Pain Assessment Practices in the Pediatric Intensive Care Unit

"Their Bodies Just Give It Away": A Qualitative Study of Pain Assessment in the Context of Pediatric Hematopoietic Stem Cell Transplantation Therapy

BACKGROUND

Children undergoing hematopoietic stem cell transplantation (HSCT) are vulnerable to pain.

OBJECTIVE

This study aimed to examine how healthcare providers and parents assessed pain and what contextual factors influenced their pain assessment practices for children hospitalized after allogeneic HSCT therapy.

METHODS

A qualitative case study was conducted in a tertiary level pediatric HSCT unit in 2 phases. Semistructured interviews with parents were conducted at 30 and 90 days after HSCT therapy. Healthcare providers participated in naturalistic observations of pain-related care provided to children during their hospitalization for HSCT therapy and a semistructured interview.

RESULTS

The assessment of pain after transplantation by healthcare providers and parents was predominantly reliant on the observation of children for behaviors indicative of pain, rather than the application of validated pain assessment tools. Without formal measures of the pain experience, judgments regarding the severity of children's pain were influenced by the context of high acuity of care posttransplantation and the emotional responses of healthcare providers and parents from bearing witness to children's pain.

CONCLUSION

Pain assessments mostly reflected children's ability to tolerate pain, rather than a genuine measurement of how significantly pain impacted the child.

IMPLICATION FOR PRACTICE

This study has emphasized how the assessment of pain for children hospitalized during HSCT therapy is limited by the complexity of the clinical environment. It is recommended that validated methods of assessing pain by healthcare providers and parents be implemented into clinical practice to ensure children's pain is visible.

Pain assessment & management decision-making in pediatric critical care

PURPOSE

The aim of this study was to explore how nurses in the Pediatric Intensive Care Unit (PICU) reach their pain management decisions in children who are mechanically ventilated and chemically paralyzed.

DESIGN AND METHODS

A qualitative descriptive design was used following a quantitative phase of a multi-method study. Eighteen PICU nurses participated in semi-structured interviews aiming at understanding how they assess pain and make management decisions. Content analysis was used to guide coding and generate themes.

RESULTS

Three major themes were identified: 1) Assessment or cues that nurses use to trigger a pain assessment; 2) Mental models or patterns that nurses create to interpret cues to guide decision-making; 3) External factors that inhibit or facilitate decision-making. Overall, nurses rely on physiological cues to assess pain. From there, a large amount of variation exists on how nurses interpret those cues to make their pain management decision. External factors such as unit culture, perceived barriers and facilitators, and the nurse's experiences impacted how decisions are made.

CONCLUSIONS

Variation exists in the mental models' nurses create to make their pain management decision in this population. Nurses reported confusion on pain and sedation scale selection and various documentation practices for pain assessment. "Assume pain present" was identified as a concept and documentation practice that may guide decisions; further research is needed.

PRACTICE IMPLICATIONS

Development of clinician decision support tools that not only aid their understanding of reliable pain cues but also help create clear documentation practices may help nurses make pain management decisions.

Using a Cascading Approach to Improve Multisite Study Procedures

BACKGROUND

Multisite studies offer larger, more diverse samples to successfully capture populations and clinical practices of interest at the point of care. However, investigators face challenges with site recruitment and sampling, differences in clinical practices across sites, and data integrity. Addressing these issues a priori can improve the rigor and reproducibility of the research.

OBJECTIVE

This article aims to describe a cascading approach to multisite research. An exemplar is provided of a study using this approach, which aimed to evaluate the prevalence of pain and the pain management practices provided to critically ill children in pediatric intensive care units in the United States.

METHODS

The cascading approach includes two or more pilot study procedures with a progressively increasing number of sites prior to a full-scale study. Following each pilot, study procedures are evaluated; feedback was obtained from site personnel and content experts; procedures were revised accordingly; approvals were obtained; sites were trained; and the revised procedures are repeated with a larger, more diverse number of sites.

RESULTS

In the exemplar provided, improvements in the efficiency and integrity of data collection were noted for the full-scale study following the pilots. All sites that completed the agreements and approvals for study participation were retained for the duration of the two pilots and full-scale study.

DISCUSSION

Borrowing from principles of process improvement, the cascading approach allows knowledge to be gained regarding site differences and informs the revision of study procedures while potentially maximizing efficiency and data integrity, minimizing site burden, and maintaining site engagement for multisite studies.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation

BACKGROUND

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice.

OBJECTIVES

To describe how PICU nurses are assessing and managing pain for children who require NMB.

METHODS

A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither.

RESULTS

A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent.

CONCLUSIONS

These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

Background

Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings.

Methods

A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal).

Results

From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%.

Conclusions

The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].

