The COMFORT-Behavior scale is useful to assess pain and distress in 0- to 3-year-old children with Down syndrome

[Measuring the intensity of restraint during care in children: Validation of the Pric scale]

Restraint is used relatively often during pediatric care. However, no scale has yet been validated to assess its intensity. The study presented here did this for the Procedural Restraint Intensity in Children tool in metrological terms (with some limitations). In the absence of a reference scale in this area, the reliability of this tool was studied under experimental conditions. It is nevertheless the first scale with metrological validation, measuring the intensity of physical constraint. Other work is underway to validate it in real clinical situations.

Translation and validation of the Comfort Behaviors Checklist in hospitalized children with chronic diseases

BACKGROUND

Different tools have been developed to measure patients' comfort. This study aims to translate, validate, and apply the Comfort Behaviors Checklist to hospitalized children with chronic diseases.

METHODS

Validity and reliability are assessed using face and content validity, construct validity (known-groups technique and Principal Component Analysis), internal consistency, and inter-rater reliability. The study takes place in a children's hospital in Iran, involving 220 children aged 4 to 6.

RESULTS

The Comfort Behaviors Checklist demonstrates acceptable face and content validity. Construct validity is supported by the lack of correlation between behavioral comfort scores in known groups. The Principal Component analysis results in five components, explaining 70.39% of the total variation. The checklist exhibits acceptable reliability, with a total Cronbach's alpha coefficient of 0.86 and an intraclass correlation coefficient of 0.835.

CONCLUSION

The Comfort Behavior Checklist is a valid and reliable tool for assessing the level of comfort in Iranian children with chronic diseases.

Perspectives on pain in Down syndrome

Down syndrome (DS) or trisomy 21 is a genetic condition often accompanied by chronic pain caused by congenital abnormalities and/or conditions, such as osteoarthritis, recurrent infections, and leukemia. Although DS patients are more susceptible to chronic pain as compared to the general population, the pain experience in these individuals may vary, attributed to the heterogenous structural and functional differences in the central nervous system, which might result in abnormal pain sensory information transduction, transmission, modulation, and perception. We tried to elaborate on some key questions and possible explanations in this review. Further clarification of the mechanisms underlying such abnormal conditions induced by the structural and functional differences is needed to help pain management in DS patients.

Discriminant properties of the Behavioral Pain Scale for assessment of procedural pain-related distress in ventilated children

OBJECTIVES

Children hospitalized in a pediatric intensive care unit (PICU) are frequently exposed to distressing and painful medical procedures and interventions. There is a lack of clinical scales to measure procedural pain-related distress in ventilated children. The Behavioral Pain Scale (BPS) was initially developed to detect procedural pain in critically ill adults. This study aims to assess the BPS's discriminant properties for measuring procedural pain-related distress in ventilated pediatric patients incorporating two instruments validated for pediatric patients.

METHODS

This prospective exploratory study was performed with ventilated children admitted to the interdisciplinary 14-bed PICU of the University Children's Hospital, University Medical Center Hamburg-Eppendorf, Germany. The nurse in charge and an independent observer simultaneously assessed the patients using German versions of the BPS, the COMFORT-B scale (CBS), and the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale immediately before and during endotracheal suctioning.

RESULTS

We analyzed 170 parallel assessments in n=34 ventilated children. Patients were (mean ± SD) 9.5 ± 4.8 years old. Internal consistency for the BPS was excellent (α=0.93). We found a high rater agreement for all clinical scales (BPS: k=0.73, CBS: k=0.80, mFLACC: k=0.71). Strong correlations were identified between BPS and CBS (r=0.89) and BPS and mFLACC (r=0.79). The BPS cutoff values showed likewise excellent results (area under the curve CBS >16: 0.97; mFLACC >2: 0.91).

CONCLUSIONS

In our population of ventilated children, the BPS was well suited to detect procedural pain-related distress compared with two validated pain scales. Further extensive validation studies should follow to support our findings.

Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit

We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.

Validity and Reliability of the Richmond Agitation-Sedation Scale in Pediatric Intensive Care Patients: A Multicenter Study

Background: There is limited data about the psychometric properties of the Richmond Agitation-Sedation Scale (RASS) in children. This study aims to analyze the validity and reliability of the RASS in assessing sedation and agitation in critically ill children. Methods: A multicenter prospective study in children admitted to pediatric intensive care, aged between 1 month and 18 years. Twenty-eight observers from 14 PICUs (pediatric intensive care units) participated. Every observation was assessed by 4 observers: 2 nurses and 2 pediatric intensivists. We analyzed RASS inter-rater reliability, construct validity by comparing RASS to the COMFORT behavior (COMFORT-B) scale and the numeric rating scale (NRS), and by its ability to distinguish between levels of sedation, and responsiveness to changes in sedative dose levels. Results: 139 episodes in 55 patients were analyzed, with a median age 3.6 years (interquartile range 0.7-7.8). Inter-rater reliability was excellent, weighted kappa (κw) 0.946 (95% CI, 0.93-0.96; p < 0.001). RASS correlation with COMFORT-B scale, rho = 0.935 (p < 0.001) and NRS, rho = 0.958 (p < 0.001) was excellent. The RASS scores were significantly different (p < 0.001) for the 3 sedation categories (over-sedation, optimum and under-sedation) of the COMFORT-B scale, with a good agreement between both scales, κw 0.827 (95% CI, 0.789-0.865; p < 0.001), κ 0.762 (95% CI, 0.713-0.811, p < 0.001). A significant change in RASS scores (p < 0.001) was recorded with the variance of sedative doses. Conclusions: The RASS showed good measurement properties in PICU, in terms of inter-rater reliability, construct validity, and responsiveness. These properties, including its ability to categorize the patients into deep sedation, moderate-light sedation, and agitation, makes the RASS a useful instrument for monitoring sedation in PICU.

Dosing of Opioid Medications During and After Pediatric Cardiac Surgery for Children With Down Syndrome

OBJECTIVE

To determine whether children with Down syndrome (DS) receive higher doses of opioid medications compared with children without DS for repair of complete atrioventricular canal (CAVC).

DESIGN

A retrospective chart review of children with and without DS who underwent primary repair of CAVC. The exclusion criteria included unbalanced CAVC and patients undergoing biventricular staging procedures. The primary outcome was oral morphine equivalents (OME) received in the first 24 hours after surgery. The secondary outcomes included intraoperative OME, OME at 48 and 72 hours, nonopioid analgesic and sedative medications received, pain scores, time to extubation, and length of stay.

