A Multidimensional Approach to Pain Assessment in Critically Ill Infants During a Painful Procedure

Objectives: Inferring the pain level of a critically ill infant is complex. The ability to accurately extract the appropriate pain cues from observations is often jeopardized when heavy sedation and muscular blocking agents are administered. Near-infrared spectroscopy is a noninvasive method that may provide the bridge between behavioral observational indicators and cortical pain processing. We aimed to describe regional cerebral and systemic hemodynamic changes, as well as behavioral reactions in critically ill infants with congenital heart defects during chest-drain removal after cardiac surgery. Methods: Our sample included 20 critically ill infants with congenital heart defects, less than 12 months of age, admitted to the cardiac intensive care unit after surgery. Results: Cerebral deoxygenated hemoglobin concentrations significantly differed across the epochs (ie, baseline, tactile stimulus, noxious stimulus) (P=0.01). Physiological systemic responses and Face Leg Activity Cry Consolability (FLACC) pain scores differed significantly across the events (P<0.01). The 3 outcome measures were not found to be associated with each other. Mean FLACC pain scores during the painful procedure was 7/10 despite administration of morphine. Midazolam administration accounted for 36% of the variance in pain scores. Discussion: We demonstrated with a multidimensional pain assessment approach that significant cerebral, physiological, and behavioral activity was present in response to a noxious procedure in critically ill infants despite the administration of analgesic treatment. Considering that the sedating agent significantly dampened pain behaviors, assessment of cerebral hemodynamic in the context of pain seems to be an important addition.National Institutes of Health (U.S.) (Grant R01EB001659)National Institutes of Health (U.S.) (Grant K24NS057568)National Institutes of Health (U.S.) (Grant R21HD056009)National Institute for Biomedical Imaging and Bioengineering (U.S.)National Institute of Neurological Disorders and Stroke (U.S.)Eunice Kennedy Shriver National Institute of Child Health and Human Development (U.S.

Adverse Behavioral Changes in Adult Mice Following Neonatal Repeated Exposure to Pain and Sucrose

Sucrose is recommended for the treatment of pain during minor procedures in preterm infants in the neonatal intensive care unit (NICU) and is currently used worldwide as the standard of care. We recently reported that adult mice repetitively exposed to sucrose compared to water during the first week of life, irrespective of exposure to an intervention, had significantly smaller brain volumes in large white matter, cortical and subcortical structures (e.g., hippocampus, striatum, fimbria). These structures are important for stress regulation and memory formation. Here, we report the effects of repeated neonatal exposure to pain and sucrose on adult behavior in mice. Neonatal C57BL/6J mice (N = 160, 47% male) were randomly assigned to one of two treatments (sucrose, water) and one of three interventions (needle-prick, tactile, handling). Pups received 10 interventions daily from postnatal day 1 (P1) to P6. A single dose of 24% sucrose or water was given orally 2 min before each intervention. At adulthood (P60-85) mice underwent behavioral testing to assess spatial memory, anxiety, motor function, pain sensitivity, and sugar preference. We found that mice that had received sucrose and handling only, had poorer short-term memory in adulthood compared to water/handling controls (p &lt; 0.05). When exposed to pain, mice treated with repetitive sucrose or water did not differ on memory performance (p = 0.1). A sugar preference test showed that adult mice that received sucrose before an intervention as pups consumed less sugar solution compared to controls or those that received water before pain (p &lt; 0.05). There were no significant group differences in anxiety, motor, or pain sensitivity. In a mouse model that closely mimics NICU care, we show for the first time that memory in adulthood was poorer for mice exposed to pain during the first week of life, irrespective of sucrose treatment, suggesting that sucrose does not protect memory performance when administered for pain. In the absence of pain, early repetitive sucrose exposure induced poorer short-term memory, highlighting the importance of accurate pain assessment

Hippocampus, Amygdala, and Thalamus Volumes in Very Preterm Children at 8 Years: Neonatal Pain and Genetic Variation