Postoperative opioid administration and post-traumatic stress symptoms in preschool children after cardiac surgery

PURPOSE

The purpose of this study was to explore relationships between postoperative opioid administration and posttraumatic stress symptoms (PTSS) in preschool-aged children surviving cardiac surgery.

DESIGN AND METHODS

This was a cross-sectional, descriptive study using survey administration and medical chart review. Primary caregivers of children aged three to six years who underwent cardiac surgery at our institution between 2018 and 2020 were invited to participate. Opioid administration was calculated according to morphine milligram equivalents and indexed to the child's body weight. Caregivers completed the Young Child Posttraumatic Stress Disorder Checklist to explore child PTSS. We used correlational methods to assess the strength and direction of relationships between postoperative opioid administration and child PTSS.

RESULTS

We did not find a statistically significant relationship between total postoperative opioid administration and child PTSS. When analyzing individual opioid agents, morphine did show a significant inverse relationship to YCPC scores (r_s = -.57, p = .017) in children with single ventricle physiology.

CONCLUSIONS

Total postoperative opioid administration was not statistically significantly related to child PTSS in our sample. Differing patterns of association were noted among children with single- versus bi-ventricular physiology. Postoperative morphine administration was favorably associated with PTSS in children with single-ventricle physiology.

PRACTICE IMPLICATIONS

Nurses caring for preschool children who undergo cardiac surgery should anticipate the potential development of PTSS in their patients. Studies using larger sample sizes and longitudinal design are needed to replicate the significant relationship between morphine administration and PTSS in preschoolers with single-ventricle physiology.

"I Didn't Want My Baby to Pass, But I Didn't Want Him Suffering Either": Comparing Bereaved Parents' Narratives With Nursing End-of-Life Assessments in the Pediatric Intensive Care Unit

Little is known about how nursing care at the end of a child's life impacts long-term parental bereavement. We aimed to explain, contextualize, and examine comparisons between quantitative trends in children's end-of-life care and parents' qualitative perceptions. We used a mixed methods design, combining quantitative data from the RESTORE clinical trial with qualitative interviews with bereaved parents. Patients who died during RESTORE were included in quantitative analyses. A subset of their parents was interviewed 7 to 11 years later. The quantitative analyses included 104 children. Eight parents were interviewed; 4 had a child die after cancer, and 4 had a child die after a complex chronic illness. Quantitatively, patients' pain and sedation scores were generally comfortable. Children died with multiple invasive devices in place. Parents' descriptions of their child's comfort and critical care requirements differed by illness trajectory (cancer, complex chronic illness). Parents' memories of their child's suffering aligned with peaks in clinical scores, rather than averages. Invasive devices and equipment altered parents' ability to make meaningful final memories with the dying child. Pediatric intensive care clinicians may need to broaden how they attend to dying children's pain and corresponding parental distress, as parents' memories of their dying child's suffering persist for years.

The comparative effects of ball squeezing and cartoon watching in pain management in children during intramuscular injection: A randomized control trial

This study was designed as a randomized controlled trial to investigate the comparative effect of ball squeezing and watching cartoons on pain management in children during intramuscular injection. The population of the study was comprised of 6-12 years old children who came to emergency for intramuscular injection. Power analysis was performed by G*Power program. Approximately 147 protocols completed with 6-12 years old children (each group 49 children). In the study, a questionnaire including child and socio-demographic characteristics their experiences of hospitalization data and Facial Pain Scale- Revised (FPS-R), Visual Analog Scale (VAS), and ball (for squeezing) were used. According to the results of the study, the FPS-R score during the procedure was the lowest in the stress ball group and was statistically significant (p˂0.05). The lowest VAS scores during the procedure the lowest score was in the stress ball group and the differences between the relevant groups were statistically significant (p˂0.05). It was determined that squeezing the ball and watching cartoons were effective in reducing pain during injection, however, the ball squeezing group had the lowest pain level. Among non-pharmacological methods, ball squeezing can be preferred as a practical and effective method, especially by pediatric nurses, in reducing pain during intramuscular injection in children.

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.

The influence of contextual factors on children's communication of pain during pediatric Haematopoietic Stem Cell Transplantation: A qualitative case study

PURPOSE

The aim of this study was to describe how contextual factors related to the clinical setting of a pediatric HSCT unit influenced children's communication of pain to their health-care providers and parents during hospitalization.

DESIGN AND METHODS

A qualitative case study design was conducted in two-phases in a tertiary level pediatric HSCT unit. The Social Communication Model of Pain provided the conceptual framework for the study. In phase one participants were parents and phase two participants were health-care providers and children in a pediatric HSCT unit. Parents participated in semi-structured interviews at 30- and 90-days post-transplantation regarding their child's communication of pain. Naturalistic observations of children receiving clinical care were conducted and health-care providers participated in semi-structured interviews.