SETTING

A pediatric academic medical center in the United States.

PARTICIPANTS

One hundred thirty-one patients with DS and 24 without, all <two years old, who underwent a CAVC repair.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Patients with DS were older than patients without DS (median 96.3 days [interquartile range {IQR} 70.7-128.2] v 75.9 days [IQR 49.8-107.3], p = 0.033) but otherwise not statistically different in the baseline characteristics. There was no difference in OME received in the first 24 hours postoperatively between groups (3.01 mg/kg [IQR 1.23-5.43] v 3.57 mg/kg [IQR 1.54-7.06], p = 0.202). OME at 48 and 72 hours was lower in the DS group compared with the control group. Similar amounts of opioid and non-opioid analgesics and sedatives were otherwise given to both groups of patients. Median pain scores did not differ between groups.

CONCLUSIONS

These results suggested that patients with DS undergoing CAVC repair do not have increased opioid requirements compared with a similar control group.

Anesthetic Management of an Adult Patient With Down Syndrome for Thoracic Surgery

The anesthetic management of adult patient with Down syndrome (DS) can be challenging due to poor patient cooperation, age-related comorbidities, and a possible difficult airway. Thoracic anesthesia requires an advanced airway management; thus, treatment of DS patients can be particularly demanding. An accurate preoperative assessment is paramount in order to plan a well-designed perioperative strategy in advance. This report describes the anesthetic management of an adult patient affected by DS who underwent pleural decortication for pleural empyema.

The performance of the heart rate variability-derived Newborn Infant Parasympathetic Evaluation Index as a measure of early postoperative pain and discomfort in infants-A prospective observational study

BACKGROUND

The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE™) Index is a continuous noninvasive tool for the assessment of pain and discomfort in infants. Little is known about its performance in the early postoperative setting, where assessment of pain/discomfort is usually based on discontinuous observational scoring systems or personal experience of medical staff.

AIMS

To investigate the performance of the NIPE as a measure of early postoperative pain and/or discomfort in infants.

METHODS

The potential of the NIPE to detect pain/discomfort, as assessed by two clinical scoring systems (FLACC and COMFORT-B scale), was investigated in postoperative infants (0-2 years).

RESULTS

Receiver operating curve (ROC) analyses investigating the power of the NIPE to distinguish between comfort and pain/discomfort, revealed areas under the curve (AUC) of 0.77 for the FLACC, 0.81 for the COMFORT-B score, and 0.77 for a combination of FLACC & COMFORT-B. Logistic regression analysis provided initial evidence that the NIPE is an independent predictor of a FLACC score ≥4 and/or a COMFORT-B score ≥17, though R² values were below .2. NIPE values associated with a FLACC ≥4 (48 [45-56]), a COMFORT-B score ≥17 (47 [42-53]), and a FLACC ≥4 & COMFORT-B ≥17 (47 [42-57]) were lower than NIPE values associated with a FLACC <4 (60 [53-68], 95% CI of difference -14 to -8, p < .0001), a COMFORT-B score <17 (61 [54-68], 95% CI of difference -16 to -10, p < .0001), and a FLACC <4 & COMFORT-B score <17 (60 [53-68], 95% CI of difference -15 to -8, p < .0001). We found no evidence of a predictive value of the NIPE regarding the occurrence of pain.

CONCLUSIONS

The NIPE detected pain and discomfort in infants after general anesthesia with reasonable areas under the ROC curve (±0.8), whereas it was not predictive of clinically detectable pain or discomfort.

Sufentanil Disposition and Pharmacokinetic Model-Based Dosage Regimen for Sufentanil in Ventilated Full-Term Neonates

INTRODUCTION

Sufentanil is a potent synthetic opioid used for analgesia in neonates; however, data concerning drug disposition of sufentanil and dosage regimen are sparse in this population. Therefore, the aim of the study was to explore sufentanil disposition and to propose optimal loading and maintenance doses of sufentanil in ventilated full-term neonates.

METHODS

Individual sufentanil pharmacokinetic parameters were calculated based on therapeutic drug monitoring data using a 2-compartmental model. Linear regression models were used to explore the covariates.

RESULTS

The median (IQR) central volume of distribution (Vdc) and clearance (CL) for sufentanil were 4.7 (4.1-5.4) L/kg and 0.651 (0.433-0.751) L/h/kg, respectively. Linear regression models showed relationship between Vdc (L) and GA (r2 = 0.3436; p = 0.0452) as well as BW (r2 = 0.4019; p = 0.0268). Median optimal sufentanil LD and MD were 2.13 (95% CI: 1.78-2.48) μg/kg and 0.29 (95% CI: 0.22-0.37) μg/kg/h, respectively. Median daily COMFORT-B (IQR) scores ranged from 6 to 23 while no significant relationship between pharmacokinetic parameters and COMFORT-B scores was found.

DISCUSSION/CONCLUSION

Body weight and gestational age were found as weak covariates for sufentanil distribution, and the dosage regimen was developed for a prospective trial.

Sedation With Midazolam After Cardiac Surgery in Children With and Without Down Syndrome: A Pharmacokinetic-Pharmacodynamic Study

OBJECTIVES

To compare the pharmacokinetics and pharmacodynamics of IV midazolam after cardiac surgery between children with and without Down syndrome.

DESIGN

Prospective, single-center observational trial.

SETTING

PICU in a university-affiliated pediatric teaching hospital.

PATIENTS

Twenty-one children with Down syndrome and 17 without, 3-36 months, scheduled for cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

Postoperatively, nurses regularly assessed the children's pain and discomfort with the validated COMFORT-Behavioral scale and Numeric Rating Scale for pain. A loading dose of morphine (100 µg/kg) was administered after coming off bypass; thereafter, morphine infusion was commenced at 40 µg/kg/hr. Midazolam was started if COMFORT-Behavioral scale score of greater than 16 and Numeric Rating Scale score of less than 4 (suggestive of undersedation). Plasma midazolam and metabolite concentrations were measured for population pharmacokinetic- and pharmacodynamic analysis using nonlinear mixed effects modeling (NONMEM) (Version VI; GloboMax LLC, Hanover, MD) software.

