Kristine M. McCulloch

Skin blood flow changes during routine nursery procedures

OBJECTIVE The objective of this study was to establish that changes in skin blood flow could serve as an index of pain and discomfort in newborn infants. METHODS Skin blood flow changes during intensive care procedures and during morphine administration were measured in a group of newborn infants using a laser Doppler technique. Heart rate, respiratory rate and oxygen saturation were also measured. Changes in skin blood flow and physiologic variables that occurred during procedures were analyzed and compared among procedures. RESULTS Measurements were made during 145 procedures in 15 infants 2-32 days old with birth weights of 500-2900 g and gestational ages of 23-37 weeks. Ten of the infants were receiving mechanical ventilation. Skin blood flow increased 27-134% during lancet puncture of the heel, physical handling, standard suctioning and chest physiotherapy, and there were no changes during closed system suctioning. Skin blood flow decreased 35% by 20 min after intravenous morphine. Changes seen in heart rate, respiratory rate and oxygen saturation were generally minimal. CONCLUSIONS We conclude that laser Doppler skin blood flow changes could be an index of neonatal pain and discomfort; even noninvasive handling procedures are associated with increases in skin blood flow; and changes in skin blood flow may be more useful than conventional physiologic variables in assessing the response to intensive care nursery procedure.

Intravenous morphine attenuates pain induced changes in skin blood flow in newborn infants

In a previous study we found that pain and discomfort caused a marked increase in skin blood flow in newborn infants, and that skin blood flow decreased after morphine. In this study we tested morphine effect on the skin blood flow response to pain more systematically. Skin blood flow was measured using a laser Doppler technique during 19 percutaneous central venous catheter placements in 18 infants, 10 of whom received intravenous morphine premedication. The mean +/- SD baseline skin blood flow was similar between the two groups: 22.5 +/- 9.5 ml 100 g-1 min-1 in the morphine group, and 23.7 +/- 8.0 ml 100 g-1 min-1 in the no-morphine group, respectively (p = n.s.). During PCVC placement in the morphine treated group, skin blood flow remained low with minimal variability. The mean value was 22.6 +/- 7.7 ml 100 g-1 min-1 (p = n.s. compared to baseline). In 7/9 infants not treated with morphine skin blood flow increased dramatically during PCVC placement, while in two it did not. But the mean skin blood flow in this group of 9 infants during PCVC placement was 45.3 +/- 34 ml 100 g-1 min-1, an overall change of 97% increase from the baseline. This was statistically significant compared with the baseline and the morphine group value during PCVC insertion (p < 0.04). During the 45 min time period after PCVC placement, skin blood flow values between groups again were similar. We conclude that morphine pretreatment for PCVC placement minimizes pain-associated increases in skin blood flow. The issue of whether skin blood flow changes could serve as measures of adequate analgesia needs to be evaluated with further studies.

Assessing adherence to standards for neonatal resuscitation taught throughout the perinatal referral area. A quality assurance activity.

The American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program provides standards for management of newborn infants in birthing areas. Certification and subsequent evaluation of birthing area personnel at perinatal network hospitals should result in better stabilization of infants prior to transport.