RESULTS

Children extensively denied pain to their parents and health-care providers. When children did communicate pain, they were motivated by a need to seek interventions for their pain. Children's willingness to communicate pain was influenced by the physiological impact of HSCT therapy, their previous experiences of pain, their relationship with parents and health-care providers and parents and an environment of fear and uncertainty.

CONCLUSIONS

There is a pressing need for child-centric approaches to support children to communicate their pain experiences to overcome the limitations imposed by the complexity of their medical treatment and the clinical environment in which they receive healthcare.

PRACTICE IMPLICATIONS

In the context of HSCT therapy children may not communicate pain until pain is severe, and no longer bearable, or outright deny the presence of pain.

Quality of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal in pediatric intensive care: a systematic review protocol

INTRODUCTION

Inadequate management of pain and sedation in critically ill children can cause unnecessary suffering and agitation, but also delirium and iatrogenic withdrawal. It is, therefore, important to address these four interrelated conditions together. Some clinical practice guidelines (CPGs) are available for the management of pain and sedation, and a few for delirium and iatrogenic withdrawal in the paediatric intensive care unit; none address the four conditions altogether. Critical appraisal of the quality of CPGs is necessary for their recommendations to be adopted into clinical practice. The aim of this systematic review is to identify and appraise the quality of CPGs and recommendations for management of either pain, sedation, delirium and iatrogenic withdrawal.

METHODS AND ANALYSIS

Researchers will conduct a systematic review in electronic databases (Medline ALL (Ovid), Embase.com, CINAHL with Full Text (EBSCO), JBI EBP Database (Ovid)), guideline repositories and websites of professional societies to identify CPGs published from 2010 to date. They will then combine index and free terms describing CPGs with pain, sedation, delirium and withdrawal. The researchers will include CPGs if they can be applied in the paediatric intensive care population (newborns to 18 years old) and include recommendation(s) for assessment of at least one of the four conditions. Two independent reviewers will screen for eligibility, complete data extraction and quality assessments using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence instruments. Researchers will report characteristics, content and recommendations from CPGs in tabulated forms.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. Results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021274364.

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.

Impact of Propofol Bolus Administration on the Nociceptive Flexion Reflex Threshold and Bispectral Index in Children—A Case Series

We analyzed the impact of propofol administration during continuous sedation and analgesia on the nociceptive flexion reflex threshold (NFRT) and Bispectral Index (BIS) in ventilated children. We examined patients who received propofol before planned endotracheal suctioning. Patients were clinically assessed using the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale and COMFORT-B (Comfort Behavior) scale. We continuously recorded the NFRT and BIS. We recorded 23 propofol administrations in eight patients with an average age of 8.6 ± 3.5 years. The median (minimum-maximum) scores for the mFLACC scale and COMFORT-B scale were 0 (0–5) and 6 (6–17), respectively, before the bolus. The administration of a weight-adjusted propofol bolus of 1.03 ± 0.31 mg/kg resulted in an increase in NFRT and burst-suppression ratio; BIS and electromyogram values decreased. Changes from baseline (95% CI) after propofol bolus administration were BIS −23.9 (−30.8 to −17.1), EMG -10.5 dB (−13.3 to −7.7), SR 14.8 % (5.6 to 24.0) and NFRT 13.6 mA (5.5 to 21.7). Further studies are needed to determine whether sedated children may benefit from objective pain and sedation monitoring with BIS and NFRT.

Mobile Health-Collected Biophysical Markers in Children with Serious Illness-Related Pain

Context: There is an ongoing established need to develop engaging pain assessment strategies to provide more effective individualized care to pediatric patients with serious illnesses. This study explores the acceptability of wireless devices as one option. Objective: To evaluate the ability of wrist-wearable technology to collect physiological data from children with serious illnesses. Methods: Single-site prospective observational study conducted between September 2017 and September 2018 at Rady Children's Hospital, San Diego, California, inpatient wards. Pediatric patients with diagnoses of cancer and sickle cell disease admitted to the hospital for acute-on-chronic pain and taking opioid pain medications were asked to complete two 24-hour continuous monitoring periods with the Empatica E4 wristband. Results: Data collected from the device correlated with manually obtained vital signs. Children responded favorably to wearing the device. Participants with reported subjective pain versus no pain had average heart rate increased by 16.4 bpm, skin temperature decreased by 3.5°C, and electrodermal activity decreased by 0.27. Conclusions: This study shows the possibility of collecting continuous biophysical data in a nonobtrusive manner in seriously ill children experiencing acute-on-chronic pain using wearable devices. It provides the framework for larger studies to explore the utility of such data in relation to metrics of pain and suffering in this patient population.

