| Background:Preterm infants refer to live-born babies who are born before37full weeks; neonates are the babies aged from born to28days and this period is the stage that they just live outside from the womb and are still in adaptive state. Neonates in this period are vulnerable compared with adults because of the immature functions of all system organs, hypo-immunity and the weak thermoregulatory function. However, the development of organs in premature newborns lags far behind and their survival rate decreases seriously. If various noxious stimulations such as trauma, blood loss, hypoxia, pain, hot and cold, fear, strenuous exercise, acute infection, operation anesthesia and so on triggering changes of all kinds of functions and metabolic processes affect preterm newborns at neonate stage, a wide range of responses in the body will be triggered as well, including those of nervous system, endocrine system, immune system, the occurrence of stress-induced apoptosis, etc, and these stress responses can even be a threat to lives of premature newborns. As clinicians, we should make an utmost effort to perform the treatment and the care of primary diseases for the infants as well as the prevention of stress responses described above. Over the years, stress responses of infants during surgeries are concerned. Major surgeries of infants will be carried out after general anesthesia implemented under the premise of stable vital signs and it can reduce stress responses as well as the degree of danger they face will decrease. But the stress responses generating from tiny stimulus are neglected. For the case of preterm newborns, even tiny stimulus will cause serious stress responses because of their poor general conditions, immature development of all systems and fragile lives.Retinopathy of prematurity (ROP) is a common ophthalmocace threatening the vision of newborns and it perhaps will have serious impacts on the quality of their lives in the future. To implement the ROP screening and laser treatment timely is a key to avoid ROP blindness. Scholars at home and abroad recognize that general or topical anesthesia has different levels of risks regardless of which anesthesia method was used, because objects of ROP laser photocoagulation treatment are preterm infants whose organs develop immaturely. In practice, our hospital give topical anesthesia to majority of infants with ROP in the laser treatment. Although most infants are stable during the treatment, some infants still have abnormal conditions during or after the treatment. So, what is the root of these problems happening in general conditions of the infants with ROP? Whether preterm infants will have stress responses or not during the laser treatment, why and what kind of stress responses will be produced? Clinically, we should prevent and relieve the stress responses through the more targeted measures in order to insure safety of infants’s lives during the treatment, however, the related report is seldom at home and abroad.The neural pathway of pain sense has developed completely in fetal period according to numerous studies both here and abroad in recent years. Therefore, the babies can sense pain after born even can the preterm infants. However, preterm infants are more sensitive to pain than older infants. Anand and colleagues suggested that pain was newborns’potential characteristic and signal system of tissue damages during early ontogeny, and they recognized that the physiological and behavioral responses of pain in neonatal period could be indexes of effective pain assessments instead of self-reports. Although infants can not describe pain degrees because of the younger age or other reasons, there have been related reports using the visual analogue scale (VAS) which is international commonly used to assess pain degrees.Mahta and colleagues studied on pain during different methods of ROP screening with76preterm infants assigned into tow groups and results revealed that eye speculums caused the highest pain degree of infants no matter what screening method was used. Dhaliwal and colleagues assessed pain of40preterm infants during ROP screening with PIPP scale and results revealed that infants had the same scores when eye speculums were used no matter in indirect ophthalmoscope examination or direct retinal camera examination. Their studies suggested that the eyelid speculum, rather than the examination method, contributed most to the pain.Mukherjee and coworkers assessed stresses generating from direct retinal camera examination and indirect ophthalmoscope examination of86preterm infants with cardiopulmonary indexes and they recorded heart rate, oxygen saturation, respiratory rate and mean blood pressure before, during and1hour after the examination. The statistical results revealed that heart rate and respiratory rate were the highest in indirect ophthalmoscope examination.Retinal laser photocoagulation treatment seems just a "tiny stimulus", but adult patients with diabetic retinopathy have pain during panretinal photocoagulation. The degree of this kind of pain will increase with the severity of retinopathy and the pain of patients in proliferative phase is heavier than patients in non-proliferative phase. However, whether retinal laser photocoagulation treatment will lead to stress responses of preterm infants or not has not been reported. This makes clinicians lack anticipations of safety risks of the