Skin conductance algesimeter

I, Hanne Storm, Associated Professor MD. PhD, is the founder and co-owner of Med-

Storm that owns the

patents for this technology

Background for the “Skin conductance algesimeter”:

• ”Skin conductance algesimeter” is developed around the lie detector technology.

• The Skin conductance peaks in the palmar surface correlate directly with skin sympathetic nerve activity.

• “Skin conductance algesimeter” use number of skin conductance peaks per sec as an index

• The skin conductance peaks react immediately to a painful stimulus (1-2 sec).

• The skin conductance peaks are not influenced from blod circulatory changes, adrenergic medication, beta blockers, clonidine, or neuromuscular blockers, because acetyl-choline acts on muscarinic receptors. In clinical doses atropine does not influence the skin conductance peaks.

• ”Pain” and ”skin conductance” 250 hits. Dubé AA et al. Brain activity associated

with the electrodermal reactivity to acute heat pain. Neuroimage 2009 Mar 1;45(1):169-80 . Burton AR et al. Effects of deep and superfcial experimentally induced acute pain on skin sympathetic nerve activity in human subjects. Exp Brain Res (2009) 195:317–324

Gjerstad AC, Storm H, Wallin G. Evaluation of the skin conductance method by using microneurographi, abstract, ISAP, Chicago 06. Presentation of skin sympathetic nervous system:

The Skin conductance algesimeter - How it works

REVIEW PAPERS OF CLINICAL UTILITY:

1. Storm H. Changes in Skin Conductance as a tool to monitor nociceptive stimulationand pain. Current Opinion in Anaesthesiology 2008, 21:796–804

VALIDATION OF THE TECHNOLOGY ON VOLENTERS:

1. Gjerstad AC, Storm H, Wallin G. Evaluation of the skin conductance method by using microneurographi, abstract, ISAP, Chicago 06. Presentation sympathetic nervous system

2. Dubé AA, Duquette M, Roy M, Lepore F, Duncan G, Rainville P.Brain activity associated with the electrodermal reactivity to acute heat pain. Neuroimage 2009 Mar 1;45(1):169-80

3.Burton AR, Birznieks I, Spaak J, Henderson LA, MaceWeld LG. .Effects of deep and superfcial experimentally induced acute pain on skin sympathetic nerve activity in human subjects. Exp Brain Res (2009) 195:317–324

4. Luis R, Storm H. Department of Paediatric Research and Department of Anaesthesiology, The National Hospital, Oslo. Measuring of stress and pain responses on voluntary adult persons after a burning injury by visual analogue scale, blood pressure, heart rate and skin conductance variables, Abstract;IASP 2002.

5. Kunimoto M, Kirno K, Elam M, Karlsson T, Wallin BG. Neuro-effector characteristics of sweat glands in the human hand activated by irregular stimuli. Acta Physiol Scand 1992;146:261-269.

6. Hagbarth KE, Hallin RG, Hongell A, Torebjørk HE, Wallin BG. General Characteristics of sympathetic activity in human skin nerves. Acta Physiol Scand 1971;84:164-176

7. Wallin BG, Sundløf G, Delius W. The effect of carotid sinus nerve stimulations on muscle and skin nerve sympathetic activity in man. Plugers Arch 1975;358:101-110.

8. Macefield VG, Wallin BG. The discharge behaviour of single sympathetic outflow in normotensive human sweat glands. J Auton Nerv Syst 1996;14:277-286.

9. Bini G, Hagbarth KE, Hynninen P, Wallin BG. Thermoregulatory and rythmgenerating mechanisms govering the sudomotor and vasoconstrictor outflow in human cutaneous nerves. J Physiol 1980:306:537-552.

10. Tranel D, Damasio H. Neuroanatomical correlates of electrodermal skinconductance responses. Psychophysiology 1994;31:427-438.

11. Edelberg R. Electrical properties of the skin. In: Brown CC (eds), Methods inPsychophysiology. Williams & Wilkins, Baltimore, 1967:1-59.

12. Christie MJ. Electrodermal activity in the 1980’s: a review. J. R. Soc Med 1981;74:616-22.

13. Fredrikson M, Furmark T, Olsson MA, Fischer H, Andersson J, Långstrom B. Functional neuroanatomical correlates of electrodermal activity: A positron emission tomographic study. Psychophysiology, 35 (1998), 179-185.

14. Patterson JC, Ungerleider LG, Bandettini PA. Task-dependent functional brain activity correlation with skin conductance changes: an fMRI study. NeuroImage 2002, 17, 1797-1806.

