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Observational Study
. 2021 Sep 1;22(9):e461-e470.
doi: 10.1097/PCC.0000000000002701.

Prediction of Nociception in Children Using the Nociceptive Flexion Reflex Threshold and the Bispectral Index-A Prospective Exploratory Observational Study

Maximilian D Mauritz  1 , Felix Uhlenberg  1 , Dario Bashir-Elahi  2 , Tobias Werther  3 , Urda Gottschalk  4 , Chinedu Ulrich Ebenebe  1 , Marlies Bergers  1 , Vito Giordano  3 , Eik Vettorazzi  5 , Dominique Singer  1 , Philipp Deindl  1
Affiliations
Observational Study

Prediction of Nociception in Children Using the Nociceptive Flexion Reflex Threshold and the Bispectral Index-A Prospective Exploratory Observational Study

Maximilian D Mauritz et al. Pediatr Crit Care Med. .

Abstract

Objectives: The prediction of patient responses to potentially painful stimuli remains a challenge in PICUs. We investigated the ability of the paintracker analgesia monitor (Dolosys GmbH, Berlin, Germany) measuring the nociceptive flexion reflex threshold, the cerebral sedation monitor bispectral index (Medtronic, Dublin, Ireland), the COMFORT Behavior, and the modified Face, Legs, Activity, Cry, Consolability Scale scores to predict patient responses following a noxious stimulus.

Design: Single-center prospective exploratory observational study.

Setting: Fourteen-bed multidisciplinary PICU at the University Children's Hospital, University Medical Center Hamburg Eppendorf, Germany.

Patients: Children on mechanical ventilation receiving analgesic and sedative medications.

Interventions: Noxious stimulation by way of endotracheal suctioning.

Measurements and main results: Two independent observers assessed modified Face, Legs, Activity, Cry, Consolability and COMFORT Behavior Scales scores during noxious stimulation (n = 59) in 26 patients. Vital signs were recorded immediately before and during noxious stimulation; bispectral index and nociceptive flexion reflex threshold were recorded continuously. Mean prestimulation bispectral index (55.5; CI, 44.2-66.9 vs 39.9; CI, 33.1-46.8; p = 0.007), and COMFORT Behavior values (9.5; CI, 9.2-13.2 vs 7.5; CI, 6.7-8.5; p = 0.023) were significantly higher in observations with a response than in those without a response. Prediction probability (Pk) values for patient responses were high when the bispectral index was used (Pk = 0.85) but only fair when the nociceptive flexion reflex threshold (Pk = 0.69) or COMFORT Behavior Scale score (Pk = 0.73) was used. A logistic mixed-effects model confirmed the bispectral index as a significant potential predictor of patient response (p = 0.007).

Conclusions: In our sample of ventilated children in the PICU, bispectral index and nociceptive flexion reflex threshold provided good and fair prediction accuracy for patient responses to endotracheal suctioning.

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Conflict of interest statement

Drs. Mauritz's, Uhlenberg’s, Ebenebe’s, Bergers’, Singer’s, and Deindl’s institutions received funding from Hamburg macht Kinder gesund eV. Drs. Mauritz, Uhlenberg, Bashir-Elahi, Ebenebe, and Bergers disclosed the off-label product use of PainTracker, Dolosys GmbH, Berlin, Germany and bispectral index, Medtronic, Dublin, Ireland. Dr. Bashir-Elahi disclosed that he previously worked for Dolosys GmbH helping to export and evaluate the nociceptive flexion reflex threshold (NFRT) data. He worked for Dolosys GmbH for the duration of the study. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Comment in

  • Quantification of Pain and Distress.
    Valkenburg AJ, Tibboel D. Valkenburg AJ, et al. Pediatr Crit Care Med. 2021 Sep 1;22(9):854-856. doi: 10.1097/PCC.0000000000002768. Pediatr Crit Care Med. 2021. PMID: 34473133 No abstract available.

References

    1. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016; 17:131–157
    1. Playfor S, Jenkins I, Boyles C, et al.; United Kingdom Paediatric Intensive Care Society Sedation; Analgesia and Neuromuscular Blockade Working Group. Consensus guidelines on sedation and analgesia in critically ill children. Intensive Care Med. 2006; 32:1125–1136
    1. Harris J, Ramelet AS, van Dijk M, et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: An ESPNIC position statement for healthcare professionals. Intensive Care Med. 2016; 42:972–986
    1. MEDICINE COFAN and SOAAP. Prevention and management of procedural pain in the neonate: An update. Pediatrics. 2016; 137:e20154271
    1. Barr J, Fraser GL, Puntillo K, et al.; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41:263–306

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