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Lim JY, Ker CJ, Lai NM, Romantsik O, Fiander M, Tan K. Dexmedetomidine for analgesia and sedation in newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev 2024; 5:CD012361. [PMID: 38695625 PMCID: PMC11064761 DOI: 10.1002/14651858.cd012361.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Dexmedetomidine is a selective alpha-2 agonist with minimal impact on the haemodynamic profile. It is thought to be safer than morphine or stronger opioids, which are drugs currently used for analgesia and sedation in newborn infants. Dexmedetomidine is increasingly being used in children and infants despite not being licenced for analgesia in this group. OBJECTIVES To determine the overall effectiveness and safety of dexmedetomidine for sedation and analgesia in newborn infants receiving mechanical ventilation compared with other non-opioids, opioids, or placebo. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and two trial registries in September 2023. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs) and quasi-RCTs evaluating the effectiveness of dexmedetomidine compared with other non-opioids, opioids, or placebo for sedation and analgesia in neonates (aged under four weeks) requiring mechanical ventilation. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were level of sedation and level of analgesia. Our secondary outcomes included days on mechanical ventilation, number of infants requiring additional medication for sedation or analgesia (or both), hypotension, neonatal mortality, and neurodevelopmental outcomes. We planned to use GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified no eligible studies for inclusion. We identified four ongoing studies, two of which appear to be eligible for inclusion; they will compare dexmedetomidine with fentanyl in newborn infants requiring surgery. We listed the other two studies as awaiting classification pending assessment of full reports. One study will compare dexmedetomidine with morphine in asphyxiated newborns undergoing hypothermia, and the other (mixed population, age up to three years) will evaluate dexmedetomidine versus ketamine plus dexmedetomidine for echocardiography. The planned sample size of the four studies ranges from 40 to 200 neonates. Data from these studies may provide some evidence for dexmedetomidine efficacy and safety. AUTHORS' CONCLUSIONS Despite the increasing use of dexmedetomidine, there is insufficient evidence supporting its routine use for analgesia and sedation in newborn infants on mechanical ventilation. Furthermore, data on dexmedetomidine safety are scarce, and there are no data available on its long-term effects. Future studies should address the efficacy, safety, and long-term effects of dexmedetomidine as a single drug therapy for sedation and analgesia in newborn infants.
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Affiliation(s)
- Jia Yi Lim
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Chin Jin Ker
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Nai Ming Lai
- School of Medicine, Taylor's University, Subang Jaya, Malaysia
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, Australia
- Monash Newborn, Monash Medical Centre, Clayton, Melbourne, Australia
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Young ED, Ferguson SH, Brewer LM, Schiedermayer BF, Brown SM, Leither LM. Using a novel in-mask non-invasive ventilator microphone to improve talker intelligibility in healthy and hospitalised adults. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023:1-16. [PMID: 37837223 PMCID: PMC11014891 DOI: 10.1080/17549507.2023.2251726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Purpose: Non-invasive ventilation (NIV) provides respiratory support without invasive endotracheal intubation but can hinder patients' ability to communicate effectively. The current study presents preliminary results using a novel in-mask ventilator microphone to enhance talker intelligibility while receiving NIV.Method: A proof-of-concept study assessed sentence intelligibility of five healthy adult talkers using a prototype model of the microphone under continuous positive airway pressure (CPAP; 5/5 cm H2O) and bilevel positive airway pressure (BiPAP; 8/4 cm H2O) ventilator conditions. A pilot study then assessed intelligibility, subjective comprehensibility and naturalness, and patient- and conversation partner-reported communication outcomes for eight patients undergoing therapeutic NIV while being treated in an intensive care unit (ICU).Result: Intelligibility increased significantly with the microphone on in the BiPAP condition for healthy volunteers. For patients undergoing NIV in an ICU, intelligibility, comprehensibility, and patient and conversation partner ratings of conversation satisfaction significantly improved with the microphone on. Patients with lower baselines without the microphone in certain measures (intelligibility, comprehensibility) generally showed a greater microphone benefit than patients with higher baselines.Conclusion: Use of a novel microphone integrated into NIV improved intelligibility during ventilation for both healthy volunteers and patients undergoing therapeutic NIV. Additional clinical studies will define precise benefits and implications of such improved intelligibility.
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Affiliation(s)
- Elizabeth D. Young
- Dept. of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT
| | - Sarah Hargus Ferguson
- Dept. of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT
| | - Lara M. Brewer
- Dept. of Anesthesiology, University of Utah, Salt Lake City, UT
| | | | - Samuel M. Brown
- Dept. of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Lindsay M. Leither
- Dept. of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
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Siddiqui AS, Ahmed A, Rehman A, Afshan G. Pain assessment in intensive care units of a low-middle income country: impact of the basic educational course. BMC MEDICAL EDUCATION 2023; 23:567. [PMID: 37559048 PMCID: PMC10413711 DOI: 10.1186/s12909-023-04523-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 07/20/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Patients admitted to ICU usually have moderate-to-severe pain at rest and during care-related activities. The "Critical Care Pain Observation Tool (CPOT)" is a reliable and validated objective assessment tool for those patients who cannot self-report pain in ICU. The objectives of the educational course were to assess the baseline knowledge, and practice of pain assessment in critically ill patients and reassess the same in all participants of the course by comparing the results of pre and post-test. METHODS The educational course of six hours of contact time on the use of CPOT for pain assessment in ICU patients was designed and conducted by the authors after approval from the Ethics Review Committee, Aga Khan University. This educational course was delivered at five different tertiary care hospitals in the Sindh province of Pakistan. A pre-test consisting of 25 true/false multiple-choice questions was conducted at the beginning of the course to assess the baseline knowledge, and practice of participants regarding pain assessment in critically ill patients and the same test was taken at the end of the course. RESULTS A total of 205 critical care physicians and nursing staff attended the courses. Both pre-test and post-test were completed by 149 (72.6%) participants, of which 53 (35.6%) were female and 96 (64.4%) were male. The mean pre-test score of participants was 57.83 ± 11.86 and the mean post-test score of participants was 67.43 ± 12.96 and this was statistically significant (p = < 0.01). In univariate analysis, the effect of training was significantly higher in the female gender (p = 0.0005) and in those participants, who belong to the metropolitan city (p = 0.010). In multivariate analysis, participants from non-metropolitan cities showed less improvement in post-test scores compared to those who come from the metropolitan city (p = 0.038). CONCLUSIONS The participating physicians and nurses showed a positive impact on the knowledge and clinical skills regarding pain assessment in CIPs. The participants from hospitals in metropolitan cities showed a significant improvement over those who were from non-metropolitan cities.
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Affiliation(s)
| | - Aliya Ahmed
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Azhar Rehman
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Gauhar Afshan
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
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Serra S, Spampinato MD, Riccardi A, Guarino M, Fabbri A, Orsi L, De Iaco F. Pain Management at the End of Life in the Emergency Department: A Narrative Review of the Literature and a Practical Clinical Approach. J Clin Med 2023; 12:4357. [PMID: 37445392 DOI: 10.3390/jcm12134357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Access to pain management is a fundamental human right for all people, including those who are at the end of life (EOL). In end-stage patients, severe and uncontrolled pain is a common cause of admission to the emergency department (ED), and its treatment is challenging due to its complex, often multifactorial genesis. The aim of this narrative review was to identify the available literature on the management of severe EOL pain in the ED. The MEDLINE, SCOPUS, EMBASE, and CENTRAL databases were searched from inception to 1 April 2023 including randomised controlled trials, observational studies, systemic or narrative reviews, case reports, and guidelines on the management of EOL pain in the ED. A total of 532 articles were identified, and 9 articles were included (5 narrative reviews, 2 retrospective studies, and 2 prospective studies). Included studies were heterogeneous on the scales used and recommended for pain assessment and the recommended treatments. No study provided evidence for a better approach for EOL patients with pain in the ED. We provide a narrative summary of the findings and a review of the management of EOL pain in clinical practice, including (i) the identification of the EOL patients and unmet palliative care needs, (ii) a multidimensional, patient-centred assessment of the type and severity of pain, (iii) a multidisciplinary approach to the management of end-of-life pain, including an overview of non-pharmacological and pharmacological techniques; and (iv) the management of special situations, including rapid acute deterioration of chronic pain, breakthrough pain, and sedative palliation.
