Pupil Light Reflex for the Assessment of Analgesia in Critically Ill Sedated Patients With Traumatic Brain Injury: A Preliminary Study.

ABSTRACT: BACKGROUND: Analgesia monitoring is essential to preserve comfort in critically ill sedated patients with traumatic brain injury (TBI). Although pupil dilation (PD) and pain behaviors can be used to assess analgesia, these indicators require application of noxious stimulations for elicitation. Recently, the pupillary light reflex (PLR) has emerged as a nonnoxious parameter that may be used to predict analgesia requirements in non-brain-injured patients. Here, we explored whether PLR can be used for the purpose of analgesia monitoring in critically ill sedated TBI patients. METHODS: Fifteen mechanically ventilated TBI patients (11 men; 54 ± 20 years) under continuous analgesia and sedation infusions were assessed at predefined time within 72 hours of intensive care unit admission. Data collection was performed using video-pupillometry and the Behavioral Pain Scale. At each assessment, pupil size and PLR at rest were recorded followed immediately by the documentation of PD and pain behaviors elicited by a calibrated noxious stimulus. Blood concentrations of analgesics/sedatives were monitored. RESULTS: One hundred three assessments were completed. PLR resulted in an average decrease of 19% in pupil diameter, and PD resulted in an average increase of 10% in pupil diameter. Variations in PLR and PD were more pronounced in subjects who showed a Behavioral Pain Scale score greater than 3 (a recognized sign of subanalgesia) compared with those with no behavioral reaction. Multiple regression analyses suggest a significant overlap between fluctuations in pupillary reflexes and blood levels of fentanyl, not propofol. CONCLUSION: In our sample, percentages of variation in PLR and PD were found to be directly representative of TBI patients' fentanyl blood concentration. Considering information about blood drug concentration is generally not available at bedside, PLR could be used as a proxy to assess analgesia requirements before a nociceptive procedure in critically ill sedated TBI patients who are vulnerable to stress.

Feasibility and acceptability of hypnosis-derived communication administered by trained nurses to improve patient well-being during outpatient chemotherapy: a pilot-controlled trial.

PURPOSE: This pilot-controlled trial aimed to examine the feasibility and acceptability of hypnosis-derived communication (HC) administered by trained nurses during outpatient chemotherapy to optimize symptom management and emotional support - two important aspects of patient well-being in oncology. METHODS: The trial was conducted in two outpatient oncology units: (1) intervention site (usual care with HC), and (2) control site (usual care). Nurses at the intervention site were invited to take part in an 8-h training in HC. Participants' self-ratings of symptoms and emotional support were gathered at predetermined time points during three consecutive outpatient visits using the Edmonton Symptom Assessment Scale and the Emotional Support Scale. RESULTS: Forty-nine patients (24 in the intervention group, 25 in the control group) with different cancer types/stages were recruited over a period of 3 weeks and completed the study. All nurses (N = 10) at the intervention site volunteered to complete the training and were able to include HC into their chemotherapy protocols (about ± 5 min/intervention). Compared to usual care, patients exposed to HC showed a significant reduction in physical symptoms during chemotherapy. In contrast, perception of emotional support did not show any significant effect of the intervention. Participants exposed to HC report that the intervention helped them relax and connect on a more personal level with the nurse during chemotherapy infusion. CONCLUSIONS: Our results suggest that HC is feasible, acceptable, and beneficial for symptom management during outpatient chemotherapy. While future studies are needed, hypnosis techniques could facilitate meaningful contacts between cancer patients and clinicians in oncology. TRIAL REGISTRATION: Clinical Trial Identifier: NCT04173195, first posted on November 19, 2019.