DEVELOPMENT OF SOFTWARE PROGRAM:

1. Storm H, Fremming A, Ødegaard S, Martinsen Ø, Mørkrid L. A software analysis program for spontaneous and stimulated skin conductance activity. Clinical Neurophysiology 2000;111:1989-1998.

2. Storm H. The development of a software analysis program for analysing spontaneous skin conductance activity in preterm infants, Clinical Neurophysiology 2001(112):1562-1568.

Preterm infant (from week 25th of gestational age) monitored before during and after painful procedure. Totally there have been studied about 500 preterm infants. Age does not influence

Preterm infants during painful procedures

Desaturation measured peripheral Sympathetic muscle outflow

(microcirculation/vasoconstri

ction)

Sympathetic skin

outflow (increase in

skin conductance

peaks)

Emotional stress

without arousal

No influence Yes

Arousal stimuli such

as sudden inspiration,

chest compression,

sudden electrical skin

shock.

Desaturation without general hypoxia

but due to peripheral hypoperfusion

Yes, vasoconstriction Yes

Frightening situation Desaturation without general hypoxia

but due to peripheral hypoperfusion

Yes, vasoconstriction Yes

Cooling Desaturation without general hypoxia

but due to peripheral hypoperfusionYes, vasoconstriction No influence

Warming Yes, inhibited outflow

vasodilatation

No influence

Respiratory rhythm Yes, influence No influence

Apnea Desaturation with general hypoxia Yes, influence No influence

Hypoxia Desaturation with general hypoxia Yes, vasoconstriction Not studied

Baroreflex control Yes, influence No influence

Valsalva manoeures Yes, influence No influence

Carotid sinus nerve

stimulation

Yes, inhibited outflow

vasodilatation.

No influence

Index based on colour code in infants:

WHITE: 0.00-0.07 peaks

per sec

The infant is calm (15 infants studied 6 times during 48 hours at behavioural state

1, peaks per sec: median: 0.00 range 0.00-0.04).

LIGHT YELLOW: 0.14

peaks per sec

The infant is calm and move a little

YELLOW: 0.21-0.027

peaks per sec

The infant is active, observe the infant, pain / discomfort threshold is reached

ORANGE: 0.33 peaks per

sec

The infant is probably in pain / discomfort, evaluate the situation

RED: 0.40 peaks per sec

or more

The infant is in increasing pain /discomfort

PAIN AND OTHER STIMULI IN INFANTS AND CHILDREN:1. Storm H. Skin conductance activity and the stress response from heel stick in premature infants. Archives of Disease in Childhood 2000;83(2):F143-F147.

2. Storm H. Development of emotional sweating in the preterm infant measured by skin conductance, Early Human Development 62(2001)149-158.

3. Hellerud BC, Storm H. Skin conductance and arousal during tactile and nociceptive stimulation in relation to postnatal age of preterm and term infants. Early Human Development 70(2002)35-46.

4. Storm HS, Fremming A. Effectiveness of oral sucrose and food intake on pain response in preterm infants measured by changes in skin conductance activity, heart rate, crying time and behavioural state, Acta Paediatrica Scandinavia 2002(91):555-560.

5. Storm H, Vandvik IH, A pilot study of how spontaneous skin conductance changes may be used as a method to measure the effect of hypnosis. mai 2000, Oslo, poster J. of Psychosomatic Research 2000(48) p 276.

6. Storm H, Østberg BC. A pilot study of spontaneous and stimulated skin conductance changes in a patient suffering from anorexia, foredrag. J. of Psychosomatic Research 2000(48) p 230.

7. Hernes K, Mørkrid L, Fremming A, Ødegaard S, Martinsen Ø, Storm H. Skin conductance activity during the first year of life, Pediatric Research 2002;52(6):837-843.

8. Eriksson M, Storm H, Fremming A, Schollin J. Skin conductance compared to a combined behavioural and physiological pain measure in newborn infants. Acta Paediatrica 2008 Jan;97(1):27-30. Epub 2007 Dec 3. PMID: 18052991 (PubMed)

9. Denise Harrison, Linda Johnston, Suzanne Boyce, Peter Loughnan, Hanne Storm, Peter Dargaville, Skin conductance as a measure of pain and stress in hospitalised infants, Early Human development 2006;82:603-8.

10. Roeggen I, Denise Harrison, Hanne Storm. Skin conductance variability between and within hospitalised infants at rest. Early Hum Dev. 2011 Jan;87(1):37-42. Epub 2010 Oct 30.