MEASUREMENTS AND MAIN RESULTS

Twenty-six children (72%) required midazolam postoperatively (15 with Down syndrome and 11 without; p = 1.00). Neither the cumulative midazolam dose (p = 0.61) nor the time elapsed before additional sedation was initiated (p = 0.71), statistically significantly differed between children with and without Down syndrome. Population pharmacokinetic and pharmacodynamics analysis revealed no statistically significant differences between the children with and without Down syndrome. Bodyweight was a significant covariate for the clearance of 1-OH-midazolam to 1-OH-glucuronide (p = 0.003). Pharmacodynamic analysis revealed a marginal effect of the midazolam concentration on the COMFORT-Behavioral score.

CONCLUSIONS

The majority of children with and without Down syndrome required additional sedation after cardiac surgery. This pharmacokinetic and pharmacodynamic analysis does not provide evidence for different dosing of midazolam in children with Down syndrome after cardiac surgery.

Specific Behavioral Responses Rather Than Autonomic Responses Can Indicate and Quantify Acute Pain among Individuals with Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) are at a high risk of experiencing pain. Pain management requires assessment, a challenging mission considering the impaired communication skills in IDD. We analyzed subjective and objective responses following calibrated experimental stimuli to determine whether they can differentiate between painful and non-painful states, and adequately quantify pain among individuals with IDD. Eighteen adults with IDD and 21 healthy controls (HC) received experimental pressure stimuli (innocuous, mildly noxious, and moderately noxious). Facial expressions (analyzed with the Facial Action Coding System (FACS)) and autonomic function (heart rate, heart rate variability (HRV), pulse, and galvanic skin response (GSR)) were continuously monitored, and self-reports using a pyramid and a numeric scale were obtained. Significant stimulus-response relationships were observed for the FACS and pyramid scores (but not for the numeric scores), and specific action units could differentiate between the noxious levels among the IDD group. FACS scores of the IDD group were higher and steeper than those of HC. HRV was overall lower among the IDD group, and GSR increased during noxious stimulation in both groups. In conclusion, the facial expressions and self-reports seem to reliably detect and quantify pain among individuals with mild-moderate IDD; their enhanced responses may indicate increased pain sensitivity that requires careful clinical consideration.

Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment

Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10 years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.

Exploring the Relationship Between Morphine Concentration and Oversedation in Children After Cardiac Surgery

Titrating analgesic and sedative drugs in pediatric intensive care remains a challenge for caregivers due to the lack of pharmacodynamic knowledge in this population. The aim of the current study is to explore the concentration‐effect relationship for morphine‐associated oversedation after cardiac surgery in children aged 3 months to 3 years. Data on morphine dosing, as well as morphine plasma concentrations, were available from a previous study on the pharmacokinetics of morphine after cardiac surgery in children. Oversedation was defined as scores below 11 on the validated COMFORT–behavioral scale. Population pharmacokinetic‐pharmacodynamic modeling was performed in NONMEM 7.3. The probability of oversedation as a function of morphine concentration was best described using a step function in which the EC₅₀ was 46.3 ng/mL. At morphine concentrations below the EC₅₀, the probability of oversedation was 2.9% (0.4& to 18%), whereas above the EC₅₀ percentages were 13% (1.9% to 52%) (median value [95% prediction interval from interindividual variability]). Additionally, the risk of oversedation was found to be increased during the first hours after surgery (P < .001) and was significantly lower during mechanical ventilation (P < .005). We conclude that morphine concentrations above approximately 45 ng/mL may increase the probability of oversedation in children after cardiac surgery. The clinician must evaluate, on a case‐by‐case basis, whether the analgesic benefits arising from dosing regimen associated with such concentrations outweigh the risks.

Nonopioid analgesics for perioperative and cardiac surgery pain in children: Current evidence and knowledge gaps

Objective:

The purpose of this review is to present the available literature on the use of nonopioid analgesics such as nonsteroidal anti-inflammatory drugs in postcardiac surgery pediatric patients, mainly to focus on patients <1 year of age, and to provide the foundation for future research.

Materials and Methods:

Published studies that address the use on nonopioid medications for postoperative sedation and analgesia in infants and children undergoing cardiac surgery were identified from online sources. Studies were reviewed by two authors independently to assess the quality of the data as well as the evidence. Due to limited availability of such studies, the review was then expanded to include use in noncardiac procedures as well as to expanded age groups. All studies that met the primary objective were included.

Results/Data Synthesis:

Majority of the studies in the population of interest were related to use of ketorolac. Five studies specifically addressed ketorolac use in cardiac patients. In addition, studies were reviewed for nonopioid analgesia in noncardiac patients and included as a part of the available evidence as in the case of acetaminophen use. Newer agents as well as agents with very limited information were also acknowledged.

Conclusion:

Nonopioid medications appear to show promise for analgesia in infants undergoing cardiac surgery, with ketorolac being the most potent agent as a potential substitute for opioids. These agents demonstrate a reasonable safety profile even in the very young. There continue to be significant gaps in knowledge before their adoption becomes routine. However, gives the awareness regarding short-term and long-term impact of opioid use in this vulnerable population, and studies of such agents are an urgent need.

Pain and Sedation Scales for Neonatal and Pediatric Patients in a Preverbal Stage of Development: A Systematic Review

IMPORTANCE

Because children in a preverbal stage of development are unable to voice their feelings, they completely depend on their caregiving team for the interpretation and management of their pain and discomfort. Thus, accurately validated scales to assess pain and sedation levels are crucial.

OBJECTIVE

To provide clinicians a complete overview on the validity and reliability of the existing pain and sedation scales for different target populations (preterm infants, term infants, and toddlers) and in different clinical contexts.

EVIDENCE REVIEW

BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycCRITIQUES, PsycINFO, PSYNDEXplus Literature and Audiovisual Media, and PSYNDEXplus Tests were the databases screened from their inception to August 2018. All studies examining the validity or reliability of a given pain or sedation scale for patients in a preverbal stage of development were included in this systematic review. Those scales that were tested for at least construct validity, internal consistency, and interrater reliability were subsequently scored using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist.

FINDINGS

In total, 89 validation articles comprising 65 scales were included. Fifty-seven scales (88%) were useful for assessing pain, 13 scales (20%) for assessing sedation, and 4 scales (6%) for assessing both conditions. Forty-two (65%) were behavioral scales, and 23 (35%) were multidimensional scales. Eleven scales (17%) were validated for infants on mechanical ventilation. Thirty-seven scales (57%) were validated for preterm infants, 24 scales (37%) for term and preterm infants, 7 scales (11%) for term-born children, 7 scales (11%) for preterm infants, term infants, and toddlers, and 17 scales (26%) for term infants and toddlers. Twenty-eight scales (43%) considered construct validity, internal consistency, and interrater reliability.

