Pain management interventions in the Paediatric Intensive Care Unit: A scoping review

An Australian survey of health professionals' perceptions of use and usefulness of electronic medical records in hospitalised children's pain care

Pain in hospitalised children is common, yet inadequately treated. Electronic medical records (EMRs) can improve care quality and outcomes during hospitalisation. Little is known about how clinicians use EMRs in caring for children with pain. This national cross-sectional survey examined the perceptions of clinician-EMR users about current and potential use of EMRs in children's pain care. One hundred and ninety-four clinicians responded (n = 81, 74% nurses; n = 21, 19% doctors; n = 7, 6% other); most used Epic (n = 53/109, 49%) or Cerner (n = 42/109, 38%). Most (n = 84/113, 74%) agreed EMRs supported their initiation of pharmacological pain interventions. Fewer agreed EMRs supported initiation of physical (n = 49/113, 43%) or psychological interventions (n = 41/111, 37%). Forty-four percent reported their EMR had prompt reminders for pain care. Prompts were perceived as useful (n = 40/51, 78%). Most agreed EMRs supported pain care provision (n = 94/110, 85%) and documentation (n = 99/111, 89%). Only 39% (n = 40/102) agreed EMRs improved pain treatment, and 31% (n = 32/103) agreed EMRs improved how they involve children and families in pain care. Findings provide recommendations for EMR designs that support clinicians' understanding of the multidimensionality of children's pain and drive comprehensive assessments and treatments. This contribution will inform future translational research on harnessing technology to support child and family partnerships in care.

Exposure to Sedation and Analgesia Medications: Short-term Cognitive Outcomes in Pediatric Critical Care Survivors With Acquired Brain Injury

Background/Objective: Pediatric intensive care unit (PICU) survivors risk significant cognitive morbidity, particularly those with acquired brain injury (ABI) diagnoses. Studies show sedative and analgesic medication may potentiate neurologic injury, but few studies evaluate impact on survivor outcomes. This study aimed to evaluate whether exposures to analgesic and sedative medications are associated with worse neurocognitive outcome. Methods: A retrospective cohort study was conducted of 91 patients aged 8 to 18 years, undergoing clinical neurocognitive evaluation approximately 1 to 3 months after PICU discharge. Electronic health data was queried for sedative and analgesic medication exposures, including opioids, benzodiazepines, propofol, ketamine, and dexmedetomidine. Doses were converted to class equivalents, evaluated by any exposure and cumulative dose exposure per patient weight. Cognitive outcome was derived from 8 objective cognitive assessments with an emphasis on executive function skills using Principal Components Analysis. Then, linear regression was used to control for baseline cognitive function estimates to calculate a standardized residualized neurocognitive index (rNCI) z-score. Multivariable linear regression evaluated the association between rNCI and medication exposure controlling for covariates. Significance was defined as P < .05. Results: Most (n = 80; 88%) patients received 1 or more study medications. Any exposure and higher cumulative doses of benzodiazepine and ketamine were significantly associated with worse rNCI in bivariate analyses. When controlling for Medicaid, preadmission comorbid conditions, length of stay, delirium, and receipt of other medication classes, receipt of benzodiazepine was associated with significantly worse rNCI (β-coefficient = -0.48, 95% confidence interval = -0.88, -0.08). Conclusions: Exposure to benzodiazepines was independently associated with worse acute phase cognitive outcome using objective assessments focused on executive function skills when controlling for demographic and illness characteristics. Clinician decisions regarding medication regimens in the PICU may serve as a modifiable factor to improve outcomes. Additional inquiry into associations with long-term cognitive outcome and optimal medication regimens is needed.

Extended Reality Use in Paediatric Intensive Care: A Scoping Review

Background: Extended reality (XR) technology such as virtual and augmented reality is increasingly being utilised in paediatric medicine due to its role in medical education and reported positive impacts on outcomes including pain, anxiety, and sleep. To the author's knowledge, no previous reviews investigating the use of XR in paediatric intensive care have been undertaken. Objectives: To scope the use of XR in paediatric intensive care, and assess its barriers to adoption, including safety considerations, cleaning and infection control. Eligibility criteria: All articles of any methodological design discussing the use of XR within paediatric intensive and critical care were included. Sources of evidence: Four databases (EMBASE, CINAHL, PsychInfo, PubMed) and Google Scholar were searched without any limitations on publication year. Charting methods: Data was extracted into Microsoft Excel by two authors independently (AG & SF) and cross-checked for completeness. Results: One hundred and eighty-eight articles were originally identified. Following the application of eligibility criteria 16 articles utilising XR in clinical interventions (n = 7) and medical education (n = 9) were included. Articles utilised VR and AR for highly variable purposes within both medical education (eg disaster preparedness, intubation) and clinical interventions (eg decrease pain, nausea, anxiety and improve Glasgow Coma Scale). Conclusions: While research into the use of XR in paediatric intensive care is still in its infancy it has increased dramatically over the past 5 years within two key areas. Firstly, in healthcare education, to assist in the acquisition of PICU-specific knowledge and practice of skills such as intubation of difficult airways. Secondly, studies have evaluated and demonstrated that with appropriate use, VR appears to be a safe and feasible intervention to decrease pain and anxiety in PICU patients.

Feedforward Control Combined with 4F Management on Postoperative Nursing Effects and Motor Function of Meniscus Sports Injuries: Based on a Prospective Case Analysis

Background

Because active functional training and management after knee cartilage sports injury is the key to treatment, care of patients after an operation with knee cartilage sports injury is critical.