11. Kim Kopenhaver Haidet, PhD, CNNP1, Cherie Adkins, PhD(c), RN1, Sarah Rebstock, PhD, MD2, Arash Salavitabar, BS2Elizabeth J. Susman, PhD1, Sheila G.West, PhD1, Charles Palmer, MB, ChB2, & Hanne Storm3, MD, PhD Measures of Stress Vulnerability in LBW Infants: An Integrative Biobehavioral Approach to Stress Reactivity Measurement, Abstract Gravens conference 2007.

12. Salavitabar A, Haidet K, Adkins C, Palmer C, Storm H. Preterm Infants Physiological and Behavioural responses to sound stimuli in the neonatal Intensive care Units. PAS, Honolulu; 4458-Neonatology, on 5/4/08, 11-3, published Advances in Neonatal Care Febr 2010.

13. Munster JMA, Simonsson L, Sindelar R. Skin conductance (SC) measurements as pain assessment in newborn infants born 22-27 gestational weeks (GW) at differentpostnatal age. E-PAS2009:5505.77, Early Human development 2012.

14. Luís Pereira-da-Silva 1,2, Ivete Monteiro 1, Sandra Gomes 1, Patrícia Rodrigues 1, Daniel Virella 1, Micaela Serelha 1, Hanne Storm 3 Skin conductance indices discriminate nociceptive responses to acute stimuli from different heel prick procedures in infants. The Journal of Maternal-Fetal and Neonatal Medicine, 2011, 1-6, Early Online

15. Rosana Tristão, José Alfredo Lacerda de Jesus, Storm H, Heart rate, oxygen saturation and skin conductance: a comparison study of acute pain in Brazilian newborns. Conf Proc IEEE Eng Med Biol Soc. 2011;2011:1875-9. doi: 10.1109/IEMBS.2011.6090532. PMID: 22254696 [PubMed - indexed for MEDLINE]

16. N Kandamany, E Hayden, JF Murphy. National Maternity Hospital Holles Street. ROP Screening and Stress in Preterm Infants. EPAS 2010 Poster.

17. Ham J. Tronick E. A procedure for the measurement of infant skin conductance and its initial validation using clap induced startle. Dev Psycho Biol 2008;50:626-631.

18. Storm H, PAIN ASSESSMENT IN NEONATES, To be published by IGI Global http://igi-global.com/AuthorsEditors/AuthorEditorResources/CallForBookChapters/CallForChapterDetails.aspx?CallForContentId=02f37e9d-dfc7-4596-9a47-cadff82a5a9c, published.

19.Cresi, Castagno, Storm, Silvesto, Minero,Savino COMBINED ESOPHAGEAL INTRALUMINAL IMPEDANCE PH AND SKIN CONDUCTANCE MONITORING TO DETECT DISCOMFORT IN GERD INFANTS” was recently published in PLOS ONE and is available online at http://dx.plos.org/10.1371/journal.pone.0043476.20. Chapter in book. Monitoraggio del dolore postoperatorio nei pazienti pediatrici. M. Astuto, G. Arena, M. Sardo, P. Murabito, H. Storm. in Governo clinico e medicina perioperatoria Springer-Verlag Italia 2012 ISBN 978-88-470-2792-3 eISBN 978-88-470-2793-30 DOI 10.1007/978-88-470-2793-0 21. Savino F, Vagliano L, Ceratto S, Viviani F, Miniero R, Ricceri F. Pain assessment in children undergoing venipuncture: theWong–Baker faces scale versus skin conductance fluctuations. PeerJ 2013;1:e37; DOI 10.7717/peerj.37.

Postoperative Pain in children and

adults

• When the pain is more than 3 at a NRS, ”the

Pain Monitor” has a sensitivity of 90% when

discovering postoperative pain, different from

blood pressure and heart rate (n=250).

• Analgesics postoperative reduces the pain and

the Pain Monitor index

Thomas Ledowski et al. Monitoring of Skin Conductance to assess postoperative pain intensity. BJA 2006:97(6):862-5. Thomas Ledowski et al. The assessment of postoperative pain by monitoring skin conductance: results of a prospective study, Anaesthesia 2007 Oct;62(10):989-93 +180 children with similar results, Anesthesiology 2009;111:513-7.

Artificial ventilated infants and children (n=20) at

the intensive care unit:

The skin conductance changes from before, during and after suction

from the airways. The skin changes increased together with an increase

in pain score “COMFORT SEDATION SCORE”. At 240 seconds, the nurse

touched the wound area.