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Affiliation(s)
- Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47521 Cesena, Italy
| | | | | | - Mario Guarino
- UOC MEU Ospedale CTO-AORN dei Colli Napoli, 80131 Napoli, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Luciano Orsi
- Palliative Care Physician and Scientific Director of "Rivista Italiane di Cure Palliative", 26013 Crema, Italy
| | - Fabio De Iaco
- Struttura Complessa di Medicina di Emergenza Urgenza Ospedale Maria Vittoria, ASL Città di Torino, 10144 Torino, Italy
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Admassie BM, Lema GF, Ferede YA, Tegegne BA. Emergency nurses perceived barriers to effective pain management at emergency department in Amhara region referral hospitals, Northwest Ethiopia, 2021. Multi-center cross sectional study. Ann Med Surg (Lond) 2022; 81:104338. [PMID: 36147186 PMCID: PMC9486582 DOI: 10.1016/j.amsu.2022.104338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/29/2022] [Accepted: 07/31/2022] [Indexed: 11/28/2022] Open
Abstract
Background Quality of pain management in emergency departments may be affected by nurses' perceived barriers. Poorly managed pain may lead to altered physiological and psychological function which affect patients’ quality of life as well as increase costs to the health care system. Objective This study aimed to assess emergency nurse's perceived barriers to pain management and associated factors at emergency departments, 2021. Methods A multi-center cross-sectional study was conducted with 153 nurses from eight emergency departments from May1-May 30, 2021 with semi-structured questionnaire. All volunteer nurses were included. Epi-info version 7 and SPSS version 20.0 were used for data entry and analysis respectively. We used descriptive statistics to report results of the study in the form of text and table. Student t-test, one way ANOVA and Post hoc test were applied to assess relationship between socio-demographic characteristics of the participants with perceived barriers. Result Of the 20 items, overcrowding 3.24 ± 0.9, nursing workload 3.16 ± 1.03, and lack of pain management guidelines/protocol2.5 ± 1.15 were the highest reported barriers to pain management at an emergency department. In addition, years of work experience as emergency nurses≤1 (p-value = 0.01), BSC level of education (p-value = 0.04), married (p-value = 0.04) and frequency of training ≤ (p-value = 0.02) were significantly associated with nurses perceived barriers on pain management. Conclusion and Recommendation: Overcrowding, nurses’ workload, absence of pain management tool, year of experience as emergency nurse ≤1, married, BSC nurses and frequency of training≤1 were the perceived barriers to pain management in the emergency department. The stakeholders in each facility should make an effort to increase the ratio of nurses to emergency patients. Professionals should develop local pain assessment and management protocol. Training should be given regularly and the opportunity of education should be maximized. The reported barriers to pain management was high. Nursing workload, and lack of pain management guidelines were the factors. Moreover, year of experience as emergency nurse ≤1 were among the perceived barriers.
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Hsu HP, Cheng MT, Lu TC, Chen YC, Liao ECW, Sung CW, Liew CQ, Ling DA, Ko CH, Ku NW, Fu LC, Huang CH, Tsai CL. Pain Assessment in the Emergency Department: A Prospective Videotaped Study. West J Emerg Med 2022; 23:716-723. [PMID: 36205678 PMCID: PMC9541978 DOI: 10.5811/westjem.2022.6.55553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 06/27/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: Research suggests that pain assessment involves a complex interaction between patients and clinicians. We sought to assess the agreement between pain scores reported by the patients themselves and the clinician’s perception of a patient’s pain in the emergency department (ED). In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment.
Methods: We conducted a prospective observational study in the ED of a tertiary academic medical center. Using a standard protocol, trained research personnel prospectively enrolled adult patients who presented to the ED. The entire triage process was recorded, and triage data were collected. Pain scores were obtained from patients on a numeric rating scale of 0 to 10. Five physician raters provided their perception of pain ratings after reviewing videos.
Results: A total of 279 patients were enrolled. The mean age was 53 years. There were 141 (50.5%) female patients. The median self-reported pain score was 4 (interquartile range 0-6). There was a moderately positive correlation between self-reported pain scores and physician ratings of pain (correlation coefficient, 0.46; P <0.001), with a weighted kappa coefficient of 0.39. Some discrepancies were noted: 102 (37%) patients were rated at a much lower pain score, whereas 52 (19%) patients were given a much higher pain score from physician review. The distributions of chief complaints were different between the two groups. Physician raters tended to provide lower pain scores to younger (P = 0.02) and less ill patients (P = 0.008). Additionally, attending-level physician raters were more likely to provide a higher pain score than resident-level raters (P <0.001).
Conclusion: Patients’ self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement between the two. Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should consider both patient and physician factors.
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Affiliation(s)
- Hao-Ping Hsu
- National Taiwan University, College of Medicine, Department of Medicine, Taipei, Taiwan
| | - Ming-Tai Cheng
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Tsung-Chien Lu
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Yun Chang Chen
- National Taiwan University Hospital Yun-Lin Branch, Department of Emergency Medicine, Hsinchu, Taiwan
| | - Edward Che-Wei Liao
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Chih-Wei Sung
- National Taiwan University Hospital Hsin-Chu Branch, Department of Emergency Medicine, Hsinchu, Taiwan
| | - Chiat Qiao Liew
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Dean-An Ling
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Chia-Hsin Ko
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Nai-Wen Ku
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Li-Chen Fu
- National Taiwan University, Department of Computer Science and Information Engineering, Taipei, Taiwan
| | - Chien-Hua Huang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Chu-Lin Tsai
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
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Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
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Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
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Duprey MS, Dijkstra-Kersten SMA, Zaal IJ, Briesacher BA, Saczynski JS, Griffith JL, Devlin JW, Slooter AJC. Opioid Use Increases the Risk of Delirium in Critically Ill Adults Independently of Pain. Am J Respir Crit Care Med 2021; 204:566-572. [PMID: 33835902 PMCID: PMC8491270 DOI: 10.1164/rccm.202010-3794oc] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 04/09/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: It is unclear whether opioid use increases the risk of ICU delirium. Prior studies have not accounted for confounding, including daily severity of illness, pain, and competing events that may preclude delirium detection.Objectives: To evaluate the association between ICU opioid exposure, opioid dose, and delirium occurrence.Methods: In consecutive adults admitted for more than 24 hours to the ICU, daily mental status was classified as awake without delirium, delirium, or unarousable. A first-order Markov model with multinomial logistic regression analysis considered four possible next-day outcomes (i.e., awake without delirium, delirium, unarousable, and ICU discharge or death) and 11 delirium-related covariables (baseline: admission type, age, sex, Acute Physiology and Chronic Health Evaluation IV score, and Charlson comorbidity score; daily: ICU day, modified Sequential Organ Failure Assessment, ventilation use, benzodiazepine use, and severe pain). This model was used to quantify the association between opioid use, opioid dose, and delirium occurrence the next day.Measurements and Main Results: The 4,075 adults had 26,250 ICU days; an opioid was administered on 57.0% (n = 14,975), severe pain occurred on 7.0% (n = 1,829), and delirium occurred on 23.5% (n = 6,176). Severe pain was inversely associated with a transition to delirium (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.53-0.97). Any opioid administration in awake patients without delirium was associated with an increased risk for delirium the next day [OR, 1.45; 95% CI, 1.24-1.69]. Each daily 10-mg intravenous morphine-equivalent dose was associated with a 2.4% increased risk for delirium the next day.Conclusions: The receipt of an opioid in the ICU increases the odds of transitioning to delirium in a dose-dependent fashion.
