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Design of temporal analysis of neonatal vagal spells at different gestational ages using the Artemis' framework
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Background Recognition of pain experienced by immature and/or critically ill newborn infants in the Neonatal Intensive Care Unit remains a challenge despite the use of objective scoring systems that depend on physiological and behavioural parameters. We consider there is a need to identify pain using only physiological data streams.
Methods Data were collected from three preterm male, gestational age 27.25±0.95 weeks (mean±SD), birth weight 941.25±189.31 grams. Heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), blood oxygen saturation (SpO2) were considered for the NN Input Vector. NN’s output were set to ‘1’ for noxious stimuli pattern (NSP) define as: HR≥160 AND MAP≥55 AND RR≥40 AND SpO2< < 901. Artifact events were captured in previous study2 and integrated with real-time physiological data streams. In this study we correlated the nociceptive event identified by NN with the artifact nociceptive event.
Results Events ‘vascular access’ and ‘reintubation’ statistically coincide with the NSP defined in 100%. Event ‘routine care’ coincides in 52.67% with NSP. HR≥160 was evident in 24.6% of the event occurrence. The events were successfully identified by the NN, shown figure 1.
Conclusion This study showed correlation of artifact nociceptive event with the physiological data streams NN patterns verifying a positive relation between nociceptive response and non-invasive physiological response. NN developed previously proved to be an accurate tool for deployment in a clinical decision support system.
References
The exposure of premature infants to stressors, such as pain intended to ensure their survival, may instead alter their brain development and contribute to several learning and behavioral difficulties observed in later childhood. The objective of this descriptive, cross-sectional study was to compare the pain responses of 72 preterm infants to a heel stick procedure taking into consideration a variety of factors, including the use of opioids and sedatives. The pain scores assessed on the Preterm Infant Pain Profile (PIPP) scale were highest for the lowest gestational age (GA) group. Multiple linear regression analysis with the four predictor variables noted to be correlated with the PIPP scores (GA, type of needle, severity of illness, and behavioral state) indicated a significant overall relationship (F [5/66] = 5.62, p < 0.01) and accounted for 44% of the variance. All but severity of illness did not add significantly to the variance. Gender, postnatal age, amount, opioids, and sedatives used were not correlated to the PIPP scores. It was concluded that sick premature infants and those who have been exposed to a variety of painful procedures may not manifest behavioral or physiological signs of pain, but may be the most to benefit from precise pain assessment and prudent management.
This Policy Statement was retired May 2012
More than 25 years have elapsed since continuous cardiorespiratory monitoring at home was suggested to decrease the risk of sudden infant death syndrome (SIDS). In the ensuing interval, multiple studies have been unable to establish the alleged efficacy of its use. In this statement, the most recent research information concerning extreme limits for a prolonged course of apnea of prematurity is reviewed. Recommendations regarding the appropriate use of home cardiorespiratory monitoring after hospital discharge emphasize limiting use to specific clinical indications for a predetermined period, using only monitors equipped with an event recorder, and counseling parents that monitor use does not prevent sudden, unexpected death in all circumstances. The continued implementation of proven SIDS prevention measures is encouraged.
Despite the increased understanding of neurophysiology of pain in infants, there are still wide variations in pain management practices across neonatal intensive care units. Fundamental to effective pain management is the ability to assess pain in a variety of high-risk infants. Pain assessment is influenced by personal beliefs and experiences. Unlike measurement, which refers to the application of a specific tool to quantify an aspect of pain (physiologic or behavioral), assessment involves subjective judgment about the quality and significance of pain for a particular infant. Over the past decade, several pain measures have been developed to assist clinicians and researchers quantify pain, evaluate the effectiveness of pain-relieving interventions, and compare pain responses across situations with the same infant and between infants. Although the quality of pain measures varies tremendously in its psychometric properties, feasibility, and clinical usefulness, the pain measures provide a framework for infant pain assessment and management. This review highlights the importance of infant pain assessment and examines various measures of infant pain. Interventions to manage acute procedural pain in high-risk preterm infants also is addressed briefly. Copyright © 2001 by W.B. Saunders Company
AbstractUntreated pain may lead to significant morbidity and increase the risk for mortality in neonatal and pediatric patients. Parents and patients expect pain relief when receiving healthcare. Furthermore, caregivers have a moral and ethical responsibility to relieve pain and suffering. This presentation provides an overview of the effects of pain on neonatal and pediatric patients, current regulatory and professional pain management standards, and pain assessment, management, and documentation strategies to comply with current standards.