Aims

To explore the effect of feedforward control combined with 4F management and after an operation nursing effect on patients with knee cartilage sports injury.

Materials and Methods

According to the random number table method, 100 patients with knee cartilage sports injury who were nursed in our hospital from June 2019 to June 2021 were selected as the research objects and divided into the control group and the instance of watching, noticing, or making a statement group with 50 cases in each group according to the different nursing order. Among them, the control group adopted 4F management combined with feedforward control nursing mode: all-weather, whole-process, whole-system, and all-around services for patients. On this basis, the instance of watching, noticing, or making a statement group cooperated with early healing/repairing training to compare fear and stress-related self-test of the two groups of patients after an operation. Knee function and quality of care are scored using tables.

Results

After nursing, the knee joint function score of the instance of watching, noticing, or making a statement group was higher than that of the control group, while the pain after the operation, sleep quality, fear, and stress self-rating scale scores were significantly lower than the control group (P < 0.05). The whole-process management, body position placement, risk evaluation, repairing training, all-weather service, whole-system management, and comprehensive service of the two groups of patients were very much improved. The nursing quality of watching, noticing, or making a statement group was significantly higher than the control group (P < 0.05).

Conclusion

Feedforward control combined with 4F management combined with early repairing training can effectively reduce the fear and stress after an operation pain and sleep quality of knee cartilage sports injury and help increase the recovery of knee combined function in a good way.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Nurses' Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review

Aim

This review aims to examine nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients.

Background

Pain is one of the worst memories among critically ill patients. However, pain among those patients is still undertreated due to several barriers that impede effective management. Therefore, addressing the perceived barriers and facilitators to pain assessment management among critical care nurses is crucial.

Methods

A systematic search of pain assessment and management in critical care patient-relevant literature from four databases was done, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

The barriers and facilitators were categorized into four groups: nurse-related, patient-related, physician-related, and system-related. The most frequently reported barriers in this study included nurses’ lack of knowledge regarding the use of pain assessment tools, patients’ inability to communicate, physicians’ prescription of analgesics being independent of pain scores evaluation, and absence of standardized guidelines and protocols for pain evaluation and control. For the facilitators, the most reported ones include ongoing education and professional training related to pain assessment and management, patients’ ability to self-report pain, effective collaboration between physicians and nurses, and productive discussion of patients’ pain scores during nurse-to-nurse handovers.

Conclusion

Various barriers and facilitators to pain assessment and management were identified and examined in this review. However, future research is still needed to further investigate these barriers and facilitators and examine any other potential associated factors among critical care nurses.

Relevance to Clinical Practice

The findings of our study could help hospital managers in developing continuous education and staff development training programs on assessing and managing pain for critical care patients. Also, our findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat pain in critical care patients.

Health Care Providers' Experiences of the Non-Pharmacological Pain and Anxiety Management and Its Barriers in the Pediatric Intensive Care Units

OBJECTIVES

Children in the intensive care unit experience a high level of pain and anxiety. This study aimed to reveal the health care providers experience of non-pharmacological pain and anxiety management and its barriers in the pediatric intensive care unit.

METHODS

This qualitative-descriptive study was conducted with thirteen nurses and five physicians in the pediatric intensive care unit in Iran. Individual, in-depth and semi-structured interviews were conducted, which were analyzed by conventional content analysis.

RESULTS

Five main categories were identified from data analysis: 1) The importance of parents' presence, 2) Disturbance in the presence of parents and communication during the COVID-19 pandemic, 3) Choosing non-pharmacological approaches according to the child's interests and conditions, 4) Building trust in the child through non-pharmacological interventions 5) Barriers to non-pharmacological pain and anxiety management in the pediatric intensive care unit.

CONCLUSION

Health care providers implement some non-pharmacological methods to manage pain and anxiety in the pediatric intensive care unit. Facilitating the open presence of parents, using innovative methods to communicate with children, and training and psychological support for nurses and parents, especially during the COVID-19 pandemic are recommended.

Comfort-holding in critically ill children: a scoping review

Purpose

To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs).

Sources

This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate.

Principal findings

Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of children < three years, < 5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding.

Conclusion

There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02090-3.

The effects of auditory interventions on pain and comfort in premature newborns in the neonatal intensive care unit; a randomised controlled trial

OBJECTIVE

This study investigated the effects of three auditory interventions; white noise, recorded mother's voice, and MiniMuffs, applied during a heel lance on pain and comfort in premature infants in the neonatal intensive care units.

DESIGN AND METHODS

This experimental, parallel, randomised controlled research was conducted in a state hospital tertiary-level neonatal intensive care unit. The sample comprised sixty-four premature infants with gestational ages of 31-36 weeks. The infants were randomly assigned to four groups: i) white noise, ii) recorded mother's voice, iii) MiniMuffs, and iv) control. Pain and comfort of newborns were evaluated according to the Neonatal Infant Pain Scale (NIPS) and the COMFORTneo scale. Oxygen saturation, heart rate, and crying time were also measured.

RESULTS

The mean of oxygen saturation levels in the white noise, recorded mother's voice, and MiniMuffs group were higher than the control group. The heart rate, crying time, mean NIPS score, COMFORTneo score of the premature neonates in the white noise, recorded mother's voice, and MiniMuffs groups were significantly lower than the control group (p < .001).

CONCLUSION

Auditory interventions used during heel lance reduce the pain and increase the comfort of the premature infants. White noise is extremely effective in preventing infants's pain.