Results

Number of skin

conductance

fluctuations (n=20)

Heart rate

(n=20)

Blood pressure

(n=20)

Sedation

score

p<0.01

r2=0.83

Not

statistical

significant

Not statistical

significant

Correlation tests performed on the data from before to during suction

in the airways between the sedation score and skin conductance

changes, heart rate and blood pressure. Number of skin conductance

fluctuations, heart rate, blood pressure, and Sedation score increased

from before to during suction of trachea

Storm H. Gjerstad AC. Hellerud BC. Wagner K, Henriksen T. Skin conductance changes as a measure to monitor discomfort in artificial ventilated children. Pediatrics 2008:122;e848-e853.

Skin conductance fluctuations during observation of

intensive care patients, intubated or not intubated.

Anders Grunther, Hanne Storm, and Peter Sackey, Karolinsk hospital and University

of Oslo,

• 20 intubated intensive care patients were studied for one hour. One

observer registrated painful stimuli, ordinary stimuli not expected to

be painful, and periods without any stimuli.

• 20 not intubated intensive care patients were studied for one hour.

One observer registrated painful procedures, ordinary stimuli not

expected to be painful, and periods without any stimuli. If the patient

was orientated the VAS score was used.

Intubated Non-intubated

Age; mean (SD) 60 (16) 55(18)

sex; Female 2 7

Male 18 13

ICU day of registration ; median

(range)

3 (1-13) 2 (1-19)

Diagnosis group (n);

Medical 4 6

Surgical 4 4

Trauma 4 6

Sepsis 8 4

*Day of registration

Score Description Definition

0 Unresponsive Does not move with noxious stimuli

1 Responsive only to

noxious stimuli

Open eyes, raises eyebrows, or turns head toward

stimulus; moves limbs with noxious stimulus

2 Responsive to touch or

name

Open eyes, raises eyebrows, or turns head toward stimulus

when touched or name is loudly spoken

3 Calm and cooperative No external stimulus in required to elicit movement;

adjusts sheets or clothes purposefully, follows commands

4 Restless and

cooperative

No external stimulus in required to elicit movement; picks

at sheets or tubes, uncovers self, follows commands

5 Agitated No external stimulus in required to elicit movement,

attempts to sit up or moves limbs out of bed, does not

consistently follow commands (eg, will lie down when

asked to but soon reverts back to attempts to sit up or

move limbs out of bed)

6 Dangerously agitated,

uncooperative

No external stimulus in required to elicit movement; pulls

at tubes or catheters, trashes side to side, strikes at staff,

tries to climb out of bed, does not calm down when asked.

Motor Activity Assessment Scale (MAAS)

Sedation/analgesia Intubated

n=20

Non-Intubated

n=20

Opiates infusion 10 0

intermittent 6 5

Bensodiazepines infusion 9 0

intermittent 1 0

Propofol infusion 6 0

intermittent 4 0

Clonidine 6 3

Epidural 2 5

Sedation and or analgesia at the time for NSCF registration

MAAS 2 MAAS 3 MAAS 4 MAAS 5 p-value

n=30 n=589 n=92 n=4

No stimulation

n=77 0

(0-0)

n=14

0.

(0-0,13)

n=98

0

(0-0.13)

n=5

No

Observation0.094

Mild stimulation

n=165 0.04

(0-0.2)

n=10

0.07

(0-0.2)

n=256

0.13

(0.07-0.27)

n=73

No

Observation0.000*

Potentially

painful

stimulation

n=53

0.3

(0.2-0.4)

n=2

0.2

(0.13-0.33)

n=66

0.33

(0.33-0.67)

n=7

No

Observation 0.007*

Expression of

pain or

discomfort

n=112

0

(0-0.07)

n=4

0.2

(0.13-0.27)

n=169

0.4

(0.33-0.73)

n=7

0.53

(0.43-0.53)

n=4

0.000*

p-value 0.016* 0.000* 0.000*

Non - intubated patients, Statistical testing performed using Kruskal Wallis test

