Objective assessment of induced acute pain in neonatology with the Newborn Infant Parasympathetic Evaluation index.

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. 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. 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. We found no significant correlation between the NIPE index and PIPP-R during routine painful or stressful procedures in preterm infants. 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.

To compare and evaluate the reliability, validity, feasibility, clinical utility, and nurses' preference of the Premature Infant Pain Profile-Revised, the Neonatal Pain, Agitation, and Sedation Scale, and the Neonatal Infant Acute Pain Assessment Scale used for procedural pain in ventilated neonates. Procedural pain is a common phenomenon but is undermanaged and underassessed in hospitalised neonates. Information for clinician selecting pain measurements to improve neonatal care and outcomes is still limited. A prospective observational study was used. A total of 1,080 pain assessments were made at 90 neonates by two nurses independently, using three scales viewing three phases of videotaped painful (arterial blood sampling) and nonpainful procedures (diaper change). Internal consistency, inter-rater reliability, discriminant validity, concurrent validity and convergent validity of scales were analysed. Feasibility, clinical utility and nurses' preference of scales were also investigated. All three scales showed excellent inter-rater coefficients (from 0.991-0.992) and good internal consistency (0.733 for the Premature Infant Pain Profile-Revised, 0.837 for the Neonatal Pain, Agitation, and Sedation Scale and 0.836 for the Neonatal Infant Acute Pain Assessment Scale, respectively). Scores of painful and nonpainful procedures on the three scales changed significantly across the phases. There was a strong correlation between the three scales with adequate limits of agreement. The mean scores of the Neonatal Pain, Agitation, and Sedation Scale for feasibility and utility were significantly higher than those of the Neonatal Infant Acute Pain Assessment Scale, but not significantly higher than those of the Premature Infant Pain Profile-Revised. The Neonatal Pain, Agitation, and Sedation Scale was mostly preferred by 55.9% of the nurses, followed by the Neonatal Infant Acute Pain Assessment Scale (23.5%) and the Premature Infant Pain Profile-Revised (20.6%). The three scales are all reliable and valid, but the Neonatal Pain, Agitation, and Sedation Scale and the Neonatal Infant Acute Pain Assessment Scale perform better in reliability. The Neonatal Pain, Agitation, and Sedation Scale appears to be a better choice for frontier nurses to assess procedural pain in ventilated neonates based on its good feasibility, utility and nurses' preference. Choosing a valid, reliable, feasible and practical measurement is the key step for better management of procedural pain for ventilated newborns. Using the right and suitable tool is helpful to accurately identify pain, ultimately improve the neonatal care and outcomes.

To evaluate the usefulness of the newborn infant parasympathetic evaluation (NIPE) percentage change instead of the NIPE absolute values. Additionally, we investigated the correlation between 2 neonatal pain assessment tools, the premature infant pain profiled-revised (PIPP-R) scale and NIPE, after blood extraction. Pain assessment is crucial for optimizing pain prevention and providing appropriate treatment; therefore, research on the best way to use pain assessment tools is required. A prospective observational study was performed with infants admitted to the neonatal intensive care unit between June 2022 and April 2023 who underwent blood collection. Demographic data, aspects related to the procedure, PIPP-R, and NIPE index at baseline and 8minutes following the procedure were recorded. The sample included 134 recordings, corresponding to 70 patients. The correlation coefficient for the association between PIPP-R scores and NIPE variations was weak: 0.32 (P <.05). To identify severe pain taking as reference PIPP-R ≥12 area under the curve (AUC) for percentage decrease of NIPE, NIPE values at first and second minutes were 0.68 (95% confidence interval: 0.59-0.78; P <.01); 0.5 (0.45-0.64; P =.4); 0.59 (0.50-0.68; P =.2) respectively. The best cutoff value for the percentage decrease in NIPE was 13%. The correlation between NIPE and PIPP-R scores was weak. The percentage decrease in the NIPE had better sensitivity, specificity, and AUC than the absolute values of the NIPE. maximum percentage decrease in NIPE detects severe pain better than the absolute NIPE value. As the correlation was weak, neonatal pain assessment should include all available tools.

Background: Heart rate variability (HRV) indices have shown ability for hypotension prediction during spinal anaesthesia in pregnant women programmed for cesarean only the same day of the surgery but not the previous day. Objective: To study changes in linear and nonlinear HRV indices of pregnant women programmed for cesarean between the previous day and the surgery day. Methods: Previous day recordings (PDR) and surgery day recordings (SDR) of 71 pregnant women programmed for cesarean have been studied during the following conditions: lateral decubitus (LD), supine decubitus (SD) and Valsalva maneuver recovery (VR). Linear HRV indices include classical temporal and spectral indices. Nonlinear HRV indices consist of sample and approximate entropy and correlation dimension (D 2). Results: Some linear HRV indices show very significant increases (p < 0.01) in SDR with respect to PDR: HRM in VR, SDNN in LD and SD, power in the very low frequency band in LD, power in the low frequency band in LD and SD. On the contrary, nonlinear HRV indices show a decrease in almost every condition and index in SDR with respect to PDR, being only statistically significant for D 2 in SD (p < 0.01). Conclusions: The increase in the former linear indices and the decrease in nonlinear indices the surgery day with respect to the previous day can be attributable to the stress induced by the imminent surgery.