treatment and lack scientific evidences for early interventions aimed at infants.At present, there are nursing routine of surgeries, but nursing care programs of retinal laser photocoagulation treatment under topical anesthesia are made by each hospital on their own and there is no uniform and standardized nursing routine; however, clinicians are easy to ignore monitoring of infants who are under topical anesthesia but in waking state and it may make abnormal conditions defiladed as well as clinicians not detect those in time, leading to occurrence of medical negligence.Therefore, this study applied the retinal laser photocoagulation treatment under topical anesthesia as the model of "tiny stimulus" to explore whether retinal laser photocoagulation treatment under topical anesthesia would trigger stress responses in preterm infants or not to a more comprehensive perspective based on combination of laboratory testing and clinical monitoring, and comprehend safety risks of the treatment. It provided scientific evidences to clinical healthcare assistants to take targeted interventions aiming to avoid the occurrence of serious medical negligence and provided references to clinical healthcare assistants to conduct similar studies on "tiny stimulus" in the future as well.Objectives:1.The study focused on laboratory testing and comprehended changes of related biochemical indexes in the blood of preterm infants receiving retinal laser photocoagulation treatment under topical anesthesia at different time before and after the treatment. It explored whether retinal laser photocoagulation treatment therapy under topical anesthesia would trigger stress responses in preterm infants or not to a scientific perspective.2.To combine the clinical monitoring of physiological indicators (HR, SpO2, RR, MAP) of preterm infants during the treatment to explore whether stress responses existed during the treatment or not comprehensively; to analyze reasons producing stress responses and potential safety risks in the laser photocoagulation treatment under topical anesthesia.3.The study provided scientific evidences to clinical healthcare assistants for developing interventions and nursing routine of retinal laser photocoagulation treatment. It will reduce complication incidence of laser photocoagulation treatment. The infants with ROP can not only acquire safe and opportune treatments, reducing the blinding rate of additional population, but also have improved quality of lives, reducing the burden of family and society.4.The study provided evidence-based of monitoring and treatment of preterm infants in retinal laser photocoagulation for clinicians, and standardized the nursing procedure.5.To provide references to other clinical operations similar to "tiny stimulus" through studying on influences of such "tiny stimulus" like retinal laser photocoagulation treatment on preterm infants. It will reduce incidence of medical negligence and the infants’s safety of lives can be guaranteed in the treatment with primary diseases.Methods:1.To collect2ml venous blood of30preterm infants undergoing retinal laser photocoagulation treatment under topical anesthesia at four time points respectively: quiet state before treatment, the end of treatment,1hour after treatment and24hours after treatment. We measured the concentration changes of7stress related biochemical indexes in blood such as dopamine, norepinephrine, epinephrine, cortisol, adrenocorticotropic hormone, blood glucose and C-reactive protein through laboratory examinations. 2.To monitor30preterm infants receiving retinal laser photocoagulation treatment under topical anesthesia with medical monitoring equipments and recorded changes of heart rate (HR), oxygen saturation of blood (SpO2), respiratory rate (RR) and mean artery pressure (MAP) of at four time points:quiet state before treatment, the end of treatment,1hour after treatment and24hours after treatment. We recorded and calculated changes range of physiological indexes of infants (SpO2, HR, MAP) during laser photocoagulation treatment.3.Data entry and statistical methods:The data was handed to statistics directly after data collection and the double check was performed. They used SPSS13.0statistical software for data processing. Indexes were described by mean±standard deviation (x±s) and the analysis of variance (ANOVA) for repeated measurement design data was used. In addition, the method of LSD was used for multiple comparisons between groups, α=0.05(two-sided) was the significant level, P<0.05meant differences had statistically significance.Results:1. Changes of stress related factors in blood of30infants before and after retinal laser photocoagulation treatment under topical anesthesia:1.1Levels of dopamine in infants at different time points had statistical significance in comparison among groups with sum(P<0.001), levels of dopamine in infants at the end of treatment and1hour after treatment were higher than that in quiet state before treatment with statistical significance(P<0.05);1.2Levels of norepinephrine in infants at different time points had statistical significance in comparison among groups with sum(P<0.001), levels of norepinephrine in infants at the end of treatment and1hour after treatment were higher than that in quiet state before treatment with statistical significance(P<0.05);1.3Levels of epinephrine in infants at different time points had statistical significance in