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Affiliation(s)
| | - Sandra M. A. Dijkstra-Kersten
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene J. Zaal
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | | | - John L. Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - John W. Devlin
- Department of Pharmacy and Health Systems Sciences and
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and
| | - Arjen J. C. Slooter
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, University Ziekenhuis Brussel and Vrije University, Brussels, Belgium
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Early prediction of extubation failure in patients with severe pneumonia: a retrospective cohort study. Biosci Rep 2021; 40:221958. [PMID: 31990295 PMCID: PMC7007404 DOI: 10.1042/bsr20192435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/03/2020] [Accepted: 01/28/2020] [Indexed: 02/05/2023] Open
Abstract
Backgroud: Severe pneumonia is one of the most common causes for mechanical ventilation. We aimed to early identify severe pneumonia patients with high risk of extubation failure in order to improve prognosis. Methods: From April 2014 to December 2015, medical records of intubated patients with severe pneumonia in intensive care unit were retrieved from database. Patients were divided into extubation success and failure groups, and multivariate logistic regressions were performed to identify independent predictors for extubation failure. Results: A total of 125 eligible patients were included, of which 82 and 43 patients had extubation success and failure, respectively. APACHE II score (odds ratio (OR) 1.141, 95% confident interval (CI) 1.022–1.273, P = 0.019, cutoff at 17.5), blood glucose (OR 1.122, 95%CI 1.008–1.249, P = 0.035, cutoff at 9.87 mmol/l), dose of fentanyl (OR 3.010, 95%CI 1.100–8.237, P = 0.032, cutoff at 1.135 mg/d), and the need for red blood cell (RBC) transfusion (OR 2.774, 95%CI 1.062–7.252, P = 0.037) were independent risk factors for extubation failure. Conclusion: In patients with severe pneumonia, APACHE II score > 17.5, blood glucose > 9.87 mmol/l, fentanyl usage > 1.135 mg/d, and the need for RBC transfusion might be associated with higher risk of extubation failure.
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Practical approaches to sedation and analgesia in the newborn. J Perinatol 2021; 41:383-395. [PMID: 33250515 PMCID: PMC7700106 DOI: 10.1038/s41372-020-00878-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.
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Bardwell J, Brimmer S, Davis W. Implementing the ABCDE Bundle, Critical-Care Pain Observation Tool, and Richmond Agitation-Sedation Scale to Reduce Ventilation Time. AACN Adv Crit Care 2020; 31:16-21. [PMID: 32168511 DOI: 10.4037/aacnacc2020451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Prolonged mechanical ventilation of patients in intensive care units across the United States consumes billions of health care dollars every year. Using the awakening and breathing coordination, delirium monitoring/management, and early mobility (ABCDE) bundle along with the Critical-Care Pain Observation Tool and the Richmond Agitation-Sedation Scale combines the best available evidence to optimize outcomes for critically ill patients. This study is the first to examine the effects of implementing the ABCDE bundle, the Critical-Care Pain Observation Tool, and the Richmond Agitation-Sedation Scale together in a coordinated effort across multiple disciplines. The aim of using this combination of evidence-based tools is to reduce ventilation time by reducing oversedation, decreasing the incidence of delirium, and improving pain management.
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Affiliation(s)
- Jennifer Bardwell
- Jennifer Bardwell is Nurse Practitioner, CHRISTUS Good Shepherd Medical Center and Taylor Medical Center Urgent Care, Longview, Texas
| | - Sushama Brimmer
- Sushama Brimmer is Chief Hospitalist and Medical Director, CHRISTUS Good Shepherd Medical Center, Longview, Texas
| | - Wesley Davis
- Wesley Davis is Assistant Professor and Emergency Nurse Practitioner Specialty Coordinator, University of South Alabama College of Nursing, Mobile, Alabama, and Emergency Nurse Practitioner, Crook County Hospital; University of South Alabama College of Nursing, HAHN 4056, 5721 USA Drive North, Mobile, Alabama 36688-0002
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12
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Romanowski KS, Carson J, Pape K, Bernal E, Sharar S, Wiechman S, Carter D, Liu YM, Nitzschke S, Bhalla P, Litt J, Przkora R, Friedman B, Popiak S, Jeng J, Ryan CM, Joe V. American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps. J Burn Care Res 2020; 41:1129-1151. [PMID: 32885244 PMCID: PMC7703676 DOI: 10.1093/jbcr/iraa119] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The ABA pain guidelines were developed 14 years ago and have not been revised despite evolution in the practice of burn care. A sub-committee of the American Burn Association's Committee on the Organization and Delivery of Burn Care was created to revise the adult pain guidelines. A MEDLINE search of English-language publications from 1968 to 2018 was conducted using the keywords "burn pain," "treatment," and "assessment." Selected references were also used from the greater pain literature. Studies were graded by two members of the committee using Oxford Centre for Evidence-based Medicine-Levels of Evidence. We then met as a group to determine expert consensus on a variety of topics related to treating pain in burn patients. Finally, we assessed gaps in the current knowledge and determined research questions that would aid in providing better recommendations for optimal pain management of the burn patient. The literature search produced 189 papers, 95 were found to be relevant to the assessment and treatment of burn pain. From the greater pain literature 151 references were included, totaling 246 papers being analyzed. Following this literature review, a meeting to establish expert consensus was held and 20 guidelines established in the areas of pain assessment, opioid medications, nonopioid medications, regional anesthesia, and nonpharmacologic treatments. There is increasing research on pain management modalities, but available studies are inadequate to create a true standard of care. We call for more burn specific research into modalities for burn pain control as well as research on multimodal pain control.
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Affiliation(s)
- Kathleen S Romanowski
- University of California, Davis and Shriners Hospitals for Children Northern California, Sacramento, California
| | - Joshua Carson
- University of Florida Health Shands Burn Center, Gainesville, Florida
| | - Kate Pape
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Sam Sharar
- University of Washington School of Medicine, Harborview Medical Center, Seattle Washington
| | - Shelley Wiechman
- University of Washington School of Medicine, Harborview Medical Center, Seattle Washington
| | | | - Yuk Ming Liu
- Loyola University Medical Center, Maywood, Illinois
| | | | - Paul Bhalla
- University of Washington School of Medicine, Harborview Medical Center, Seattle Washington
| | - Jeffrey Litt
- University of Missouri School of Medicine, Columbia, Missouri
| | - Rene Przkora
- University of Florida Health, Anesthesiology and Pain Medicine, Gainesville, Florida
| | | | | | - James Jeng
- Nathan Speare Regional Burn Treatment Center Crozer Chester Medical Center, Upland, Pennsylvania
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and Shriners Hospitals for Children-Boston®, Boston, Massachusetts
| | - Victor Joe
- University of California Irvine Regional Burn Center, Orange, California
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Long DA, Koyfman A, Long B. Oncologic Emergencies: Palliative Care in the Emergency Department Setting. J Emerg Med 2020; 60:175-191. [PMID: 33092975 DOI: 10.1016/j.jemermed.2020.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 06/25/2020] [Accepted: 09/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Palliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL). OBJECTIVE This narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain. DISCUSSION As the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL. CONCLUSIONS Emergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.