Pediatric Pain Assessment in the Intensive Care Unit: An Evidence-Based Algorithm

BACKGROUND

Conducting an adequate pain assessment in the Pediatric Intensive Care Unit (PICU) is multifactorial and complex due to the diversity of the population. It is critical that validated pain assessment methods are used appropriately and consistently to aid in evaluation of pain and pain management interventions.

PURPOSE

The aim of this evidence-based practice project was to improve pain assessment practices in the PICU through a decision-support algorithm.

DESIGN & METHODS

The Iowa Model-Revised was used to guide the development and implementation of an evidence-based decision algorithm. Pre- and postdata were collected via surveys (nursing knowledge and confidence) and documentation audits (nursing pain assessments). Various implementation strategies were used to facilitate the integration and sustainability of the algorithm in practice.

RESULTS

The majority of survey items showed an increase in nursing knowledge and confidence. Audits of pain assessment documentation displayed an increase in appropriate pain assessment documentation related to a child's communicative ability. However, there is a need for reinfusion related to the documentation of sedation assessments.

CONCLUSIONS

The use of an algorithm supported the ability of PICU nurses to critically consider and choose the pain assessment method most appropriate for the patient's condition. The algorithm promotes nursing clinical judgement, prioritizes pain management, and includes patients receiving sedation. The algorithm supports a comprehensive pain assessment in a difficult pediatric patient population. Future research is needed to strengthen and standardize the usage of terms "assume pain present" and "assume pain managed," and to also improve the overall feasibility and effectiveness of the algorithm.

Dynamics on the field: a focused study on the culture and context of pediatric pain management at four Ghanaian hospitals

Background

As part of efforts to develop and implement a short course educational program on pediatric pain management, the current study sought to understand the culture and contextual factors that influence children’s pain management in order to improve the practice in pediatric care settings.

Methods

Guided by Bourdieu’s theory of practice, a focused ethnographic study was conducted from October, 2018 to February, 2019. The study was contextualized at four Ghanaian hospitals among purposefully sampled nurses, physicians, hospitalized children and their families. During the 20-week study period, three ethnographers spent 144 h conducting participant-observation sessions. Formal and informal interviews were held with participants in addition to review of hospital records.

Results

Analysis of the field data resulted in four themes. “Children’s pain expression and response of caregivers” described the disposition (habitus) of both children and caregivers to act in particular ways due to children’s incomplete health status (bodily capital) which caused them pain and also resulted in discomforting procedures. “Pharmacological pain management practices and attitudes” elucidated the use of analgesics as the mainstay disposition (habitus) in children’s pain management due to high level of respect (symbolic capital) given to such interventions on the pediatric units (field). “Managing pain without drugs” illustrated healthcare providers and family caregivers’ disposition (habitus) of using diverse nonpharmacological methods in managing children’s pain. “Communication and interaction between pain actors” depicted how children’s access to care givers (social capital) can serve as a powerful tool in influencing pediatric pain assessment and management disposition (habitus) on the pediatric units (field).

Conclusions

The habitus of pediatric pain actors toward pain assessment and management practices are influenced by various forms of capital (social, cultural, symbolic, bodily and economic) operating at different levels on the pediatric care field. Quality improvement programs that seek to enhance pediatric pain management should use the insights obtained in this study to guide the development, implementation and evaluation stages.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12887-020-02399-w.

Feasibility and Clinical Utility of the Finnish Version of the FLACC Pain Scale in PICU

PURPOSE

To describe the feasibility and clinical utility of the Finnish FLACC scale when assessing children's pain in a Pediatric Intensive Care Unit (PICU).

DESIGN AND METHODS

A non-experimental, descriptive cross-sectional study design was used to describe the feasibility and clinical utility in a Finnish PICU between May and August 2018. The nurses were asked to complete a data collection questionnaire about the feasibility and clinical utility of the Finnish FLACC every time they used the scale to assess pain in children. In total, the data consisted of 157 pain assessments cases. Quantitative data were analyzed statistically and responses to open-ended questions were analyzed using content analysis.

RESULTS

In most cases, the nurses agreed that the Finnish FLACC scale was clearly structured (97%), easy to use (98%), helpful in assessing pain intensity (77%), and useful when reassessing pain after interventions (67%). Nurses found the scale more useable for children over one year old than for younger children. When assessing cry and consolability, pain was easier to score if the child was not intubated.

CONCLUSIONS

The Finnish FLACC scale exhibits adequate feasibility and clinical utility when assessing pain in children in a PICU. However, more information is needed about its use during painful short-term procedures and with children under one year old.

PRACTICE IMPLICATIONS

The Finnish FLACC scale is a helpful tool for nurses when assessing children's pain in a PICU. However, the Finnish version of the modified FLACC is needed for use with intubated children in the future.

Pain in child patients: A review on managements

Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

Purpose of Review

We briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting.

Recent Findings

Numerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

Summary

Although initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.

Pain in child patients: A review on managements

Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.