comparison among groups with sum (P<0.05),the level of epinephrine in infants at the end of treatment was higher than that in quiet state before treatment with statistical significance(P<0.05);1.4Levels of cortisol in infants at different time points had statistical significance in comparison among groups with sum(P<0.001), levels of cortisol in infants at the end of treatment and1hour after treatment were higher than that in quiet state before treatment with statistical significance(P<0.05);1.5Levels of adrenocorticotropic hormone in infants at different time points had statistical significance in comparison among groups with sum(P<0.001), the level of adrenocorticotropic hormone in infants at the end of treatment was higher than that in quiet state before treatment with statistical significance(P<0.001);1.6Levels of blood glucose in infants at different time points had statistical significance in comparison among groups with sum(P<0.001),the level of blood glucose in infants at the end of treatment was higher than that in quiet state before treatment with statistical significance(P<0.001);1.7Levels of C-reactive protein in infants at different time points had no statistical significance in comparison among groups with sum(P>0.05).2. Changes of physiological indicators of infants before and after retinal laser photocoagulation treatment under topical anesthesia:2.1Levels of heart rate (HR) of infants at different time points had statistical significance in comparison among groups with sum(P<0.001), HR levels of infants at the end of treatment,1hour after treatment and24hours after treatment had statistical significance compared with that in quiet state before treatment(P<0.05);2.2Levels of mean artery pressure (MAP) of infants at different time points had statistical significance in comparison among groups with sum(P<0.001), the MAP level of infants at the end of treatment were higher than that in quiet state before treatment with statistical significance(P<0.001);2.3Levels of respiratory rate (RR) of infants at different time points had statistical significance in comparison among groups with sum(P<0.001), RR levels of infants at the end of treatment,1hour after treatment and24hours after treatment were higher than that in quiet state before treatment with statistical significance(P<0.05);2.4Levels of oxygen saturation of blood (SpO2) of infants at different time points had statistical significance in comparison among groups with sum(P<0.001), SpO2levels of infants at1hour and24hours after treatment were higher than that in quiet state before treatment with statistical significance (P<0.05).3. Changes of behavioral and physiological indicators of infants during retinal laser photocoagulation treatment:3.1Changes of SpO2:SpO2of2infants (6.7%) decreased below80%,1case (3.3%) fluctuated between80%～90%and27cases (90%) contained higher than90%.3.2Changes of HR and MAP:HR and MAP of2.(6.7%) cases decreased more than20%of those before treatment,13cases (43.3%) increased less than20%of those before treatment and15cases (50%) increased no less than20%of those before treatment.Conclusions and Implications for Clinicians:1. Preterm infants in waking state under topical anesthesia had stress responses during retinal laser photocoagulation treatment.2. The changes of stress related biochemical indexes in blood of preterm infants proved that stress responses existed during the retinal laser photocoagulation treatment.3. To monitor changes of behavioral and physiological indicators of preterm infants could suggest that stress responses existed.4. Clinicians should attach importance to monitoring preterm infants receiving retinal laser photocoagulation treatment under topic anesthesia and take interventions in time because of the time limitation of laboratory testing.5. The change of physiological indexes triggered by stressors provided monitoring and nursing evidences for clinicians. Although preterm infants are in waking state, clinicians can not ignore assessments and monitoring of preterm infants from the beginning to24hours after retinal laser photocoagulation treatment. Nurses should enhance inspection and assessment to prevent infants from excessive external stimulus.6. Stress responses of preterm infants during retinal laser photocoagulation treatment were induced by coactions of various stressors.7. Clinicians should pay attention to the influence of stimulus similar to such "tiny stimulus" in retinal laser photocoagulation treatment on preterm infants in clinical work.Innovation points:1. It scientifically demonstrated that preterm infants had stress responses during retinal laser photocoagulation treatment under topic anesthesia through both laboratory testing of stress factors in blood and clinical monitoring of physiological indexes of these preterm babies.2. The study applied results of stress responses to trace back to stressors of preterm infants, and provided evidences to clinical nurses for implementing treatment and nursing interventions of the retinal laser photocoagulation treatment as well as developing standardized nursing routine.3. The study recognized the safety risks during such "tiny stimulus" like retinal laser treatments through the methods of laboratory testing and clinical monitoring, and provided references for other clinicians conducting the similar related studies on "tiny stimulus". |
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