CONCLUSIONS AND RELEVANCE

Clinicians should consider using scales that are validated for at least construct validity, internal consistency, and interrater reliability, combining this information with the population of interest and the construct the scale is intended to measure.

Down Syndrome and Postoperative Complications in Children Undergoing Intestinal Operations

OBJECTIVE

This paper intends to evaluate the association between Down Syndrome (DS) and postoperative medical and surgical complications and inpatient postoperative mortality in pediatric patients undergoing intestinal operations.

METHODS

The 2012 Kids' Inpatient Database was queried to compare short-term postoperative medical and surgical complications and in-patient mortality among patients with DS undergoing intestinal operations to a cohort without DS using inverse probability weighting. Subset analysis was performed for patients undergoing intestinal operations exclusive of gastrostomy placement. Adverse treatment effects were calculated for the outcomes of interest.

RESULTS

Of 17,026 pediatric patients undergoing intestinal operations, 444 had DS. In unadjusted analysis, medical complications (urinary tract infection, deep venous thrombosis, sepsis, pneumonia) occurred in 7.9% of patients with DS, compared to 14.1% of those without (p < 0.001). Surgical complications (wound disruption, hemorrhage, superficial or deep wound infection) occurred in 3.5% of patients with DS, compared to 4.6% of those without (p = 0.34), and in-patient mortality occurred in 0.3% of patients with DS, compared to 2.7% of those without (p = 0.009). Adverse treatment effects (ATE) calculated after inverse probability weighting demonstrated no difference for medical or surgical complications but a significantly decreased mortality with DS.

CONCLUSIONS

Contrary to common perception and data extrapolated from the adult literature, pediatric patients with DS have neither higher medical nor surgical complication rates after intestinal operations. Similar to patients undergoing congenital heart surgery, pediatric patients with DS have a lower postoperative inpatient mortality after these general operations compared to those without DS. Mechanisms influencing risks in DS patient remain unknown.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Observational study of newborn infant parasympathetic evaluation as a comfort system in awake patients admitted to a pediatric intensive care unit

To compare the newborn infant parasympathetic evaluation system (NIPE) scores with a validated clinical scale using two different nebulizers in children with bronchiolitis admitted to a PICU. Comfort was evaluated using the COMFORT-behavior scale (CBS) before (T1), during (T2) and after (T3) each nebulization. In order to compare NIPE and CBS values during the whole T1 to T3 period, the variable Dif-CBS was defined as the difference between maximal and minimal CBS scores, and Dif-NIPE as the difference between 75th and 25th percentile NIPE values. Analyses were carried out, firstly for the total of nebulizations and secondly comparing two different nebulization systems: a jet nebulizer (JN) and a nebulizer integrated in high flow nasal cannulas (NHF). 84 nebulizations were recorded on 14 patients with a median [25th–75th percentile] age of 6 months (3.1–9.5). A Dif-CBS of 4 points (2–7), as well as changes in CBS scores between T1 and T2, defined the nebulization as a discomfort stimulus. The NIPE system, represented as the Dif-NIPE, showed a median variation of 9 points (7–10), and was poorly correlated to Dif-CBS [r_s 0.162 (P = 0.142)]. Discomfort during nebulization, assessed by CBS was greater with the JN system compared to NHF: 17 (13–22) vs 13 (9–15) (P = 0.001). NIPE monitoring detected no significant differences between both nebulization systems (P = 0.706). NIPE monitoring showed a variation in comfort during nebulization in the patient with bronchiolitis, though correlation with CBS was poor. Further research is required before NIPE can be suggested as a comfort monitoring system for the awake infant.

What are the validity and reliability of the modified Yale Preoperative Anxiety Scale-Short Form in children less than 2 years old?

BACKGROUND

Accurate measurement of preoperative anxiety is important for pediatric surgical patients' care as well as for monitoring anxiety-reducing interventions. The modified Yale Preoperative Anxiety Scale-short form is well validated for this purpose in children aged 2 years and above, but not in younger children.

AIMS

We aimed to validate the Dutch version of the modified Yale Preoperative Anxiety Scale-short form for measuring preoperative anxiety in children less than 2 years old.

METHODS

Two investigators independently assessed infants' anxiety at the holding area and during induction of anesthesia with the modified Yale Preoperative Anxiety Scale-short form and the COMFORT-Behavior scale-live and from video observations. Construct validity and responsiveness of both scales were tested with Pearson correlation coefficient. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was assessed using Cronbach's α, and inter-rater reliability and intra-rater reliability were tested using the intraclass correlation coefficient and Cohen's linearly weighted kappa. Hypotheses for sufficient inter-rater reliability (r > 0.60) and validity (r > 0.65) had been formulated a priori in line with the COSMIN guidelines.

RESULTS

Behavior of 129 infants (89.1% male) with a median age of 6.5 months (range 0.9-16.5 months) was observed. The correlations between the modified Yale Preoperative Anxiety Scale-short form and COMFORT-Behavioral scale were strong at the holding area and at induction of anesthesia, as were the correlation of change scores between the holding area and induction. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was excellent at both the holding area and at induction of anesthesia. Inter-rater reliability was good to excellent on scale level and moderate to good on item level.

CONCLUSION

These findings support the validity and reliability of the Dutch version of the modified Yale Preoperative Anxiety Scale-short form in children less than 2-years-old.

Turkish Neonatal Society guideline on the neonatal pain and its management

Pain control is an important ethical issue to be considered and constitutes the basis of treatment in premature and term newborns. The inadequacy of pain control in these infants in neonatal intensive care units leads to neurodevelopmental and behavioral problems in the long term. For this reason, it is extremely important to raise awareness of the presence of pain in newborn infants, to reduce invasive procedures applied to infants as much as possible, and to minimize pain with non-pharmacologic or pharmacologic treatments when it is inevitable.

Hemodynamic Tolerance to IV Clonidine Infusion in the PICU

OBJECTIVES

Clonidine is an antihypertensive drug used for analgosedation in the PICU. Lack of reliable data on its hemodynamic tolerance limits its use. This study explores the hemodynamic tolerance of IV clonidine infusion in a broad population of children with high severity of disease.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

A tertiary and quaternary referral PICU.