After completing this article, readers should be able to: 1. Describe the pain assessment tools used for preterm and term neonates. 2. List painful procedures in the neonatal intensive care unit (NICU). 3. Describe nonpharmacologic interventions for alleviating neonatal pain. 4. Describe pharmacologic methods used for neonatal analgesia. 5. Delineate the adverse effects of the common forms of pain relief. Neonates are sensitive to pain and vulnerable to both its short- and long-term effects. However, there is a lack of consistency in both attitudes and practices among NICU staff with regard to pain assessment and management in neonates. Recognition of the clinical importance of neonatal pain and stress has been delayed and hampered by the lack of awareness that newborns are capable of experiencing pain, insufficient knowledge about the developing nervous system, difficulty in assessing neonatal pain, lack of evidence for the safety and efficacy of different modalities available for the treatment of pain, and fears about adverse effects associated with analgesic use. Neonatal pain has been of minimal concern until the last 25 years. For example, at one time, neonates were given paralytic drugs without anesthesia for major surgical procedures because physicians believed that neonates were incapable of interpreting or remembering pain. Further, there was no understanding of the consequences of untreated pain. Newer technologies to sustain life have exposed neonates to multiple invasive procedures and prolonged hospital stays that are associated with acute and chronic pain and stress. In 2001, an international evidence-based group for neonatal pain developed guidelines for the assessment, prevention, and treatment of neonatal pain in an effort to standardize practices for physicians and health care facilities. Within the consensus statement, the group defined general principles to prevent and treat pain and listed the most commonly performed diagnostic, therapeutic, and surgical procedures in the NICU. The guidelines also indicated the …

Validity and Reliability of Pain and Behavioral Scales for Preterm Infants: A Systematic Review

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.

Silent myocardial ischemic episodes as well as decreased heart rate variability (HRV) indices are associated with an unfavorable outcome in patients with coronary artery disease. Nipradilol, which is a nonselective beta-adrenergic and nitrate-like vasodilator anti-anginal agent developed in Japan, may ameliorate silent myocardial ischemia, while it also improves exercise tolerance and HRV indices in patients with chronic stable angina. To investigate the effect of nipradilol (6 mg daily) on silent myocardial ischemic episodes and HRV indices, and to study its effect on the relationship between them, 24 patients with chronic stable angina underwent exercise treadmill testing and a 24-hour ambulatory electrocardiogram (ECG). The study protocol utilized a single blind, 4-week placebo-controlled design. The HRV indices from ambulatory ECG included mean RR (ms), SDNN (ms), SDANN (ms), SD (ms), rMSSD (ms), pNN50 (%); frequency analysis of HRV consisted of total (ms, 0.01-1.00 Hz), low (ms, 0.04-0.15 Hz) and high (ms, 0.15-0.40 Hz) components. Nipradilol significantly decreased the mean heart rate at submaximal and maximal exercise and the mean pressure rate product at submaximal and maximal exercise. It significantly improved exercise-induced maximal ST segment depression from -1.7 +/- 0.6 mm to -1.1 +/- 0.7 mm (p < 0.05). Silent myocardial ischemic episodes recorded during the 24-hour ambulatory ECG significantly decreased after nipradilol administration. Nipradilol also significantly influenced several HRV indices as well as the relationship between silent myocardial ischemic episodes and the HRV indices. Nipradilol significantly increased SD, rMSSD, pNN50, total spectra, low frequency spectra and high frequency spectra. In addition, nipradilol significantly decreased the LF/HF ratio from 1.7 (1.5-2.0) to 1.5 (1.3-1.8). These effects of nipradilol on HRV indices concomitantly occurred with the reduction in silent myocardial ischemic episodes. Nipradilol was found to effectively improve the episodes of silent myocardial ischemia as well as exercise-induced ischemia probably due to its beta-blocking properties and not nitrate-like actions. In addition, nipradilol also had a favorable effect on the HRV indices.

BackgroundNeonates undergo many painful procedures during their neonatal intensive care stay. These may include tracheal intubation/ventilation, skin-breaking procedures, drainage/suctioning of body orifices or cavities. Inherent subjectivity and difficulties associated with...

Heart rate variability and inflammation: A meta-analysis of human studies

BackgroundThe 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. MethodsA 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. Results9 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. ConclusionNIPE 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 StudySystematic Review. Level of EvidenceLevel II.

Correlation Between Chronic Neck Pain and Heart Rate Variability Indices at Rest: A Cross-sectional Study

Heart Rate Variability Reflects Severity of COPD in PiZ α1-Antitrypsin Deficiency

Reproducibility of heart rate (HR) and heart rate variability (HRV) indices from ambulatory electrocardiograms (AECGs) is a prerequisite for their use as predictors or monitors of disease progression, or response to therapeutic interventions. This study sought to determine the stability over time of HR and HRV indices in patients with coronary artery disease. Five AECGs, recorded at 1-week intervals in 21 clinically stable patients, were used to calculate minimum, average, and maximum HR, and three commonly used HRV indices in data samples of 15, 30, 60, 120, daytime and nighttime intervals (complete data were available on 17 patients). All parameters studied were stable over time (p = NS). Diurnal variation was found only for the average and maximum HR, with values being higher for daytime than for nighttime. Intercorrelations of the HR and HRV indices were poor and varied among the five AECGs, suggesting that these parameters reflect different aspects of HRV. The HR and HRV variables calculated from short-time intervals correlated poorly with the corresponding information from 24-h recordings, and such relationships varied among the five AECGs. Thus, HR and HRV indices from five consecutive AECGs recorded at 1-week intervals are reproducible. The poor intercorrelations between pairs of the studied indices suggest that none of these parameters can be used as surrogate of the others. Finally, the poor performance of HR and HRV indices, deriving from short-time intervals, indicate that they cannot be employed in lieu of parameters calculated from 24-h AECGs.

Prediction of echocardiographic parameters in Chagas disease using heart rate variability and machine learning