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Affiliation(s)
- Drew A Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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14
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Theerawit P, Natpobsuk N, Petnak T, Sutherasan Y. The efficacy of the WhisperFlow CPAP system versus high flow nasal cannula in patients at risk for postextubation failure: A Randomized controlled trial. J Crit Care 2020; 63:117-123. [PMID: 33012589 DOI: 10.1016/j.jcrc.2020.09.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 09/13/2020] [Accepted: 09/22/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Compare the efficacy(reintubation rate) between a high-flow nasal cannula(HFNC) and the WhisperFlow CPAP system in patients at risk for postextubation failure. MATERIAL AND METHODS RCT was conducted in patients who had at least one high-risk criterion for postextubation failure. All patients were randomly assigned to CPAP or HFNC for 48 h. RESULTS Of 140 patients, sixty-nine were assigned to the CPAP group and 71 to the HFNC group. The reintubation rate was similar between the HFNC and WhisperFlowCPAP [5 cases(7.0%) vs. 6 cases(8.7%); P = 0.76]. The postextubation respiratory failure rate was not significantly different between the HFNC and WhisperFlow CPAP groups [10 cases(14.1%)vs.7cases(10.1%); P = 0.48]. The respiratory rate was lower in the HFNC than CPAP group(P = 0.04). The pain rating scale score was lower in the HFNC group than in the WhisperFlow CPAP group at 24 h (2.8 ± 2.0 vs. 3.7 ± 1.9, P = 0.02) and 48 h (2.8 ± 1.8 vs. 3.8 ± 1.9, P = 0.002). CONCLUSIONS We are unable to demonstrate a reduction in postextubation respiratory failure in at risk patients with the use of HFNC compared with the WhisperFlow CPAP system probably because small sample size, but HFNC was better tolerated.
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Affiliation(s)
- Pongdhep Theerawit
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawat Natpobsuk
- Department of Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok, Thailand
| | - Yuda Sutherasan
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok, Thailand.
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Ho J, Burger D. Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment. BMJ Open Qual 2020; 9:bmjoq-2020-000987. [PMID: 32958472 PMCID: PMC7507888 DOI: 10.1136/bmjoq-2020-000987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe opioid-related adverse event. In September 2018, Sierra View Medical Center identified two areas of opportunity for quality improvement: bedside bar code medication administration (BCMA) and pain reassessments. At baseline (April 2018 to September 2018) only 81% of medications were scanned prior to administration with pain reassessments completed only 41% of the time 1 hour postopioid administration. OBJECTIVE To improve BCMA scanning rates (goal ≥95%) and pain reassessments within 1 hour postopioid administration (goal ≥90%). METHODS Implementation methods included data transparency, weekly dashboards, education and plan-do-study-act (PDSA) cycles informed by feedback from key stakeholders. RESULTS Following a series of PDSA cycle implementations, barcode medication administration (BCMA) scanning rates improved by 14% (from 81% to 95%) and pain reassessments improved by 50% (from 41% to 91%), sustained 17 months postproject implementation (October 2018 to February 2019). The number of adverse drug events (ADEs) related to administration errors decreased by 17% (estimated annual cost savings of $120 750-239 725 per year) and opioid-related ADEs decreased by 2.6% (estimated annual cost savings of $72 855-80 928 per year). CONCLUSION Adopting John Kotter's model for change, developing performance dashboards and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance. The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favourable financial impact.
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Affiliation(s)
- Jackie Ho
- Pharmacy, Sierra View Medical Center, Porterville, California, USA
| | - David Burger
- Pharmacy, Sierra View Medical Center, Porterville, California, USA
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16
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Khan SH, Xu C, Purpura R, Durrani S, Lindroth H, Wang S, Gao S, Heiderscheit A, Chlan L, Boustani M, Khan BA. Decreasing Delirium Through Music: A Randomized Pilot Trial. Am J Crit Care 2020; 29:e31-e38. [PMID: 32114612 DOI: 10.4037/ajcc2020175] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Management of delirium in intensive care units is challenging because effective therapies are lacking. Music is a promising nonpharmacological intervention. OBJECTIVES To determine the feasibility and acceptability of personalized music (PM), slow-tempo music (STM), and attention control (AC) in patients receiving mechanical ventilation in an intensive care unit, and to estimate the effect of music on delirium. METHODS A randomized controlled trial was performed in an academic medical-surgical intensive care unit. After particular inclusion and exclusion criteria were applied, patients were randomized to groups listening to PM, relaxing STM, or an audiobook (AC group). Sessions lasted 1 hour and were given twice daily for up to 7 days. Patients wore noise-canceling headphones and used mp3 players to listen to their music/audiobook. Delirium and delirium severity were assessed twice daily by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the CAM-ICU-7, respectively. RESULTS Of the 1589 patients screened, 117 (7.4%) were eligible. Of those, 52 (44.4%) were randomized, with a recruitment rate of 5 patients per month. Adherence was higher in the groups listening to music (80% in the PM and STM groups vs 30% in the AC group; P = .01), and 80% of patients surveyed rated the music as enjoyable. The median number (interquartile range) of delirium/coma-free days by day 7 was 2 (1-6) for PM, 3 (1-6) for STM, and 2 (0-3) for AC (P = .32). Median delirium severity was 5.5 (1-7) for PM, 3.5 (0-7) for STM, and 4 (1-6.5) for AC (P = .78). CONCLUSIONS Music delivery is acceptable to patients and is feasible in intensive care units. Further research testing use of this promising intervention to reduce delirium is warranted.
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Affiliation(s)
- Sikandar H. Khan
- Sikandar H. Khan is an assistant professor, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, and a scientist, Center for Aging Research, Indiana University, Indianapolis, Indiana
| | | | - Russell Purpura
- Russell Purpura is an internal medicine resident, Department of Medicine, Indiana University School of Medicine
| | - Sana Durrani
- Sana Durrani is a research associate, Center for Aging Research, Indiana University
| | - Heidi Lindroth
- Heidi Lindroth is a T32 postdoctoral fellow, Center for Aging Research, Indiana University, and a postdoctoral fellow, Indiana University School of Nursing
| | - Sophia Wang
- Sophia Wang is an assistant professor, Department of Psychiatry, Indiana University School of Medicine
| | - Sujuan Gao
- Sujuan Gao is a professor, Department of Biostatistics, Indiana University School of Medicine
| | - Annie Heiderscheit
- Annie Heiderscheit is an associate professor of music and director of music therapy, Augsburg University, Minneapolis, Minnesota
| | - Linda Chlan
- Linda Chlan is a professor, Department of Nursing, and associate dean, Nursing Research Division, Mayo Clinic, Rochester, Minnesota
| | - Malaz Boustani
- Malaz Boustani is a professor of medicine, Center for Aging Research, Indiana University, and a scientist, Center for Health Innovation and Implementation Science, Indianapolis, Indiana
| | - Babar A. Khan
- Babar A. Khan is an associate professor, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, and a scientist, Center for Aging Research, Indiana University
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Schuster J, Hoyer C, Ebert A, Alonso A. Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study. BMC Neurol 2020; 20:18. [PMID: 31937259 PMCID: PMC6961294 DOI: 10.1186/s12883-020-1606-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/08/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pain is a common and burdensome complication in patients with acute stroke. We assessed the impact of impaired communication in stroke patients on pain assessment and treatment. METHODS We included 909 (507 male, mean age 71.8 years) patients admitted to our stroke unit from 01/2015 to 12/2015 in the analysis. Patients were assigned to four groups: able to communicate (AC), not able to communicate prior to index stroke (P-NAC), due to focal symptoms of index stroke (S-NAC), due to a reduced level of consciousness (C-NAC). Pain prevalence, documentation of pain and use of analgesics were evaluated. C-NAC patients were excluded from analyses regarding analgesic treatment due to relevant differences in patient characteristics. RESULTS 746 patients (82.1%) were classified as AC, 25 (2.8%) as P-NAC, 90 (9.9%) as S-NAC and 48 (5.3%) as C-NAC. Pain was documented on the Numeric Rating Scale and in form of free text by nurses and physicians. Nurses documented pain more frequently than physicians (p < 0.001). Pain prevalence was 47.0% (n.s. between groups). The use of analgesic medication increased from 48.7% in the AC group, to 76.0% in the P-NAC group, and 77.8% in the S-NAC group (p < 0.001). Opioid use was significantly more frequent in NAC patients (p < 0.001). The response to the treatment was poorly documented with significantly lowest rates in S-NAC patients (p < 0.001). CONCLUSIONS Our study suggests that post-stroke pain in patients with inability to communicate is not attended enough, not systematically assessed and therefore not sufficiently treated.