PATIENTS

Critically ill children age 0-18 years old who received an IV clonidine infusion for analgosedation of at least 1 hour.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary endpoints were the prevalences of bradycardia and hypotension. Secondary endpoints were changes in heart rate, blood pressure, Vasoactive-Inotropic Score, COMFORT Behavior score (a sedation scoring scale), and body temperature during the infusion. The association of bradycardia with other hemodynamic variables was explored, as well as potential risk factors for severe bradycardia. One-hundred eighty-six children (median age, 12.9 mo [interquartile range, 3.5-60.6 mo]) receiving a maximum median clonidine infusion of 0.7 µg/kg/hr (interquartile range, 0.3-1.5) were included. Severe bradycardia and systolic hypotension occurred in 72 patients (40.2%) and 105 patients (58%), respectively. Clonidine-associated bradycardia was hemodynamically well tolerated, as it was not related with hypotension and the need for vasoactive drugs decreased in parallel with a sedation score guided clonidine infusion rate increase. Younger age was the only identified risk factor for clonidine-associated bradycardia.

CONCLUSIONS

Although administration of clonidine is often associated with bradycardia and hypotension, these complications do not seem clinically significant in a mixed PICU population with a high degree of disease severity. Clonidine may have a vasoactive-inotropic sparing effect.

Intravenous morphine versus intravenous paracetamol after cardiac surgery in neonates and infants: a study protocol for a randomized controlled trial

BACKGROUND

Morphine is worldwide the analgesic of first choice after cardiac surgery in children. Morphine has unwanted hemodynamic and respiratory side effects. Therefore, post-cardiac surgery patients may potentially benefit from a non-opioid drug for pain relief. A previous study has shown that intravenous (IV) paracetamol is effective and opioid-sparing in children after major non-cardiac surgery. The aim of the study is to test the hypothesis that intermittent IV paracetamol administration in children after cardiac surgery will result in a reduction of at least 30% of the cumulative morphine requirement.

METHODS

This is a prospective, multi-center, randomized controlled trial at four level-3 pediatric intensive care units (ICUs) in the Netherlands and Belgium. Children who are 0-36 months old will be randomly assigned to receive either intermittent IV paracetamol or continuous IV morphine up to 48 h post-operatively. Morphine will be available as rescue medication for both groups. Validated pain and sedation assessment tools will be used to monitor patients. The sample size (n = 208, 104 per arm) was calculated in order to detect a 30% reduction in morphine dose; two-sided significance level was 5% and power was 95%.

DISCUSSION

This study will focus on the reduction, or replacement, of morphine by IV paracetamol in children (0-36 months old) after cardiac surgery. The results of this study will form the basis of a new pain management algorithm and will be implemented at the participating ICUs, resulting in an evidence-based guideline on post-operative pain after cardiac surgery in infants who are 0-36 months old.

TRIAL REGISTRATION

Dutch Trial Registry ( www.trialregister.nl ): NTR5448 on September 1, 2015. Institutional review board approval (MEC2015-646), current protocol version: July 3, 2017.

Morphine Pharmacokinetics in Children With Down Syndrome Following Cardiac Surgery

OBJECTIVES

To assess if morphine pharmacokinetics are different in children with Down syndrome when compared with children without Down syndrome.

DESIGN

Prospective single-center study including subjects with Down syndrome undergoing cardiac surgery (neonate to 18 yr old) matched by age and cardiac lesion with non-Down syndrome controls. Subjects were placed on a postoperative morphine infusion that was adjusted as clinically necessary, and blood was sampled to measure morphine and its metabolites concentrations. Morphine bolus dosing was used as needed, and total dose was tracked. Infusions were continued for 24 hours or until patients were extubated, whichever came first. Postinfusion, blood samples were continued for 24 hours for further evaluation of kinetics. If patients continued to require opioid, a nonmorphine alternative was used. Morphine concentrations were determined using a unique validated liquid chromatography tandem-mass spectrometry assay using dried blood spotting as opposed to large whole blood samples. Morphine concentration versus time data was modeled using population pharmacokinetics.

SETTING

A 16-bed cardiac ICU at an university-affiliated hospital.

PATIENTS

Forty-two patients (20 Down syndrome, 22 controls) were enrolled.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The pharmacokinetics of morphine in pediatric patients with and without Down syndrome following cardiac surgery were analyzed. No significant difference was found in the patient characteristics or variables assessed including morphine total dose or time on infusion. Time mechanically ventilated was longer in children with Down syndrome, and regarding morphine pharmacokinetics, the covariates analyzed were age, weight, presence of Down syndrome, and gender. Only age was found to be significant.

CONCLUSIONS

This study did not detect a significant difference in morphine pharmacokinetics between Down syndrome and non-Down syndrome children with congenital heart disease.

A literature review of comfort in the paediatric critical care patient

AIMS AND OBJECTIVES

To investigate the meaning of comfort and to contextualise it within the framework of paediatric critical care.

BACKGROUND

The concept of comfort is closely linked to care in all health contexts. However, in specific settings such as the paediatric critical care unit, it takes on particular importance.

DESIGN

A literature review was conducted.

METHODS

A literature search was performed of articles in English and Spanish in international health science databases, from 1992-March 2017, applying the quality standards established by the PRISMA methodology and the Joanna Briggs Institute.

RESULTS

A total of 1,203 publications were identified in the databases. Finally, 59 articles which met the inclusion criteria were entered in this literature review. Almost all were descriptive studies written in English and published in Europe. The concept of comfort was defined as the immediate condition of being strengthened through having the three types of needs (relief, ease and transcendence) addressed in the four contexts of experience (physical, psychospiritual, social and environmental). Only two valid and reliable tools for assessing comfort were found: the Comfort Scale and the Comfort Behavior Scale.

CONCLUSIONS

Comfort is subjective and difficult to assess. It has four facets: physical, emotional, social and environmental. High levels of noise and light are the inputs that cause the most discomfort. Comfort is a holistic, universal concept and an important component of quality nursing care.

Instruments to assess patient comfort during hospitalization: A psychometric review

AIM

To analyse the psychometric properties and the utility of instruments used to measure patient comfort, physical, social, psychospiritual and/or environmental, during hospitalization.

BACKGROUND

There are no systematic reviews nor psychometric reviews of instruments used to measure comfort, which is considered an indicator of quality in health care associated with quicker discharges, increased patient satisfaction and better cost-benefit ratios for the institution.

DESIGN

Psychometric review.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Web of Knowledge, ProQuest Thesis&Dissertations, Google.

REVIEW METHODS

We limited our search to studies published between 1990-2015. The psychometric analysis was performed using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN), along with the Quality Criteria for Measurement Properties. The utility of the instruments was assessed according to their cost-efficiency, acceptability and educational impact. Protocol registration in PROSPERO, CRD42016036290.