MAAS 0 MAAS 1 MAAS 2 MAAS 3 MAAS 4p-

value

n=11 n=339 n=221 n=96 n=68

No

stimulatio

n

n=126

0.07

(0-0.07)

n=7

0

(0-0.07)

n=85

0

(0-0.17)

n=16

0.33

(0.2-0.4)

n=18

No

observatio

n0.000*

Mild

stimulatio

n

n=329

0.07

(0-0.13)

n=3

0

(0-0.13)

n=110

0.07

(0-0.07)

n=116

0.20

(0-0.33)

n=64

0.24

(0.13-0.33)

n=36

0.000*

Potentially

painful

stimulatio

n

n=225

0.07

(0.07-0.07)

n=1

0.13

(0-0.27)

n=121

0.07

(0-0.13)

n=68

0.27

(0,24-0,37)

n=12

0.27

(0.13-0.33)

n=23

0.000*

Expressio

n of pain

or

discomfort

n=47

No

observation

0.07

(0-0.20)

n=15

0.07

(0-0.13)

n=21

0.23

(0.13-0.33)

n=2

0.33

(0.27-0.33)

n=9

0.001*

p-value 0.191 0.000* 0.004* 0.047 0.085

Intubated patients Statistical testing performed using Kruskal Wallis test.

The PainMonitor Index based on colour code in

intensive care unit patients and patients

postoperatively (infants, children and adults):

WHITE:

0.00 – 0.07 peaks per

sec

No pain

LIGHT YELLOW:

0.13No pain

YELLOW:

0.21-0.27 peaks per

sec

Patient is active, can be pain VAS 40-50

ORANGE:

0.33 peaks per secPatient is possible in pain, VAS 60-80,

go and evaluate the situation RED:

0.40-0.70 peaks per

sec

The patient is probably in pain, VAS 80-100, go and find out how to help the patient

References postoperative and intensive care unit patients:

1.Thomas Ledowski, Hanne Storm et al. Monitoring of skin conductance to assess postoperative pain intensity. British Journal of Anaesthesia 2006;97(6):862-5.

2. Ledowski T, Bromilow J, Wu J, Paech MJ, Storm H, Schug SA. The assessment of postoperative pain by monitoring skin conductance: results of a prospective study, Anaesthesia. 2007 Oct;62(10):989-93

3. Hullett B, Chambers N, Preuss J, Zamudio I, Lange J, Pascoe E, Ledowski T, Monitoring Electrical Skin Conductance A Tool for the Assessment of Postoperative Pain in Children? Anesthesiology 2009; 111:513–7

4. Ledowski T, Preuss J, Schug SA. The effects of neostigmine and glycopyrrolate on skin conductance as a measure of pain, Eur J Anaesthesiol. 2009 Sep;26(9):777-81.

5. Choo EK, Magruder W, Montgomery C, Lim J, Brant R, Ansermino M. (2010). Skin Conductance Fluctuations Correlate Poorly with Postoperative Self-report Pain Measures in School-aged Children. Anesthesiology, 113, 175– 82

6. Gjerstad AC, Hellerud BC, Wagner K, Henrichsen T, Storm H. Skin conductance as a measure of discomfort in artificial ventilated children, submitted and Abstract ESA 2002, Pediatrics

2008;122;e848-e853.

7 . Skin conductance monitoring and its ability to detect discomfort during a painful stimulus in an Intensive Care Unit populationMichel E. van Genderen, Thijs van der Arend, Alexandre Lima, Jan Bakker, Jasper van Bommel Dept. of Intensive Care, Erasmus MC, Rotterdam, the Netherlands

8. Gunther A, Bottai M, Schandel AR, Storm H, Rossi P, Sackey P. Skin conductance changes in intensive care patients, Critical Care 2013 17:R51.

Sensitivity and Spesificity of the PainMonitor is

dependent on the level of sedation

Sensitivity Specificity Level of

seda?on (↑)

Adult-

children

89% 68% - 74% Postoperativ

e (↑)

Adult 82% /

100%

84% / 91% Intensive

care (↑↑):

with anxiety

/without

anxiety

Adult 86% 86% / 100% Anesthesia

(↑↑↑↑↑

↑): surgical

stress score /

no stimulus

Sensitivity Specificity Level of seda?on (↑)

Adult-children 89% 68% - 74% PostoperaDve (↑)

Adult 82% / 100% 84% / 91% Intensive care (↑↑): with

anxiety /without anxiety

Adult 86% 86% / 100% Anesthesia (↑↑↑↑↑↑):

surgical stress score / no

stimulus

Conclusion

• Pain in anaesthesised and awake patients can be

monitored by Med-Storm’s Pain Monitor.

In both groups of patients the Pain Monitor

Index is reduced when analgesics is given

against the pain.

Contact

Associated professor MD.PhD Hanne Storm

E-mail:hanne.storm@medisin.uio.no

Phone: +4723074398/+4790788976