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Affiliation(s)
| | | | - A Ebert
- Department of Neurology, Medical Faculty of Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - A Alonso
- Department of Neurology, Medical Faculty of Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, 68167, Mannheim, Germany.
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Attwell C, Jöhr J, Pincherle A, Pignat JM, Kaufmann N, Knebel JF, Berney L, Ryvlin P, Diserens K. Neurosensory stimulation outdoors enhances cognition recovery in cognitive motor dissociation: A prospective crossover study. NeuroRehabilitation 2019; 44:545-554. [PMID: 31282434 PMCID: PMC6700645 DOI: 10.3233/nre-192692] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND: Neurosensory stimulation is effective in enhancing the recovery process of severely brain-injured patients with disorders of consciousness. Multisensory environments are found in nature, recognized as beneficial to many medical conditions. Recent advances detected covert cognition in patients behaviorally categorized as un- or minimally responsive; a state described as cognitive motor dissociation (CMD). OBJECTIVE: To determine effectiveness of a neurosensory stimulation approach enhanced by outdoor therapy, in the early phases of recovery in patients presenting with CMD. METHODS: A prospective non-randomized crossover study was performed. A two-phase neurosensory procedure combined identical individually goal assessed indoor and outdoor protocols. All sessions were video-recorded and observations rated offline. The frequency of volitional behavior was measured using a behavioral grid. RESULTS: Fifteen patients participated in this study. The outdoor group patients had statistically significant higher number of intentional behaviors than the indoor group on seven features of the grid. Additionally, for all items assessed, total amount of behaviors in the outdoor condition where higher than those in the indoor condition. CONCLUSIONS: Although preliminary, this study provides robust evidence supporting the effectiveness and appropriateness of an outdoor neurosensory intervention in patients with covert cognition, to improve adaptive goal-oriented behavior. This may be a step towards helping to restore functional interactive communication.
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Affiliation(s)
- Caroline Attwell
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Jane Jöhr
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Alessandro Pincherle
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Jean-Michel Pignat
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Nina Kaufmann
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Jean-François Knebel
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Loric Berney
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
| | - Karin Diserens
- Department of Clinical Neurosciences, Neurology, Acute Neurorehabilitation Unit, University Hospital CHUV, Lausanne, Vaud, Switzerland
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Ismail A, Forgeron P, Polomeno V, Gharaibeh H, Dagg W, Harrison D. Pain management interventions in the Paediatric Intensive Care Unit: A scoping review. Intensive Crit Care Nurs 2019; 54:96-105. [DOI: 10.1016/j.iccn.2019.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/13/2019] [Accepted: 05/18/2019] [Indexed: 01/18/2023]
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20
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Tao H, Galagarza SR. P-CPOT: An Adaptation of the Critical-Care Pain Observation Tool for Pediatric Intensive Care Unit Patients. Pain Manag Nurs 2019; 21:172-178. [PMID: 31506237 DOI: 10.1016/j.pmn.2019.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Pediatric Critical-Care Observation Tool (P-CPOT) is an adaption of the Critical-Care Pain Observation Tool (CPOT) originally designed to assess pain in nonverbal critically-ill adults. AIM The study validated the P-CPOT in assessing nociceptive procedure pain in pediatric intensive care unit (PICU) children who are unable to verbalize pain. METHODS Content validity was tested using a two-round expert panel review with 8 experts. With a sample of 78 PICU patients, prospective repeated measures were designed to detect the change over time at pre- (T1), during (T2), and post- (T3) for routinely scheduled nociceptive procedures. Each measure was independently completed by two raters using two scales, the P-CPOT and the FLACC (Faces, Legs, Activity, Cry and Consolability). RESULTS All categories had Item-level content validity indices of 0.88 to 1.00. A one-factor structure containing 5 items was established and accounted for 85% variance in P-CPOT scores. Inter-rater reliability was substantial with correlation coefficient of 0.996 and Kappa value of 0.90. A threshold value of 4 resulted in excellent balance between sensitivity (98.6%) and specificity (97.6%). Both tools detected the score changes over time (p = .025). P-CPOT had a larger effect size (Cohen's d = 4.1) as well as a higher score than FLACC at T2 (p = .039). Linear regression revealed that patients being ventilated tended to have a P-CPOT score of 1.1 higher than the FLACC score while controlling for heart rates (p < .001), meaning that P-CPOT is more sensitive than FLACC for detecting pain increase during nociceptive procedures in ventilated patients. CONCLUSION The P-CPOT is a valid scale for assessing pain in PICU patients with very good psychometric performance. It is especially adept in detecting pain in ventilated patients.
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Affiliation(s)
- Hong Tao
- AdventHealth Whole-Person Research, Orlando, Florida.
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21
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Gilder E, Parke RL, McGuinness S, Jull A. Study protocol: A randomized controlled trial assessing the avoidance of endotracheal suction in cardiac surgical patients ventilated for ≤ 12 hr. J Adv Nurs 2019; 75:2006-2014. [PMID: 30843238 DOI: 10.1111/jan.13994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/23/2018] [Accepted: 01/21/2019] [Indexed: 11/27/2022]
Abstract
AIMS To assess the safety and efficacy of avoiding endotracheal suction in postoperative cardiac surgical patients mechanically ventilated for ≤ 12 hr. DESIGN A prospective, single centre, single blind, non-inferiority, randomized controlled trial evaluating the safety and efficacy of avoiding suction in uncomplicated, postoperative, adult cardiac surgical patients mechanically ventilated for ≤ 12 hr. METHODS Randomization will be performed on return to intensive care (ICU) with allocation to either usual postoperative care including suction or to usual care with no suction (intervention arm). The primary outcome is the ratio of partial pressure of oxygen (PaO2 ) to fraction of inspired oxygen (FiO2 ) (P/F) 6 hr after extubation. Pain assessments will be performed before, during and after endotracheal suction (ETS) and the patient experience will be investigated with a brief interview the following day. Ethics approval was received in October 2015. DISCUSSION Endotracheal suction is performed as part of airway management but has potential complications and there is little robust evidence to guide practice. This study will add to the evidence base about the need and benefit of endotracheal suction in this patient cohort. IMPACT As there is currently no published evidence about the safety of avoiding endotracheal suction. This study will provide the first evidence about avoidance of endotracheal suction in patients ventilated for less than 1 day. If non-inferior, the results have the capacity to change nursing practice by avoiding a potentially unnecessary procedure, it will build on the body of knowledge about the patient experience.