RESULTS

Instruments reviewed showed moderate methodological quality and their utility was poorly reported. Thus, we cannot recommend any questionnaire without reservations, but the Comfort Scale, the General Comfort Questionnaire and their adaptations in adults and older patients, the Psychosocial Comfort Scale and the Incomfort des Patients de Reanimation are the most recommendable instruments to measure comfort.

CONCLUSIONS

The methodology of the studies should be more rigorous and authors should adequately report the utility of instruments. This review provides a strategy to select the most suitable instrument to assess patient comfort according to their psychometric properties and utility, which is crucial for nurses, clinicians, researchers and institutions.

Psychometric analysis of subjective sedation scales used for critically ill paediatric patients

AIMS

This study evaluated the psychometric properties of subjective sedation scales using one psychometric scoring system to identify the appropriate scale that is most suitable for clinical care practice.

BACKGROUND

A number of published sedation assessment scales for paediatric patients are currently used to attempt to achieve a moderate depth of sedation to avoid the undesirable effects caused by over- or undersedation. However, there has been no systematic review of these scales.

SEARCH STRATEGY

We searched the Cochrane Library, PubMed, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, etc., to obtain relevant articles. The quality of the selected studies was evaluated according to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist.

INCLUSION CRITERIA

Articles that had been published or were in press and discussed the psychometric properties of sedation scales were included. The population comprised critically ill infants and non-verbal children ranging in age from 0 to 18 years who underwent sedation in an intensive care unit.

FINDINGS

Data were independently extracted by two investigators using a standard data extraction checklist: 43 articles were included in this review, and 13 sedation scales were examined. The quality of the psychometric evidence for the Comfort Scale and Comfort Behaviour Scale was 'very good', with the Comfort Scale having a higher quality (total weighted scores, Comfort Scale = 17·3 and Comfort Behaviour Scale = 15·5).

CONCLUSIONS

We suggest that the scales be systematically and comprehensively tested in terms of development method, reliability, validation, feasibility and correlation with clinical outcome. The Comfort Scale and Comfort Behaviour Scale are useful tools for measuring sedation in paediatric patients.

RELEVANCE TO CLINICAL PRACTICE

Nursing staff should choose one subjective sedation scale that is suitable for assessing paediatric patients' depth of sedation. We recommend the Comfort Scale and Comfort Behaviour Scale as optimal choices if the clinical environment permits.

Physiological and Behavioral Responses to Calibrated Noxious Stimuli Among Individuals with Cerebral Palsy and Intellectual Disability

Objective

As individuals with intellectual disability (ID) due to cerebral palsy (CP) are at high risk of experiencing pain, measuring their pain is crucial for adequate treatment. While verbal reports are the gold standard in pain measurements, they may not be sufficient in ID. The aim was to detect behavioral/autonomic responses that may indicate the presence and intensity of pain in individuals with CP and ID, using calibrated stimuli, here for the first time.

Subjects

Thirteen adults with CP and ID (CPID), 15 healthy controls (HC), and 5 adults with CP with no ID (CPNID).

Methods

Subjects received pressure stimuli of various intensities. Self-reports (using a pyramid scale), facial expressions (retrospectively analyzed with Facial Action Coding System = FACS), and autonomic function (heart rate, heart rate variability, pulse, galvanic skin response) were analyzed.

Results

Self-reports and facial expressions but not the autonomic function exhibited stimulus-response relationship to pressure stimulation among all groups. The CPID group had increased pain ratings and facial expressions compared with controls. In addition, the increase in facial expressions along the increase in noxious stimulation was larger than in controls. Freezing in response to pain was frequent in CPID.

Conclusions

1) Individuals with CP and ID have increased responses to pain; 2) facial expressions and self-reports, but not autonomic variables can reliably indicate their pain intensity; 3) the pyramid scale is suitable for self-report in this population. Although facial expressions may replace verbal reports, increased facial expressions at rest among these individuals may mask pain, especially at lower intensities.

Effectiveness of α2agonists for sedation in paediatric critical care: study protocol for a retrospective cohort observational study

INTRODUCTION

Mechanically ventilated children in paediatric intensive care units are commonly administered analgesics and sedative agents to minimise pain and distress and facilitate cooperation with medical interventions. Opioids and benzodiazepines are the most common analgesic and sedative agents but have safety concerns. The α₂ agonists clonidine and dexmedetomidine are alternative sedatives in use despite neither having robust evidence to support their use. Studies evaluating effectiveness of α₂ agonists to date have not focused on sedation-based outcomes instead focusing on opioid-sparing properties and ventilation outcomes. The aim of this study is to evaluate if an opioid-based sedation regimen, with an α₂ agonist adjunct (clonidine or dexmedetomidine), produces a non-inferior proportion of time adequately sedated compared with a control group without an α₂ agonist adjunct, while conferring potential additional benefits such as reduced opioid administration and less exposure to potential additional agents such as benzodiazepines.

METHODS AND ANALYSIS

We will conduct a retrospective cohort study in two Irish paediatric intensive care units using clinical information on patient characteristics, sedation scores and drug use. Eligible children admitted between January 2014 and June 2016 who were mechanically ventilated and received an opioid infusion will be included. Patients will be categorised into two exposure categories (received an α₂ agonist or did not receive an α₂ agonist) and the time adequately sedated (measured using the COMFORT Behaviour Score) will be calculated using interpolation of nursing sedation scores at each recorded time point. At least 150 per group is planned for inclusion to ensure adequate study power. Propensity score matching will be used in analysis to account for potential confounding by indication.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committees of both hospitals. Dissemination will occur via local, national and international presentations for academic and healthcare audiences as well as through peer reviewed publications.

Implementation of a Nurse-Driven Sedation Protocol in a PICU Decreases Daily Doses of Midazolam

OBJECTIVES

To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation.

DESIGN

A single-center prospective before and after study was conducted from October 2010 to December 2013.

SETTING

Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France.

PATIENTS

A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed.

INTERVENTIONS

During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol.

MEASUREMENTS AND MAIN RESULTS

In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139).

CONCLUSIONS

Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.

[Pain assessment scales in newborns: integrative review]

OBJECTIVE

To analyze studies on methods used to assess pain in newborns.

DATA SOURCES

Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.

DATA SYNTHESIS

29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.

CONCLUSION

Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.

