目的：早產兒視網膜病變(Retinopathy of prematurity, ROP)是極低體重早產兒常見之合併症，檢查過程造成的早產兒疼痛/壓力處理研究，除局部麻醉劑有實證成效外，其餘照護措施仍莫衷一是，且未涵蓋點散瞳劑至檢查結束後期間，實有必要重新探索臨床場域之真實現象，了解早產兒疼痛與壓力反應以及可能相關因素，提供建立完整照護方案之參考。
方法：採自然觀察研究法，以非參與式角色錄製自接受散瞳前20分鐘至ROP檢查結束後2小時之影片，包括早產兒本身及生命徵象監視器，並書寫現場觀察日誌。根據文獻查證及臨床經驗發展自擬半結構性譯碼指引，並檢驗專家效度(CVI 0.97)、評分者內與評分者間信度(百分同意度88%；85%)。觀察變項包括個案屬性、執行流暢度、發展性照護介入措施評值(Evaluation of Intervention, EVIN)等，疼痛與壓力表現除哭泣反應、心搏過緩情形外，以行為評估(Behavioral Evaluation)量表測量壓力行為，早產兒疼痛量表修訂版(Premature Infant Pain Profile- Revised, PIPP-R)測量疼痛反應。於南部某醫學中心之新生兒加護病房接受ROP檢查之早產兒方便取樣，排除最近一次腦部超音波檢查結果為腦室周圍白質軟化症(periventricular leukomalacia, PVL)或其他嚴重腦部疾病者，每人最多被觀察4次，每人次觀察12個事件/時間點。
結果：自2014年8月至2015年4月，共23位早產兒參加研究，取得43次檢查過程影片，出生週數平均為27.6周，體重1025克，檢查時矯正年齡平均為33.7週，體重1612克。ROP檢查平均約花3分鐘，點完雙眼藥水平均約為36秒。壓力(BE)與疼痛(PIPP-R)分數具類似趨勢，點散瞳劑與檢查過程各觀察事件/時間點與基礎點有統計上顯著差異，最高者依序為固定壓迫眼球、放入張眼器及第一次點散瞳劑(p<0.001)，並且通常伴隨著哭泣，體重較低的早產兒則傾向以心搏過緩代替哭泣。收案對象大多在檢查結束後平均約12.4分鐘(742.2 ± 764.5秒) 後回到原本生命徵象狀態(心跳、呼吸、血氧濃度)，壓力與疼痛分數則於檢查後10分鐘之觀察時間點回復。出生時疾病嚴重度(Apgar scores 1’ and 5’及CRIB分數)、性別、發展性照護分數(EVIN)、檢查時週數、檢查時體重與最近一次血比容值跟部分觀察事件/時間點的疼痛、壓力分數或復原時間相關(p<0.05)。質性觀察分析後發現手直接寧握與非營養性吸吮有助於早產兒放鬆、自我整合與調整狀態。此外，在生命徵象狀態回復後立即停止檢查期間給予的額外氧氣或是檢查後立即進行例行性照護活動，例如換尿布或口胃管護理，會使有些早產兒出現生命徵象不穩定情形。
早產兒接受ROP檢查時，從點散瞳劑即開始表現疼痛與壓力反應直至結束後10分鐘，且約13分鐘後生命徵象才回復。出生疾病嚴重度、性別、檢查時週數與體重、最近一次血比容數值、發展性照護、以手寧握、非營養性吸吮、延長額外氧氣給予時間，以及足夠的復原時間均與早產兒較低的疼痛與壓力反應有關。性別與檢查時的體重對疼痛及壓力表現的影響，需未來研究收集更多樣本以釐清，建議發展早產兒ROP檢查之疼痛與壓力處理方案或照護準則時應將本研究所發現之相關因素、疼痛/壓力時間點、及評值時間點與項目列入考量。

Background: Retinopathy of prematurity (ROP) is a common complication affecting premature infants. Except for the local anesthetic eye drops proved by empirical studies, there is no consensus among the pain/stress managements from initial of mydriasis until after the examination and discussing associated factors rarely. It is essential to explore the clinical fact thoroughly to understand the pain/stress performances under ROP exams and to investigate the associated factors.
Method: A natural observation method was used. Period from twenty minutes before administration of mydriatic eye drops until one hour after ROP exam was digital videotaped and described qualitatively. A semi-structured coding instruction was developed and the content validity index was 0.97, and the intra-rater and inter-rater reliability was 88% and 85% respectively. The potential associated items contained characteristics of participants and context, smoothness level of the administration, developmental care quantified by Evaluation of Intervention (EVIN), and other possible factors. Meanwhile, except for crying and bradycardia, pain and stress performances were measured by Premature Infant Pain Profile-Revised (PIPP-R) and Behavioral Evaluation (BE) respectively. Convenient sampling was used in a neonatal intensive care unit in a tertiary hospital in southern Taiwan. Each participant was observed four times maximally. Each recording of exam was sampled at 12 event/time points.
Results: Between August 2014 to April 2015, 23 preterm infants were enrolled and 43 ROP exams were recorded. In average, the participants were 27.6 weeks gestational age (GA) with body weight (BW) 1025 gm at birth and 33.7 weeks postmenstrual age (PMA) with 1612 gm when they received the exam. Approximately, the mean period of each administration of mydriatic eye drops was 36 seconds while the ROP exam was 3 minutes. The trends of pain/stress performances are similar. Scores at event/time points were statistically significantly higher than baseline from the initial of administration of mydriatic eye drops until ten minutes after the exam. The top pain/stress scores were measured at scleral indention, insertion of eye lid speculum, and first dosage of mydratic eye drops (p<0.001) and usually accompanied with crying or bradycardia. Instead of crying, participants with lower BW tended to show bradycardia. Most of the participants took about 12.4 minutes (742.2 ± 764.5 seconds) to get back to the baseline heart rate, respiratory rate and oxygen saturation level, and BE and PIPP-R scores decreased to baseline at the point of 10 minutes after exam. We also found Apgar scores at 1st and 5th minute (Apgar 1’ and 5’), CRIB scores at birth, sex, the EVIN scores, mode of ventilation, environmental housing care, PMA and BW on exam day (RBW) and the latest hematocrit (lHct) level were associated with PIPP-R or BE scores at part event/time points, or recovery time (p<0.05). Qualitative analysis revealed that containment directly by hands and non-nutritive sucking may make the participants relax, self-integration, and adjust their infant state. In addition, some participants showed unstable vital signs after the immediate cease of the extra oxygen providing during examination determined by SpO2 recovery or after the routine care activities right after the completion of examination, such as changing diapers or oral gastric tube care.
Conclusion: The premature infants showed pain/stress performances from the initial of administration of mydriatic eye drops until ten minutes and physiologically recovered until around 13 minutes after the exam. Severity of the condition at birth, sex, severity of the condition on exam day, growth characteristics of the preterm infants, developmental care, containment directly by hands, non-nutritive sucking, extend the duration of extra oxygen supply, and enough time to recover were correlated to pain/stress responses. Further studies with larger sample size were needed to identify the influences of sex and RBW. We suggested considering these measuring points, outcome variables, and associated factors when developing intervention program or clinical guideline of providing effective care for ROP exam.

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