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Affiliation(s)
- Eileen Gilder
- FANZCA, Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.,School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Rachael L Parke
- FANZCA, Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.,School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,FANZCA, Australian and New Zealand Intensive Care Research Centre, Melbourne, Vic., Australia.,Medical Reseach Institute of New Zealand (MRINZ), Wellington, New Zealand
| | - Shay McGuinness
- FANZCA, Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.,FANZCA, Australian and New Zealand Intensive Care Research Centre, Melbourne, Vic., Australia.,Medical Reseach Institute of New Zealand (MRINZ), Wellington, New Zealand
| | - Andrew Jull
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Noel C, Mallemat H. Sedation and Analgesia for Mechanically Ventilated Patients in the Emergency Department. Emerg Med Clin North Am 2019; 37:545-556. [PMID: 31262420 DOI: 10.1016/j.emc.2019.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mechanically ventilated patients can experience significant pain and anxiety associated with their care. These symptoms should be aggressively treated, but can be challenging to manage without a systematic approach. This article reviews recent literature, current guidelines, and best practices in managing pain, agitation, and anxiety in mechanically ventilated patients in the emergency department.
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Affiliation(s)
- Christopher Noel
- Critical Care Medicine, Cooper University Hospital, One Cooper Plaza, D427C, Camden, NJ 08103, USA.
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Olmos M, Varela D, Klein F. ENFOQUE ACTUAL DE LA ANALGESIA, SEDACIÓN Y EL DELIRIUM EN CUIDADOS CRÍTICOS. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Modanloo M, Mohsenpour A, Rahmani H, Moghaddam S, Khoddam H. Impact of Implementing the Critical Care Pain Observation Tool on Nurses' Performance in Assessing and Managing Pain in the Critically Ill Patients. Indian J Crit Care Med 2019; 23:165-169. [PMID: 31130786 PMCID: PMC6521825 DOI: 10.5005/jp-journals-10071-23146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and aims Pain management is one of the most important responsibilities of nurses in an intensive care unit (ICU). It is difficult to perform pain assessment appropriately in patients who are unable to report their pain. This study is aimed to determine the impact of implementing the critical care pain observation tool (CPOT) on the amount and frequency of analgesics' administration in ICUs. Materials and methods This interventional study was conducted in 2014. Sixty nurses and 240 patients were studied. This study was carried out in three phases: first the data about amount and frequency of analgesic administration were extracted from patients' medical files. Then the CPOT was implemented into the nursing assessment process and finally, nurses' performance regarding the amount and frequency of analgesic administration was recorded. This data obtained before and after intervention were analyzed using chi-square and independent t-test p values less than 0.05 were considered significant. Results In this interventional study, we found that there was no difference in the demography and cause of ICU admission before and after implementation of CPOT (age p = 0.937, gender p = 0.996, and the cause of admission p = 0.996). We found that after implementing the CPOT into the nursing assessment process, the amount of analgesics administered (7.95 ± 8.77 mg vs. 11.01 ± 11.04 mg, p = 0.018) and the frequency of administration (2.91 ± 1.38 vs. 4.16 ± 0.99, p <0.001) increased significantly. Moreover, there was a significant increase in the frequency of pain assessment per patient per day in nursing practice after implementation of CPOT as compared to the practice before (7.2 ± 2.48 vs. 1.03 ± 1.63, p <0.001). The mean pain scores before and after the intervention (5.5 ± 1.08 vs.2.2 ± 0.48) were also significantly different. Conclusion Applying CPOT, as an objective mean of pain assessment, was effective in improving the performance of ICU nurses in assessment and management of patients' pain. It increased the amount and frequency of analgesic administration. We can recommend that COPT is a useful tool for assessment and management of pain in ICU patients and should be implemented in all ICUs. How to cite this article Modanloo M, Mohsenpour A, et al. Impact of Implementing the Critical Care Pain Observation Tool on Nurses' Performance in Assessing and Managing Pain in the Critically Ill Patients. Indian J Crit Care Med 2019;23(4):165-169.
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Affiliation(s)
- Mahnaz Modanloo
- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Afsaneh Mohsenpour
- Critical Care Nursing, Nursing and Midwifery School, Golestan University of Medical Sciences, Gorgan, Iran
| | - Hossein Rahmani
- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Shahram Moghaddam
- Department of Anesthesiology, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Homeira Khoddam
- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
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Gutysz-Wojnicka A, Ozga D, Mayzner-Zawadzka E, Dyk D, Majewski M, Doboszyńska A. Psychometric Assessment of Physiologic and Behavioral Pain Indicators in Polish Versions of the Pain Assessment Scales. Pain Manag Nurs 2018; 20:292-301. [PMID: 30269914 DOI: 10.1016/j.pmn.2018.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 04/10/2018] [Accepted: 07/20/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is an urgent need to prepare a reliable and accurate tool for pain assessment in patients who are unable to self-report. Translating pain assessment scales into foreign languages requires further validation testing. AIM The aim of the study was to carry out psychometric assessment of behavioral and physiological indicators of pain included in two Polish versions of pain assessment scales, the Behavioral Pain Scale (BPS) and the original Adult Non-Verbal Pain Scale (NVPS). DESIGN A prospective repeated-measure descriptive study was conducted. SETTINGS AND PARTICIPANTS Twenty-eight adult non-communicative mechanically ventilated ICU patients were included in the study. The study took place in five hospitals in Poland, one 15-bed general ICU of a university teaching hospital and four 6-bed medical ICUs of district hospitals. METHODS Pain assessment was conducted at rest, during non-painful and painful procedures independently by two observers. RESULTS Internal consistency of the Polish version of the scales was below the expected 0.7 value (Cronbach's alpha for the BPS 0.6883 and NVPS 0.6697). Principal component analysis showed that for the Polish version of the BPS, all three domains formed one separate factor (63.9%), while in the case of the NVPS two separate factors were found, one covering four domains of the NVPS (47.1%) and the other exclusively covering the category of Vital sign (20.2%). There was a significant difference between the pain scores with the NVPS (χ2 = 228.95 p < .001) and the BPS (χ2 = 236.46 p < .001) during three observation phases. There were no significant differences between scores obtained by different raters. The analysis of variance demonstrated a statistically significant difference in the values of physiological indicators of pain (SBP, DBP, MAP) between observation phases. CONCLUSIONS The Polish version of the BPS has better psychometric properties than the Polish version of the NVPS. It is necessary to define precisely the descriptors used in the scales and to implement a staff training program.
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Affiliation(s)
- Aleksandra Gutysz-Wojnicka
- Department of Nursing, Faculty of Health Sciences, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland.
| | - Dorota Ozga
- Department of Obstetrics and Emergency Medicine, Medical Faculty, University of Rzeszow, Rzeszów, Poland
| | - Ewa Mayzner-Zawadzka
- Department of Anesthesiology and Intensive Care, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Danuta Dyk
- The Institute of Anesthesiological and Intensive Care Nursing, Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland
| | - Mariusz Majewski
- Department of Human Physiology, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Anna Doboszyńska
- Department of Nursing, Faculty of Health Sciences, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
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Hadjileontiadis LJ. Continuous wavelet transform and higher-order spectrum: combinatory potentialities in breath sound analysis and electroencephalogram-based pain characterization. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2018; 376:rsta.2017.0249. [PMID: 29986918 PMCID: PMC6048582 DOI: 10.1098/rsta.2017.0249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/11/2018] [Indexed: 05/05/2023]
Abstract
The combination of the continuous wavelet transform (CWT) with a higher-order spectrum (HOS) merges two worlds into one that conveys information regarding the non-stationarity, non-Gaussianity and nonlinearity of the systems and/or signals under examination. In the current work, the third-order spectrum (TOS), which is used to detect the nonlinearity and deviation from Gaussianity of two types of biomedical signals, that is, wheezes and electroencephalogram (EEG), is combined with the CWT to offer a time-scale representation of the examined signals. As a result, a CWT/TOS field is formed and a time axis is introduced, creating a time-bifrequency domain, which provides a new means for wheeze nonlinear analysis and dynamic EEG-based pain characterization. A detailed description and examples are provided and discussed to showcase the combinatory potential of CWT/TOS in the field of advanced signal processing.This article is part of the theme issue 'Redundancy rules: the continuous wavelet transform comes of age'.