The detection of the incidents of apnoea of prematurity (AP) in preterm infants is important in the intensive care unit, but this detection is often based on simple threshold techniques, which suffer from poor specificity. Three methods for the automatic detection of AP were designed, tested and evaluated using approximately 2426 h of continuous recording from 54 neonates (μ = 44 h and σ = 7 h). The first method was based on the cumulative sum of the time series of heart rate (HR), respiratory rate (RR) and oxygen saturation (SpO(2)) along with the sum of their Shannon entropy. The performance of this method gave 94.53% sensitivity, 74.72% specificity and 77.84% accuracy. The second method was based on the correlation between the time series of HR, RR and SpO(2), which were used as inputs to an artificial neural network. This gave 81.85% sensitivity, 75.83% specificity and 76.78% accuracy. The third method utilized the derivative of the three time series and yielded a performance of 100% sensitivity, 96.19% specificity and 96.79% accuracy. Although not optimized to work in real time, the latter method has the potential for forming the basis of a real time system for the detection of incidents of AP.
In an attempt to determine physiologic responses to neonatal apnea, we evaluated changes in heart rate and oxygen saturation as measured by pulse oximetry during 2082 episodes of apnea lasting 15 seconds or more in 47 infants less than 34 weeks of gestational age with idiopathic apnea of prematurity. Of these episodes, 832 (39.9%) were central, 1032 (49.6%) were mixed, and 218 (10.5%) were obstructive. Oxygen saturation decreased with increasing duration of apnea regardless of type or treatment, and the decrease in saturation was correlated with preapnea saturation. The baseline heart rate was similar for all apnea types. Infants receiving doxapram had a lower baseline heart rate (137.8 +/- 10.5 beats/min) than did infants receiving no therapy (142.8 +/- 16.6 beats/min) and infants receiving theophylline (149.7 +/- 15.0 beats/min) (p = < 0.001). A heart rate fall to less than 100 beats/min was seen more frequently with central apnea than with mixed or obstructive events, and in infants who were not receiving therapy. Falls in heart rate were significantly less in infants receiving doxapram (27.8% +/- 18.0%) than in infants receiving theophylline (44.5% +/- 19.0%) or no therapy (48.4% +/- 18.3%) (p = < 0.001). The most common heart rate pattern overall was a gradual decrease interrupted by accelerations, whereas an initial heart rate acceleration was the most common pattern in obstructive apnea. We conclude that heart rate response to neonatal apnea is a complex and is dependent on therapy and on type and duration of apnea.
In a mature organism, the contact between various liquids and the laryngeal mucosa triggers lower airway protective responses (cough, swallowing, arousal). These laryngeal chemoreflexes (LCR) are essential for preventing aspiration. In contrast, previous studies showed that LCR are responsible for apnea and bradycardia in the neonatal mammal. Consequently, LCR, especially when triggered by acid gastrolaryngeal reflux, are deemed responsible for some apneas of prematurity and many life-threatening events of infancy and, probably, for some cases of sudden infant death syndrome. Recently, we have revisited LCR in full-term lambs during quiet sleep. Our results showed that the LCR triggered by HCl (pH 2), mimicking the acid component of an acid gastro-oesophageal reflux, were consistently like the mature LCR reported in adult mammals, without significant apneas and bradycardias (St-Hilaire 2005). These results prompted us to question whether premature birth alters LCR. Results show that LCR triggered in pre-term lambs by both saline and HCl are much more marked and clinically relevant than the ones observed in full-term lambs. Indeed, life-threatening responses to HCl, including repetitive apneas for more than 90 seconds, severe desaturation and bradycardia, were observed in 2 lambs at postnatal day 7 (D7). In addition, LCR were significantly blunted at D14. In conclusion, HCl can trigger potentially dangerous LCR in pre-term lambs at D7, suggesting that LCR in response to acid gastrolaryngeal refluxes are likely involved in some apnea/bradycardia/desaturation in pre-term infants, before they reach a post-conceptional age equivalent to full gestation.