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Defining Procedural Distress in the NICU and What Can Be Done About It

DOI:10.1891/0730-0832.36.1.12
Authors:
Martin Schiavenato at Gonzaga University
Martin Schiavenato
Liisa Holsti at University of British Columbia - Vancouver
Liisa Holsti
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A bstract Procedural distress is a common occurrence in the NICU and is tied to attempts to support the life and development of vulnerable premature infants. We discuss the epidemiology of procedural distress and the potential negative consequences on infant neurodevelopment. We define procedural distress in the NICU and outline three approaches to limit or to reduce its detrimental effects including minimizing the number of procedures, instituting measures for developmentally supportive care, and using preemptively pharmacologic and nonpharmacologic analgesia. Despite the pervasiveness of procedural distress in the NICU, clinical and administrative measures are available to ameliorate possible harmful outcomes.
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... Estas concepciones erróneas motivaron un insuficiente tratamiento del dolor en esta etapa de la vida, con las consiguientes consecuencias sobre la salud física y psíquica. (1,2) Actualmente se sabe que existen receptores y vías de transmisión y procesamiento del dolor desde el período fetal. En el recién nacido a término y pretérmino están inmaduros aún muchos mecanismos inhibitorios, por lo que estos pueden presentar, incluso, respuestas fisiológicas y hormonales exageradas frente a un mismo estímulo doloroso, con respecto a las mostradas por niños de mayor edad o adultos, además de presentar menor umbral para el dolor a medida que la edad gestacional del paciente es menor. ...
... (1) En el recién nacido prematuro, debido a la inmadurez de su desarrollo neurológico, el dolor, sobre todo cuando es prolongado, se ha asociado a trastornos a largo plazo, como alteraciones en el crecimiento cerebral, trastornos del desarrollo cognitivo, motor y emocional; además de alteraciones en la sensibilidad al dolor, problemas de conducta y de la visión, entre otros. (2) Las respuestas que se producen frente a un estímulo doloroso han permitido, a su vez, establecer diversas escalas, de las que han sido publicadas y validadas más de 50, pero que tienen pobre empleo en la práctica clínica. (3,4,5) Una de las más utilizadas ha sido la escala Revista Cubana de Pediatría. ...
Effectiveness of a protocol for pain management in newborns with less than 1 500 grams
Article
Full-text available
Introduction: Pain management is a priority in Neonatal Intensive Care Units. There are not antecedents in Cuba of any protocol carried out for management of neonatal pain, apart from the pharmacological treatment during neonatal respiratory assistance or surgery. Objective: To determine effectiveness of a protocol for prevention and pain relief in infants with less than 1500 grams, mainly based on recommendations of the Ibero-American Society of Neonatology. Methods: A prospective analytical study of before and after was made in 55 infants with less than 1500 grams, who were born in the Teaching Gynecological and Obstetric Provincial Hospital of Matanzas, Cuba, in the period from March,2016 to March, 2018. For the study, the intensity of pain was compared by means of the COMFORTneo scale, which was carried out during the performance of three procedures: umbilical vein catheterization, percutaneous venous catheterization and heel lance; in two patients groups: one before (n=29) and the other after the implementation of the pain protocol (n=26). Spearman coefficient was used for statistical analysis of ordinal qualitative variables. All p< 0.05 values were considered significant. Results: The average weight of the studied newborns was 1 180 grams. After implementing the protocol, a significant decrease in pain intensity was observed during the performance of the selected procedures. Non-pharmacological measures were the most used. Conclusion: The implemented protocol is effective for decrease pain intensity in newborns with less than 1 500 grams.
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... Estas concepciones erróneas motivaron un insuficiente tratamiento del dolor en esta etapa de la vida, con las consiguientes consecuencias sobre la salud física y psíquica. (1,2) Actualmente se sabe que existen receptores y vías de transmisión y procesamiento del dolor desde el período fetal. En el recién nacido a término y pretérmino están inmaduros aún muchos mecanismos inhibitorios, por lo que estos pueden presentar, incluso, respuestas fisiológicas y hormonales exageradas frente a un mismo estímulo doloroso, con respecto a las mostradas por niños de mayor edad o adultos, además de presentar menor umbral para el dolor a medida que la edad gestacional del paciente es menor. ...
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Efectividad de un protocolo para la atención del dolor en neonatos menores de 1 500 gramos
Article
Full-text available
  • Mar 2019
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... Infants in intensive care units may need ventilators and are frequently subjected to invasive and painful processes such as endotracheal suctioning. [4][5][6] Suction is performed frequently to eliminate excessive secretions and reduce possible airway obstruction, and although necessary, it is a harmful stimulant. Pain-induced behavioral and physiological changes have been observed in infants during suctioning. ...