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Affiliation(s)
- Leontios J Hadjileontiadis
- Department of Electrical and Computer Engineering, Aristotle University of Thessaloniki, 54124 Thessaloniki, GreeceDepartment of Electrical and Computer Engineering, Khalifa University of Science and Technology, PO Box 127788, Abu Dhabi, UAE
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Deldar K, Froutan R, Ebadi A. Challenges faced by nurses in using pain assessment scale in patients unable to communicate: a qualitative study. BMC Nurs 2018; 17:11. [PMID: 29568232 PMCID: PMC5857143 DOI: 10.1186/s12912-018-0281-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/08/2018] [Indexed: 11/10/2022] Open
Abstract
Background One helpful strategy adopted for pain management in non-verbal, intubated patients is the use of a proper pain assessment scale. The purpose of the present study is to achieve a better and deeper understanding of the existing nurses' challenges in using pain assessment scales among patients unable to communicate. Methods This qualitative study was conducted using content analysis. Purposive sampling was used to select the participants and continued until data saturation. The participants included 20 nurses working in intensive care units. Data was collected using semi-structured interviews and analysis was done using an inductive approach. Results Four categories and ten sub-categories were extracted from the experiences of the nurses working in the intensive care units in terms of nursing challenges in using non-verbal pain assessment scales. The four categories included "forgotten priority", "organizational barriers", "attitudinal barriers", and "barriers to knowledge". Conclusions The findings of the present study have shown that various factors might influence on the use of non-verbal pain assessment scales in patients unable to communicate. Identifying these challenges for nurses can help take effective steps such as empowering nurses in the use of non-verbal pain assessment scales, relieving pain, and improving the quality of care services.
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Affiliation(s)
- Kolsoum Deldar
- 1Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Razieh Froutan
- 2Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abbas Ebadi
- 3Behavioral Sciences Research Center, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran
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28
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Wiegand DL, Wilson T, Pannullo D, Russo MM, Kaiser KS, Soeken K, McGuire DB. Measuring Acute Pain Over Time in the Critically Ill Using the Multidimensional Objective Pain Assessment Tool (MOPAT). Pain Manag Nurs 2018; 19:277-287. [PMID: 29398346 DOI: 10.1016/j.pmn.2017.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 10/07/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND A valid and reliable instrument is needed to assess acute pain in critically ill patients unable to self-report and who may be transitioning between critical care and other settings. AIM To examine the reliability, validity, and clinical utility of the Multidimensional Objective Pain Assessment Tool (MOPAT) when used over time by critical care nurses to assess acute pain in non-communicative critically ill patients. METHODS Twenty-seven patients had pain assessed at two time points (T1 and T2) surrounding a painful event for up to 3 days. Twenty-one ICU nurses participated in pain assessments and completed the Clinical Utility Questionnaire. RESULTS Internal consistency reliability coefficient alphas for the MOPAT were .68 at T1 and .72 at T2. Inter-rater agreement during painful procedures or turning was 68% for the behavioral dimension and 80% for the physiologic dimension. Validity was evidenced by decreases (p < .001) in the MOPAT total and behavioral and physiologic dimension scores when comparing T1 and T2. Nurses found the tool clinically useful. CONCLUSION The MOPAT can be used in the critical care setting as a helpful tool to assess pain in non-communicative patients. The MOPAT is unique in that the instrument can be used over time and across settings.
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Affiliation(s)
- Debra L Wiegand
- University of Maryland School of Nursing, Baltimore, Maryland.
| | - Tracey Wilson
- Medical Intensive Care Unit, University of Maryland Medical Center, Baltimore, Maryland
| | - Diane Pannullo
- Surgical Intensive Care Unit, University of Maryland Medical Center, Baltimore, Maryland
| | - Marguerite M Russo
- Palliative Care, University of Maryland Medical Center, Baltimore, Maryland; University of Maryland Baltimore Graduate School, Baltimore, Maryland
| | | | - Karen Soeken
- University of Maryland School of Nursing, Baltimore, Maryland
| | - Deborah B McGuire
- Virginia Commonwealth University School of Nursing, Richmond, Virginia
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Mohamed WRA, Leach MJ, Reda NA, Abd-Ellatif MM, Mohammed MA, Abd-Elaziz MA. The effectiveness of clinical pathway-directed care on hospitalisation-related outcomes in patients with severe traumatic brain injury: A quasi-experimental study. J Clin Nurs 2018; 27:e820-e832. [PMID: 29193516 DOI: 10.1111/jocn.14194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To compare the effectiveness of clinical pathway-directed care to usual care on hospitalisation-related outcomes in patients with severe traumatic brain injury (STBI). BACKGROUND Severe traumatic brain injury is a major cause of disability and mortality in young adults. Clinical pathways endeavour to bring evidence and clinical practice closer together to foster the delivery of best practice and to improve patient outcomes. DESIGN Quasi-experimental study. METHODS The study was conducted in a trauma intensive care unit of a large teaching hospital in Egypt. Patients aged 18-60 years with a diagnosis of STBI, a Glasgow Coma Scale score between 3-8 and a nonpenetrating head injury were consecutively assigned to 15 days of care. The outcomes assessed were complications related to hospitalisation, clinical variances, length of intensive care unit (ICU) stay, ICU readmission rate and patient/family satisfaction. RESULTS Sixty participants completed the study (30 in each arm). Apart from age, there were no significant differences between groups in baseline characteristics. The clinical pathway group demonstrated statistically significantly fewer cases of hospitalisation-related complications on day 15, and a significantly shorter length of ICU stay, lower ICU readmission rate and a high level of patient/family satisfaction when compared with the usual care group. The effect of the intervention on fever, pressure ulceration, hyperglycaemia and readmission to the ICU was no longer statistically significant after controlling for age. CONCLUSIONS The findings of the current study suggest that the implementation of a clinical pathway for patients with severe TBI may be helpful in improving the patient experience as well as some hospitalisation-related outcomes. RELEVANCE TO CLINICAL PRACTICE The provision of clinical pathway-directed care in a trauma ICU may offer benefits to the patient, family and institution beyond that provided by usual care.