Pharmacodynamics and Pharmacokinetics of Morphine After Cardiac Surgery in Children With and Without Down Syndrome

OBJECTIVE

To compare the pharmacodynamics and pharmacokinetics of IV morphine after cardiac surgery in two groups of children-those with and without Down syndrome.

DESIGN

Prospective, single-center observational trial.

SETTING

PICU in a university-affiliated pediatric teaching hospital.

PATIENTS

Twenty-one children with Down syndrome and 17 without, 3-36 months old, scheduled for cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

A loading dose of morphine (100 μg/kg) was administered after coming off bypass; thereafter, morphine infusion was commenced at 40 μg/kg/hr. During intensive care, nurses regularly assessed pain and discomfort with validated observational instruments (COMFORT-Behavior scale and Numeric Rating Scale-for pain). These scores guided analgesic and sedative treatment. Plasma samples were obtained for pharmacokinetic analysis.

MEASUREMENTS AND MAIN RESULTS

Median COMFORT-Behavior and Numeric Rating Scale scores were not statistically significantly different between the two groups. The median morphine infusion rate during the first 24 hours after surgery was 31.3 μg/kg/hr (interquartile range, 23.4-36.4) in the Down syndrome group versus 31.7 μg/kg/hr (interquartile range, 25.1-36.1) in the control group (p = 1.00). Population pharmacokinetic analysis revealed no statistically significant differences in any of the pharmacokinetic variables of morphine between the children with and without Down syndrome.

CONCLUSIONS

This prospective trial showed that there are no differences in pharmacokinetics or pharmacodynamics between children with and without Down syndrome if pain and distress management is titrated to effect based on outcomes of validated assessment instruments. We have no evidence to adjust morphine dosing after cardiac surgery in children with Down syndrome.

The clinimetric properties of the COMFORT scale: A systematic review

The COMFORT scale is a measurement tool to assess distress, sedation and pain in nonverbal paediatric patients. Several studies have described the COMFORT scale, but no formal assessment of the methodological quality has been undertaken. Therefore, we performed a systematic review to study the clinimetric properties of the (modified) COMFORT scale in children up to 18 years. We searched Central, CINAHL, Embase, Medline, PsycInfo and Web of Science until December 2014. The selection, data extraction and quality assessment were performed independently by two reviewers. Quality of the included studies was appraised using the COSMIN checklist. We found 30 studies that met the inclusion criteria. Most participants were ventilated children up to 4 years without neurological disorders. The results on internal consistency and interrater reliability showed values of >0.70 in most studies, indicating an adequate reliability. Construct validity resulted in correlations between 0.68 and 0.84 for distress, between 0.42 and 0.94 for sedation and between 0.31 and 0.96 for pain. The responsiveness of the (modified) COMFORT scale seems to be adequate. The quality of the included studies ranged from poor to excellent. The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain. The included studies were clinically and methodologically heterogeneous, hampering firm conclusions. WHAT DOES THIS REVIEW ADD?: An in-depth assessment of the clinimetric properties of the COMFORT scale. The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain.

Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals

Background

This position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain-related distress (adequacy of sedation, iatrogenic withdrawal syndrome and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient.

Methods

A multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain-related distress in critically ill and nonverbal children, and searched the PubMed/Medline, CINAHL and Embase databases for studies describing the psychometric properties of assessment instruments. Furthermore, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added on the basis of the level of evidence.

Results

An ESPNIC position statement was drafted which provides clinical recommendations on assessment of pain (n = 5), distress and/or level of sedation (n = 4), iatrogenic withdrawal syndrome (n = 3) and delirium (n = 3). These recommendations were based on the available evidence and consensus amongst the experts and other members of ESPNIC.

Conclusions

This multidisciplinary ESPNIC position statement guides professionals in the assessment and reassessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4344-1) contains supplementary material, which is available to authorized users.

Sedation in Critically Ill Children with Respiratory Failure

This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.

Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy?

This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.

The COMFORT behavioural scale provides a useful assessment of sedation, pain and distress in toddlers undergoing minor elective surgery

AIM

The COMFORT behavioural scale was developed to assess sedation, pain and distress in children unable to report pain. Our aims were to test construct validity of the scale in toddlers undergoing minor surgery and determine the inter-rater reliability of the scale.

METHODS

We consecutively enrolled 45 children aged 12-36 months from a Norwegian surgical outpatient care unit. The level of sedation, pain and distress was assessed before and after surgery with the COMFORT behavioural scale. Inter-rater reliability was estimated and construct validity was tested based on a priori defined hypotheses. A 2.5-point (15%) change in the scale was considered clinically important.

RESULTS

We obtained 307 scores covering most of the scale's range, but a floor effect was clearly present. Inter-rater reliability was high between assessors (intraclass correlation coefficient = 0.96; 95% CI 0.92-0.98). Clinically important differences were seen between baseline and light sedation (3.1 points, p < 0.001) and between light and deep sedation (4.6 points, p = 0.002). The difference between baseline and our definition of a pain/distress state was not clinically important (1.5 points, p = 0.039).

CONCLUSION

The COMFORT behavioural scale can provide one aspect of an overall clinical assessment of sedation, and probably pain and distress, in toddlers before and after surgery.

Pain perception in people with Down syndrome: a synthesis of clinical and experimental research

People with an intellectual disability experience both acute and chronic pain with at least the same frequency as the general population. However, considerably less is known about the pain perception of people with Down syndrome. In this review paper, we evaluated the available clinical and experimental evidence. Some experimental studies of acute pain have indicated that pain threshold was higher than normal but only when using a reaction time method to measure pain sensitivity. However, when reaction time is not part of the calculation of the pain threshold, pain sensitivity in people with Down syndrome is in fact lower than normal (more sensitive to pain). Clinical studies of chronic pain have shown that people with an intellectual disability experience chronic pain and within that population, people with Down syndrome also experience chronic pain, but the precise prevalence of chronic pain in Down syndrome has yet to be established. Taken together, the literature suggests that people with Down syndrome experience pain, both acute and chronic, with at least the same frequency as the rest of the population. Furthermore, the evidence suggests that although acute pain expression appears to be delayed, once pain is registered, there appears to be a magnified pain response. We conclude by proposing an agenda for future research in this area.

Pain assessment scales in newborns: integrative review

OBJECTIVE: To analyze studies on methods used to assess pain in newborns.DATA SOURCES: Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.DATA SYNTHESIS: 29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.CONCLUSION: Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.