Altered hippocampal morphology and reduced volumes have been found in children born preterm compared to full-term. Stress inhibits neurogenesis in the hippocampus, and neonatal stress/noxious stimulation in rodent pups are associated with long-term alterations in hippocampal volumes. We have previously shown reduced cortical thickness and cerebellar volumes in relation to more exposure to pain-related stress of neonatal invasive procedures in children born very preterm. We have reported targeted gene-by-pain environment interactions that contribute to long-term brain development and outcomes in this population. We now aim to determine whether exposure to pain-related stress (adjusted for clinical factors and genotype) differentially impacts regional structures within the limbic system and thalamus, and investigate relationships with outcomes in very preterm children. Our study included 57 children born very preterm (&lt;32 weeks GA) followed longitudinally from birth who underwent 3-D T1 MRI neuroimaging at ∼8 years. Hippocampal subfields and white matter tracts, thalamus and amygdala were automatically segmented using the MAGeT Brain algorithm. The relationship between those subcortical brain volumes (adjusted for total brain volume) and neonatal invasive procedures, gestational age (GA), illness severity, postnatal infection, days of mechanical ventilation, number of surgeries, morphine exposure, and genotype (COMT, SLC6A4, and BDNF) was examined using constrained principal component analysis. We found that neonatal clinical factors and genotypes accounted for 46% of the overall variance in volumes of hippocampal subregions, tracts, basal ganglia, thalamus and amygdala. After controlling for clinical risk factors and total brain volume, greater neonatal invasive procedures was associated with lower volumes in the amygdala and thalamus (p = 0.0001) and an interaction with COMT genotype predicted smaller hippocampal subregional volume (p = 0.0001). More surgeries, days of ventilation, and lower GA were also related to smaller volumes in various subcortical regions (p &lt; 0.002). These reduced volumes were in turn differentially related to poorer cognitive, visual-motor and behavioral outcomes. Our findings highlight the complexity that interplays when examining how exposure to early-life stress may impact brain development both at the structural and functional level, and provide new insight on possible novel avenues of research to discover brain-protective treatments to improve the care of children born preterm

Relations entre les dispositions de pensée critique, les connaissances relatives à la douleur et le jugement clinique chez des étudiantes du programme de baccalauréat en sciences infirmières

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal

Near-infrared spectroscopy (nirs) to measure nociception following noxious stimulation in critically ill infants

