrzypek M, De Jonckheere J, Jean-Noel M, Piotrowski A. Procedural Pain Assessment in Infants Without Analgosedation: Comparison of Newborn Infant Parasympathetic Evaluation and Skin Conductance Activity - A Pilot Study. Front Pediatr 2021; 9:746504. [PMID: 35087770 PMCID: PMC8787338 DOI: 10.3389/fped.2021.746504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/30/2021] [Indexed: 01/24/2023] Open
Abstract
Objective: New technologies to measure pain responses, such as heart rate variability and skin conductance hold promise in the development of tools that can be reliable and quantifiable of detecting pain. The main objective of this study was to assess the capability of two monitors i.e., Newborn Infant Parasympathetic Evaluation (NIPE) and Skin Conductance Algesimeter for detecting procedural pain in non-anesthetized infants. Materials and Methods: Thirty-three non-anesthetized infants were enrolled to the study. To detect pain caused by heel stick, NIPE, and Skin Conductance monitors and behavioral pain scales were used. Three minutes before and just after heel stick, pain was evaluated by behavioral scales, and simultaneously over the whole period by NIPE and SCA. Results: A statistically significant decrease of NIPE Index and an increase of SCA values were found after the HS procedure. There were no statistically significant differences between the decrease in NIPEi values and the increase in PPS values between subgroups based on pain assessment by behavioral-scale scores. Conclusion: Both NIPE and SCA can be useful for detection of procedural pain and may constitue an additional valuable tool for better handling of pain among patients treated in NICUs. More studies on larger groups of patients are needed.
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Affiliation(s)
- Wojciech Walas
- Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Zenon P Halaba
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Tomasz Szczapa
- Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Department of Neonatology, Poznań University of Medical Sciences, Poznań, Poland
| | - Julita Latka-Grot
- Neonatal Department, Children's Memorial Health Institute, Warszawa, Poland
| | - Iwona Maroszyńska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódz, Poland
| | - Ewelina Malinowska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódz, Poland
| | | | - Agata Kubiaczyk
- Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Department of Neonatology, Poznań University of Medical Sciences, Poznań, Poland
| | - Monika Wrońska
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
| | - Michał Skrzypek
- Department of Biostatistics, School of Public Health, Medical University of Silesia, Bytom, Poland
| | | | | | - Andrzej Piotrowski
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
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16
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Chiera M, Cerritelli F, Casini A, Barsotti N, Boschiero D, Cavigioli F, Corti CG, Manzotti A. Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review. Front Neurosci 2020; 14:561186. [PMID: 33071738 PMCID: PMC7544983 DOI: 10.3389/fnins.2020.561186] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/28/2020] [Indexed: 12/18/2022] Open
Abstract
Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come. When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility. However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.
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Affiliation(s)
- Marco Chiera
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Research Commission on Manual Therapies and Mind-Body Disciplines, Societ Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | - Francesco Cerritelli
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Alessandro Casini
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Nicola Barsotti
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Research Commission on Manual Therapies and Mind-Body Disciplines, Societ Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | | | - Francesco Cavigioli
- Neonatal Intensive Care Unit, "V. Buzzi" Children's Hospital, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
| | - Carla G Corti
- Pediatric Cardiology Unit-Pediatric Department, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
| | - Andrea Manzotti
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Neonatal Intensive Care Unit, "V. Buzzi" Children's Hospital, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy.,Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
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17
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Wu L, Wang S, Wang Y, Zhang K, Bai J, Zheng J. Prediction of Hemodynamic Reactivity by Electroencephalographically Derived Pain Threshold Index in Children Undergoing General Anesthesia: A Prospective Observational Study. J Pain Res 2019; 12:3245-3255. [PMID: 31819608 PMCID: PMC6899069 DOI: 10.2147/jpr.s231596] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/15/2019] [Indexed: 12/17/2022] Open
Abstract