Evaluation of pain in healthy newborns and in newborns with developmental problems (Down syndrome)

Newborns are often subjected to invasive and painful medical procedures. This happens even more frequently when they require hospitalization. The aim of this paper was to evaluate pain in healthy newborns and in newborns with Down syndrome (DS). We performed a prospective cohort study in the neonatal service of the San Cecilio University Hospital in Granada (Spain) from January 2008 to September 2013. The universe of our study comprised a study group of 20 newborns with DS and a control group of 20 newborns without DS. All of the infants were hospitalized, and thus had to undergo painful medical procedures. The variables studied were basal recovery time (as reflected in crying and the normalization of biological constants), number of punctures, oxygen saturation, heartbeat, blood pressure, response to skin-to-skin contact, and gestational age. The evaluation was performed during blood extraction, vein canalization, and heel puncture. The significant differences in the basal recovery time between the two groups of newborns indicated that those with DS were slower to express pain, and when they did, their response was not as clearly defined as that of babies without DS. The oxygen saturation in babies with DS after the puncture was found to be significantly lower than that of the control group (p < .001). The results of this study revealed that babies with DS were not as quick to perceive pain after a puncture. However, when pain was finally perceived, it persisted for a longer time. This situation should be taken into account in the design of pharmacologic and nonpharmacologic therapies.

Postoperative pain management in children and infants: an update

Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.

An evaluation of instruments for scoring physiological and behavioral cues of pain, non-pain related distress, and adequacy of analgesia and sedation in pediatric mechanically ventilated patients: A systematic review

OBJECTIVES

Advancing technology allows for successful treatment of children with life-threatening illnesses. Effectively assessing and optimally treating a child's distress during their stay in the Pediatric Intensive Care Unit (PICU) is paramount. Objective measures of distress in mechanically ventilated pediatric patients are increasingly available but few have been evaluated. The objectives of this systematic review were to identify available instruments appropriate for measuring physiological and behavioral cues of pain, non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated pediatric patients, and evaluate these instruments in terms of their psychometric properties.

DESIGN

A systematic review of original and validation reports of objective instruments to measure pain and non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated PICU patients was undertaken.

DATA SOURCES

A comprehensive search was conducted in 10 databases from January 1970 to June 2011. Reference lists of relevant articles were reviewed to identify additional articles.

REVIEW METHODS

Studies were included in the review if they met pre-established eligibility criteria. Two independent reviewers reviewed studies for inclusion, assessed quality, and extracted data.

RESULTS

Twenty-five articles were included, identifying 15 instruments. The instruments had different foci including: assessing pain, non-pain related distress, and sedation (n=2); assessing pain exclusively (n=4); assessing sedation exclusively (n=7), assessing sedation in mechanically ventilated muscle relaxed PICU patients (n=1); and assessing delirium in mechanically ventilated PICU patients (n=1). The Comfort Scale demonstrated the greatest clinical utility in the assessment of pain, non-pain related distress, and sedation in mechanically ventilated pediatric patients. Modified FLACC and the MAPS are more appropriate, however, for the assessment of procedural pain and other brief painful events. More work is required on instruments for the assessment of distress in mechanically ventilated muscle relaxed PICU patients, and the assessment of delirium in PICU patients.

CONCLUSIONS

This review provides essential information to guide PICU clinicians in choosing instruments to assess pain, non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated pediatric patients. Effective knowledge translation is essential in the implementation, adoption, and successful use of these instruments.

Behavioral pain indicators in people with intellectual disabilities: a systematic review

People with intellectual disabilities (IDs) have a higher risk of painful medical conditions. Partly because of the impaired ability to communicate about it, pain is often undertreated. To strengthen pain assessment in this population, we conducted a systematic review to identify behavioral pain indicators in people with IDs by using Embase, PubMed, PsycINFO, CINAHL, and Cochrane. Inclusion criteria were 1) scientific papers; 2) published in the last 20 years, that is, 1992 to 2012; 3) written in English, 4) using human subjects, 5) intellectual disabilities, 6) pain, 7) behavior, and 8) an association between observable behavior and pain experience. From 527 publications, 27 studies were included. Pain was acute in 14 studies, chronic in 2 studies, both acute and chronic in 2 studies, and unspecified in 9 studies. Methodological quality was assessed with the Mixed Methods Appraisal Tool. Of the 14 categories with behavioral pain indicators, motor activity, facial activity, social-emotional indicators, and nonverbal vocal expression were the most frequently reported. Most of the behavioral pain indicators are reported in more than 1 study and form a possible clinical relevant set of indicators for pain in people with IDs. Determination of a behavioral pattern specific for pain, however, remains a challenge for future research.

PERSPECTIVE

This review focuses on categories of behavior indicators related to pain in people with IDs. The quality of evidence is critically discussed per category. This set of indicators could potentially help clinicians to recognize pain in this population, especially when unique individual pain responses are also identified.

Update on pain assessment in sick neonates and infants

This article describes developments in pain assessment in critically ill neonates and infants during the last 5 to 6 years. Pain assessment instruments show a redundancy of items and a lack of profound psychometric background. Although most research focuses primarily on acute pain, in clinical practice there is also the challenge of assessing prolonged and/or persisting pain. The effectiveness of pain assessment is still a matter of debate and has recently been challenged as a primary end point in analgesia-related trials. Integration of observation of behavior with reliable and specific neurobiology-based parameters remains a challenge.

Skin conductance peaks could result from changes in vital parameters unrelated to pain

INTRODUCTION

Pain is usually assessed by the interpretation of behavior, which can be subjective. Therefore, there is an ongoing search for more objective methods. Performance of skin conductance measurement as a pain assessment tool is variable, as some studies report low specificity and a low predictive value of the method. The aim of this pilot study was to test whether autoregulation of the skin temperature influences the skin conductance of pain-free infants.

RESULTS

Skin conductance was highly correlated with skin temperature in all subjects. Moreover, a significant change in all other vital parameters was observed on comparing before- and after-peak data.

DISCUSSION

These results indicate that sympathetic neural activity to maintain homeostasis (such as autoregulation of skin temperature) results in skin conductance peaks. Real-time evaluation of the sympathetic nervous system would be valuable for pain assessment. However, the technique should be better defined to increase both sensitivity and specificity for the measurement of pain before use in daily practice can be advocated.

METHODS

We included 11 infants, median (interquartile range (IQR)) age of 34 (13-76) d, who were admitted to the surgical high-care unit for monitoring after surgery. None was treated with opioids or sedatives, and observational pain scores were low.