The Effect of Endotracheal Suctioning Using the Four-handed Care on Physiological Criteria and Behavioral Responses of the Preterm Infants: Randomized Crossover Clinical Trial
Article
Full-text available
  • Jan 2022
Background: Endotracheal suctioning, despite its necessity, is one of the procedures that can cause pain and stress for infants admitted to neonatal intensive care units. Pain and stress manifest with physiological and behavioral responses in infants. Purpose: This study is a cross-sectional clinical trial that aimed to investigate the effect of endotracheal suctioning using four-handed care on the physiological criteria and behavioral responses of preterm infants. Methods:In this study, 40 infants were randomly divided into two groups of 20, one group was first suctioned by the routine method (two hands) and then with the four-handed method. The other group was first suctioned by the four-handed method and then with the routine one. The ALPS NEO was used to evaluate behavioral criteria. One camera recorded facial expressions and body movements, and physiological data were recorded from the monitor simultaneously. Results:Four-handed suctioning method can prevent an increase in heart rate during and two minutes after suctioning but it did not affect behavioral responses and oxygen saturation of the preterm infants admitted to NICUs. Since one of the symptoms of pain and stress in infants is the change of vital signs, especially the heart rate, stable heart rate during painful procedures can be an indication of the effectiveness of the four-hand method in invasive procedures such as suctioning. Implications for Practice: We recommend four-handed method for suctioning of endotracheal tube. Implications for Research: Evaluate the effect of four-handed care by mother on physiological criteria and behavioral responses of the preterm infants.
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Physiological Effects of Handling in Moderate to Late Preterm Infants Receiving Neonatal Intensive Care
Article
  • Feb 2023
Background: Of all preterm births, approximately 82% are moderate to late preterm. Moderate to late preterm infants are often treated like full-term infants despite their physiological and metabolic immaturity, increasing their risk for mortality and morbidity. Purpose: To describe the relationship between routine caregiving methods and physiological markers of stress and hypoxemia in infants born between 32 and 36 weeks' gestation. Methods: This descriptive study used a prospective observational design to examine the relationship between routine caregiving patterns (single procedure vs clustered care) and physiological markers of stress and hypoxemia such as regional oxygen saturation, quantified as renal and cerebral regional oxygen saturation (StO2), systemic oxygen saturation (Spo2), and heart rate (HR) in moderate to late preterm infants. Renal and cerebral StO2 was measured using near-infrared spectroscopy during a 6-hour study period. Spo2 and HR were measured using pulse oximetry. Results: A total of 231 procedures were captured in 37 participants. We found greater alterations in cerebral StO2, renal StO2, Spo2, and HR when routine procedures were performed consecutively in clusters than when procedures were performed singly or separately. Implications for practice and research: Our results suggest that the oxygen saturation and HR of moderate to late preterm infants were significantly altered when exposed to routine procedures that were performed consecutively, in clusters, compared with when exposed to procedures that were performed singly or separately. Adequately powered randomized controlled trials are needed to determine the type of caregiving patterns that will optimize the health outcomes of this vulnerable population.
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Pain Management in Newborns
Article
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The Neurodevelopmental Impact of Neonatal Morphine Administration
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Medical management of newborn infants often necessitates recurrent painful procedures, which may alter nociceptive pathways during a critical developmental period and adversely effect neuropsychological outcomes. To mitigate the effects of repeated painful stimuli, opioid administration for peri-procedural analgesia and ICU (intensive care unit) sedation is common in the NICU (neonatal intensive care unit). A growing body of basic and animal evidence suggests potential long-term harm associated with neonatal opioid therapy. Morphine increases apoptosis in human microglial cells, and animal studies demonstrate long-term changes in behavior, brain function, and spatial recognition memory following morphine exposure. This comprehensive review examines existing preclinical and clinical evidence on the long-term impacts of neonatal pain and opioid therapy.
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Early repetitive pain in preterm infants in relation to the developing brain
Article
Full-text available
  • Mar 2014
SUMMARY Infants born preterm (<37 weeks of gestation) are particularly vulnerable to procedural stress and pain exposure during neonatal intensive care, at a time of rapid and complex brain development. Concerns regarding effects of neonatal pain on brain development have long been expressed. However, empirical evidence of adverse associations is relatively recent. Thus, many questions remain to be answered. This review discusses the short- and long-term effects of pain-related stress and associated treatments on brain maturation and neurodevelopmental outcomes in children born preterm. The current state of the evidence is presented and future research directions are proposed.