Purpose The pain threshold index (PTI) is a novel measure of nociception based on integrated electroencephalogram parameters during general anesthesia. The wavelet index (WLI) reflects the depth of sedation. This study aims to evaluate the ability of the PTI and WLI to predict hemodynamic reactivity after tracheal intubation and skin incision in pediatric patients. Patients and methods Pediatric patients (n=134) undergoing elective general surgery or urinary surgery were analyzed. Measurements at predefined time-points during tracheal intubation and skin incision included the PTI, WLI, heart rate (HR), and mean blood pressure (MBP). Receiver-operating characteristic (ROC) curves were computed to evaluate the predictive performance of the PTI and WLI in measuring hemodynamic reactivity (an increase of more than 20% in either MBP or HR) during general anesthesia. Results Of the 134 patients evaluated, positive reactivity of HR and MBP was observed in 95 (70.9%) and 61 (45.5%) patients induced by intubation, respectively, and 19 (14.2%) and 24 (17.9%) patients induced by skin incision, respectively. Using either HR or MBP reactivity induced by intubation as a dichotomous variable, the areas under the curves (AUCs) [95% CI] of PTI and WLI were 0.81[0.73–0.87] and 0.58[0.49–0.67] with the best cutoff values of 62 and 49. The AUCs [95% CI] of PTI and WLI were 0.82[0.75–0.88] and 0.61[0.52–0.69] after skin incision. The best cutoff values of PTI and WLI were 60 and 46, respectively. Conclusion The PTI can predict hemodynamic reactivity with the best cutoff values of 62 and 60 after tracheal intubation and skin incision in pediatric patients during general anesthesia. The WLI failed in predicting hemodynamic changes.
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Affiliation(s)
- Lei Wu
- Department of Anesthesiology, Shanghai Children's Medical Center Affiliated to School of Medicine, Shanghai Jiao Tong University, Pudong, Shanghai, People's Republic of China
| | - Siyuan Wang
- Department of Anesthesiology, 3201 Hospital, Hanzhong City, Shaanxi, People's Republic of China
| | - Yanting Wang
- Department of Anesthesiology, Shanghai Children's Medical Center Affiliated to School of Medicine, Shanghai Jiao Tong University, Pudong, Shanghai, People's Republic of China
| | - Kan Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center Affiliated to School of Medicine, Shanghai Jiao Tong University, Pudong, Shanghai, People's Republic of China
| | - Jie Bai
- Department of Anesthesiology, Shanghai Children's Medical Center Affiliated to School of Medicine, Shanghai Jiao Tong University, Pudong, Shanghai, People's Republic of China
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center Affiliated to School of Medicine, Shanghai Jiao Tong University, Pudong, Shanghai, People's Republic of China.,Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center Affiliated to School of Medicine, Shanghai Jiao Tong University, Pudong, Shanghai, People's Republic of China
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Lim BG. Nociception monitoring tools using autonomic tone changes for intraoperative analgesic guidance in pediatric patients. Anesth Pain Med (Seoul) 2019; 14:380-392. [PMID: 33329766 PMCID: PMC7713809 DOI: 10.17085/apm.2019.14.4.380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/03/2022] Open
Abstract
Nociception monitoring devices using changes in autonomic nervous system activity have been developed in numerous ways. Although there have been few studies conducted on children, compared to the relatively higher number of studies on adults, most of the nociception monitors in children, as in adults, appear to be more useful than the standard clinical practice that uses hemodynamic parameters in the evaluation and treatment of intraoperative nociception (pain) during general anesthesia. Particularly, when monitoring the surgical pleth index (SPI) in anesthetized children, the application of a new target range of SPI values (≤ 40) to the SPI monitoring criteria seems to be necessary for providing a more proper intraoperative analgesia. The analgesia nociception index (ANI) shows promising results in anesthetized adults, and recently, positive results along with cardiorespiratory coherence have been reported in pediatric patients. Newborn infant parasympathetic evaluation (NIPE) could be useful for providing adequate analgesia in newborns, infants, and children under 2 years of age in anesthetized or awake states. In cases of skin conductance and pupillometry, further studies are needed. Understanding the pros, cons, and limitations of these nociception monitoring tools will provide more effective and safe intraoperative analgesia to pediatric patients undergoing general anesthesia, and it may also help to plan and conduct promising research on the use of perioperative nociception monitoring in pediatric patients in the future.
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Affiliation(s)
- Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
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