Background An admission to the intensive care unit causes major physical and psychological stress for children. Pain contributes significantly to this distressing experience. To optimize pain relief, a sound pain assessment tool is essential. Although this need is recognized, only a few pain assessment instruments have been thoroughly tested with this population using a rigorous scientific approach, and none have been shown to be superior to the other. Recent studies using near-infrared spectroscopy (NIRS) in term and premature infants indicate that nociceptive stimuli cause haemodynamic changes in specific cortical regions. This suggests a new avenue for assessing and quantifying pain processing in critically ill infants that could be more sensitive and specific to the nociceptive response. Aims In this series of studies we examined regional cerebral and systemic haemodynamic changes, as well as behavioural reactions in critically ill infants with congenital heart defect (CHD) during chest drain removal following open heart surgery. Specifically, we examined changes within subjects, as well as individual factors (age, sex, medication) affecting the change and associations between cerebral haemodynamic changes, systemic physiological changes, and Face Legs Activity Cry Consolability (FLACC) pain scores. Subjects Critically ill infants less than 12 months of age admitted to a cardiac intensive care unit after cardiac surgery for CHB comprised the sample. Outcome measures Changes in cerebrovascular haemoglobin concentrations (NIRS), as well as heart rate (ECG), systemic arterial oxygen saturation (pulse oximetry), and mean arterial blood pressure (arterial line) were recorded during three distinct epochs (Baseline, Tactile stimulation, and Chest-drain removal). Behavioural manifestations were also captured through video and were subsequently rated for pain with the FLACC scale. Design Descriptive correlational design. Results We studied 32 infants with CHD and obtained FLACC pain scores in 20 of these infants. Cerebral deoxygenated haemoglobin concentrations significantly increased across the epochs (p&lt;.01). Physiological systemic responses were not found to be associated with the cerebral haemodynamic parameters. Mean FLACC pain scores significantly increased across the epochs (p &lt; .001) with a mean score of 7/10 during the noxious procedure, despite administration of an analgesic agent (morphine). Sex of patients was found to be a determining factor in the cerebral haemodynamic responses and pain FLACC scores. Pharmacological treatments, age and weight of patients were significantly associated with cerebral and systemic haemodynamic responses, as well as the FLACC pain scores. The administration of a sedating agent (midazolam) had a significant dampening effect on the pain behaviours as assessed by the FLACC scale.ConclusionsUsing a multidimensional pain measurement approach, we demonstrated that significant cerebral, physiological and behavioural activity was present in response to a noxious procedure in critically ill infants despite the administration of analgesic treatment. Although pain behaviours were significantly dampened by the sedating agent, the cerebral response was still evident. Thus, assessment of cerebral haemodynamics in the context of pain seems to be an important addition when a sedating agent is administered. Our data suggest that NIRS is a potentially useful technique for assessing pain evoked cerebral activation in critically ill infants.Introduction Une admission à l'unité des soins intensifs est une source de stress physique et psychologique chez l'enfant. La douleur contribue grandement à cette expérience affligeante. Pour optimiser le soulagement de la douleur, un bon outil de mesure est essentiel. Malgré que ce besoin soit reconnu, très peu d'instruments ont subi des tests scientifiques rigoureux auprès de cette population et aucun outil ne s'est démarqué des autres. Des études récentes utilisant la spectroscopie par infrarouge (SPIR) chez les nouveau-nés à terme et prématurés ont indiqué que des stimuli nociceptifs causent des changements hémodynamiques dans des régions cérébrales spécifiques. Cette approche semble prometteuse auprès des jeunes enfants gravement malades. Objectifs Nous avons examiné les changements hémodynamiques cérébraux et systémiques, ainsi que les réactions comportementales reliés au retrait d'un drain thoracique chez de jeunes enfants ayant subi une chirurgie à cœur ouvert pour une cardiopathie congénitale. Spécifiquement, nous avons exploré et comparé les changements de chaque enfant, ainsi que les facteurs individuels (âge, sexe, médication) affectant ces changements. De plus, les associations entre les changements hémodynamiques cérébraux et physiologiques, ainsi que les scores de douleur selon l'échelle Face Legs Activity Cry Consolability (FLACC) furent étudiées. Échantillon L'échantillon comprenait de jeunes enfants gravement malades âgés de moins de 12 mois admis à l'unité des soins intensifs cardiaques. Mesure des paramètres Les changements de concentrations en oxygène de l'hémoglobine (SPIR), ainsi que le rythme cardiaque (ECG), la saturation artérielle en oxygène (oxymétrie pulsatile), et la pression artérielle moyenne (ligne artérielle) furent recueillis pendant trois périodes distinctes (mesures initiales, stimulation tactile et retrait drain thoracique). Les manifestations comportementales furent obtenues par vidéo et évaluées, subséquemment, pour la douleur à l'aide de l'échelle FLACC. Devis Devis descriptif corrélationnel. Résults Nous avons étudié 32 enfants avec cardiopathie congénitale et avons obtenu des scores de douleur FLACC auprès de 20 de ces enfants. La concentration cérébrale de désoxygénation de l'hémoglobine a significativement augmenté entre les trois périodes (p&lt;.01). Les réponses physiologiques systémiques ne furent pas associées aux paramètres hémodynamiques cérébraux. Les scores de douleur FLACC moyens ont significativement augmentés entre les périodes (p &lt; .001), dont la moyenne était de 7/10 en réponse à la procédure douloureuse, malgré l'administration d'un agent analgésique (morphine). Le sexe des participants fut un facteur déterminant de la réponse hémodynamique cérébrale ainsi que pour les scores de douleur FLACC. L'administration de traitements pharmacologiques, l'âge et le poids des enfants furent associés de façon significative aux changements hémodynamiques cérébraux et systémiques, ainsi que ceux des scores de douleur FLACC. L'administration d'un agent sédatif (midazolam) a eu un effet atténuant significatif sur les comportements de douleur tels que mesurés par l'échelle FLACC. Conclusions Nous avons démontré, à l'aide d'une approche multidimensionnelle, que des manifestations cérébrales, physiologiques et comportementales significatives étaient présentes en réponse à une procédure nociceptive chez le jeune enfant gravement malade, et ce, malgré l'administration d'un traitement analgésique. Les comportements communiquant une douleur furent significativement atténués par l'administration d'un agent sédatif. Par conséquent, l'évaluation de l'activité hémodynamique cérébrale lors de situation douloureuse s'avère être un important ajout lorsque des médicaments sédatifs sont administrés. Il semble que la SPIR soit une technique potentielle pour évaluer l'activation cérébrale évoquée par une stimulation nociceptive chez le jeune enfant gravement malade