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Invasive Procedures in Preterm Children: Brain and Cognitive Development at School Age
Article
Full-text available
Very preterm infants (born 24-32 weeks' gestation) undergo numerous invasive procedures during neonatal care. Repeated skin-breaking procedures in rodents cause neuronal cell death, and in human preterm neonates higher numbers of invasive procedures from birth to term-equivalent age are associated with abnormal brain development, even after controlling for other clinical risk factors. It is unknown whether higher numbers of invasive procedures are associated with long-term alterations in brain microstructure and cognitive outcome at school age in children born very preterm. Fifty children born very preterm underwent MRI and cognitive testing at median age 7.6 years (interquartile range, 7.5-7.7). T1- and T2-weighted images were assessed for the severity of brain injury. Magnetic resonance diffusion tensor sequences were used to measure fractional anisotropy (FA), an index of white matter (WM) maturation, from 7 anatomically defined WM regions. Child cognition was assessed using the Wechsler Intelligence Scale for Children-IV. Multivariate modeling was used to examine relationships between invasive procedures, brain microstructure, and cognition, adjusting for clinical confounders (eg, infection, ventilation, brain injury). Greater numbers of invasive procedures were associated with lower FA values of the WM at age 7 years (P = .01). The interaction between the number of procedures and FA was associated with IQ (P = .02), such that greater numbers of invasive procedures and lower FA of the superior WM were related to lower IQ. Invasive procedures during neonatal care contribute to long-term abnormalities in WM microstructure and lower IQ.
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Neonatal Pain and Developmental Outcomes in Children Born Preterm A Systematic Review
Article
Background: Neonates cared for in neonatal intensive care units are exposed to many painful and stressful procedures that, cumulatively, could impact later neurodevelopmental outcomes. However, a systematic analysis of these effects is yet to be reported. Objectives: The aim of this research was to review empirical studies examining the association between early neonatal pain experiences of preterm infants and the subsequent developmental outcomes of these children across different ages. Methods: The literature search was performed using the PubMed, PsycINFO, Lilacs, and SciELO databases and included the following key words: "pain," "preterm," and "development." In addition, a complementary search was performed in online journals that published pain and developmental studies to ensure all of the target studies had been found. The data were extracted according to predefined inclusion and exclusion criteria. Results: Thirteen studies were analyzed. In infants born extremely preterm (gestational age ≤29 wk) greater numbers of painful procedures were associated with delayed postnatal growth, with poor early neurodevelopment, high cortical activation, and with altered brain development. In toddlers born very preterm (gestational age ≤32 wk) biobehavioral pain reactivity-recovery scores were associated with negative affectivity temperament. Furthermore, greater numbers of neonatal painful experiences were associated with a poor quality of cognitive and motor development at 1 year of age and changes in cortical rhythmicity and cortical thickness in children at 7 years of age. Conclusions: For infants born preterm, neonatal pain-related stress was associated with alterations in both early and in later developmental outcomes. Few longitudinal studies examined the impact of neonatal pain in the long-term development of children born preterm.
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Using Lean principles to optimise inpatient phlebotomy services
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In the USA, inpatient phlebotomy services are under constant operational pressure to optimise workflow, improve timeliness of blood draws, and decrease error in the context of increasing patient volume and complexity of work. To date, the principles of Lean continuous process improvement have been rarely applied to inpatient phlebotomy. To optimise supply replenishment and cart standardisation, communication and workload management, blood draw process standardisation, and rounding schedules and assignments using Lean principles in inpatient phlebotomy services. We conducted four Lean process improvement events and implemented a number of interventions in inpatient phlebotomy over a 9-month period. We then assessed their impact using three primary metrics: (1) percentage of phlebotomists drawing their first patient by 05:30 for 05:00 rounds, (2) percentage of phlebotomists completing 08:00 rounds by 09:30, and (3) number of errors per 1000 draws. We saw marked increases in the percentage of phlebotomists drawing their first patient by 05:30, and the percentage of phlebotomists completing rounds by 09:30 postprocess improvement. A decrease in the number of errors per 1000 draws was also observed. This study illustrates how continuous process improvement through Lean can optimise workflow, improve timeliness, and decrease error in inpatient phlebotomy. We believe this manuscript adds to the field of clinical pathology as it can be used as a guide for other laboratories with similar goals of optimising workflow, improving timeliness, and decreasing error, providing examples of interventions and metrics that can be tailored to specific laboratories with particular services and resources.
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The utility of pain scores obtained during 'regular reassessment process' in premature infants in the NICU
Article
  • Apr 2014
Objective: To examine the association of pain assessment scores achieved through regular reassessment practice, as required by the Joint Commission (JC), with painful events and the use of analgesics in premature, ventilated infants. Study design: A cross-sectional study was performed in two tertiary level neonatal intensive care units. Pain was assessed at regular intervals at each center using validated multidimensional instruments in accordance with the JC standards. Result: Sample comprised 196 ventilated premature infant patient-days. Overall, 2% of scores suggested the presence of pain, and 0.1% of pain scores were associated with analgesia. Ventilated infants who were exposed to multiple pain-associated procedures in a day never demonstrated pain score elevations despite infrequent preemptive or continuous analgesic administration. Conclusion: Pain assessment scores achieved using regular reassessment processes were poorly correlated with exposure to pain-associated procedures or conditions. Low pain scores achieved through regular reassessment may not correlate to low pain exposure. Resources that are expended on regular reassessment processes may need to be reconsidered in light of the low yield for clinical alterations in care in this setting.
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