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Affiliation(s)
| | - Matthew J Leach
- Department of Rural Health, University of South Australia, Adelaide, SA, Australia
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The Influence of Context on Utilizing Research Evidence for Pain Management in Jordanian Pediatric Intensive Care Units (PICU). J Pediatr Nurs 2018; 38:e39-e46. [PMID: 29103732 DOI: 10.1016/j.pedn.2017.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 10/20/2017] [Accepted: 10/20/2017] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to gain a beginning understanding of the contextual factors that influence the use of research for pain management in Jordanian Pediatric Intensive Care Units (PICUs). DESIGN AND METHODS A paper or online questionnaire was used to collect data on instrumental research use (IRU) and conceptual research use (CRU) and ten contextual variables from 73 registered nurses working in four Jordanian PICUs. The Pearson product-moment correlation coefficient was used to test the relationship between continuous (demographic and contextual) factors and IRU and CRU. One way ANOVA and independent t-test were used to examine the differences between sociodemographic variables and IRU and CRU. Generalized Estimating Equations (GEE) was used to determine the demographic and contextual factors that influenced research use. We modeled the significant variables identified by bivariate correlation, t-test, and ANOVA at (p≤0.10). RESULTS Nine of the contextual factors significantly and positively correlated with the IRU for pain assessment, eight with the IRU for pain treatment, and six with the CRU for pain management (including assessment and treatment). Hospital type (public) predicted the IRU for pain assessment. Social capital, structural, and electronic resources predicted the IRU for pain treatment. Social capital predicted the CRU for pain management. CONCLUSION Context influences Jordanian PICU nurses' use of research for pain management. PRACTICE IMPLICATIONS Concentrating on modifiable contextual factors may positively influence Jordanian PICU nurses' use of research for pain management. This influence may extend to reduce children's pain in Jordanian PICUs.
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Khan SH, Wang S, Harrawood A, Martinez S, Heiderscheit A, Chlan L, Perkins AJ, Tu W, Boustani M, Khan B. Decreasing Delirium through Music (DDM) in critically ill, mechanically ventilated patients in the intensive care unit: study protocol for a pilot randomized controlled trial. Trials 2017; 18:574. [PMID: 29187230 PMCID: PMC5708104 DOI: 10.1186/s13063-017-2324-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/14/2017] [Indexed: 11/13/2022] Open
Abstract
Background Delirium is a highly prevalent and morbid syndrome in intensive care units (ICUs). Changing the stressful environment within the ICU via music may be an effective and a scalable way to reduce the burden of delirium. Methods/design The Decreasing Delirium through Music (DDM) study is a three-arm, single-blind, randomized controlled feasibility trial. Sixty patients admitted to the ICU with respiratory failure requiring mechanical ventilation will be randomized to one of three arms (20 participants per arm): (1) personalized music, (2) non-personalized relaxing music, or (3) attention-control. Music preferences will be obtained from all enrolled participants or their family caregivers. Participants will receive two 1-h audio sessions a day through noise-cancelling headphones and mp3 players. Our primary aim is to determine the feasibility of the trial design (recruitment, adherence, participant retention, design and delivery of the music intervention). Our secondary aim is to estimate the potential effect size of patient-preferred music listening in reducing delirium, as measured by the Confusion Assessment Method for the ICU (CAM-ICU). Participants will receive twice daily assessments for level of sedation and presence of delirium. Enrolled participants will be followed in the hospital until death, discharge, or up to 28 days, and seen in the Critical Care Recovery Clinic at 90 days. Discussion DDM is a feasibility trial to provide personalized and non-personalized music interventions for critically ill, mechanically ventilated patients. Our trial will also estimate the preliminary efficacy of music interventions on reducing delirium incidence and severity. Trial registration ClinicalTrials.gov, Identifier: NCT03095443. Registered on 23 March 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2324-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. .,IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN, USA.
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA.,Indiana University Center of Health Innovation and Implementation Science, Indianapolis, IN, USA
| | - Amanda Harrawood
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN, USA
| | - Stephanie Martinez
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN, USA
| | | | - Linda Chlan
- Department of Nursing, Nursing Research Division, Mayo Clinic, Rochester, MN, USA
| | - Anthony J Perkins
- Indiana University Center of Health Innovation and Implementation Science, Indianapolis, IN, USA.,Indiana Clinical and Translational Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Wanzhu Tu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Malaz Boustani
- Indiana University Center of Health Innovation and Implementation Science, Indianapolis, IN, USA.,IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN, USA.,Indiana Clinical and Translational Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN, USA.,Division of Geriatrics and General Internal Medicine, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Babar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN, USA
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Ismail A, Forgeron P, Polomeno V, Gharaibeh H, Harrison D. Pain Management Practice and Guidelines in Jordanian Pediatric Intensive Care Units. Pain Manag Nurs 2017; 19:195-203.e4. [PMID: 29153297 DOI: 10.1016/j.pmn.2017.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 06/13/2017] [Accepted: 07/21/2017] [Indexed: 11/18/2022]
Abstract
Limited knowledge exists of current pain management practices and supporting guidelines in Jordanian pediatric intensive care units. To determine the current pain management practices and the availability and content of practice guidelines in Jordanian pediatric intensive care units, we conducted a cross-sectional and multisite survey of four pediatric intensive care units in Jordan. A questionnaire was developed and orally administered over the phone or in person to head nurses or their nominees to capture pain management practices and the existence and content of guidelines. All units had written pain management guidelines that included pain assessment, documentation, and management. All four units used one or more pain assessment tools. In three units, pain management was considered multidisciplinary and routinely discussed on unit rounds. In two units, continuous infusion of intravenous opioids was used as well as sedatives and neuromuscular blockers for most ventilated patients. In the two other units, continuous intravenous infusion of opioids was not used and only sedatives were administered for patients on mechanical ventilation. In two units, there were no specific guidelines on the use of nonopioid analgesics, patient-controlled anesthesia, or the management of postoperative pain. No unit used an opioid or sedative withdrawal assessment tool or had pain management guidelines on the use of topical anesthetic agents or sucrose. Pain management practices and guidelines varied across the four units, suggesting that there is an opportunity for improvement in pain management in pediatric intensive care units in Jordan.
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Affiliation(s)
- Ahmad Ismail
- From the School of Nursing, University of Ottawa, Ottawa, Ontario, Canada.
| | - Paula Forgeron
- From the School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Viola Polomeno
- From the School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Huda Gharaibeh
- Jordan University of Science and Technology, Irbid, Jordan
| | - Denise Harrison
- From the School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
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Kemp HI, Bantel C, Gordon F, Brett SJ, Laycock HC. Pain Assessment in INTensive care (PAINT): an observational study of physician-documented pain assessment in 45 intensive care units in the United Kingdom. Anaesthesia 2017; 72:737-748. [PMID: 28832908 PMCID: PMC5434893 DOI: 10.1111/anae.13786] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2016] [Indexed: 11/29/2022]
Abstract
Pain is a common and distressing symptom experienced by intensive care patients. Assessing pain in this environment is challenging, and published guidelines have been inconsistently implemented. The Pain Assessment in INTensive care (PAINT) study aimed to evaluate the frequency and type of physician pain assessments with respect to published guidelines. This observational service evaluation considered all pain and analgesia-related entries in patients' records over a 24-h period, in 45 adult intensive care units (ICUs) in London and the South-East of England. Data were collected from 750 patients, reflecting the practice of 362 physicians. Nearly two-thirds of patients (n = 475, 64.5%, 95%CI 60.9-67.8%) received no physician-documented pain assessment during the 24-h study period. Just under one-third (n = 215, 28.6%, 95%CI 25.5-32.0%) received no nursing-documented pain assessment, and over one-fifth (n = 159, 21.2%, 95%CI 19.2-23.4)% received neither a doctor nor a nursing pain assessment. Two of the 45 ICUs used validated behavioural pain assessment tools. The likelihood of receiving a physician pain assessment was affected by the following factors: the number of nursing assessments performed; whether the patient was admitted as a surgical patient; the presence of tracheal tube or tracheostomy; and the length of stay in ICU. Physician-documented pain assessments in the majority of participating ICUs were infrequent and did not utilise recommended behavioural pain assessment tools. Further research to identify factors influencing physician pain assessment behaviour in ICU, such as human factors or cultural attitudes, is urgently needed.
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Affiliation(s)
| | - C. Bantel
- Imperial CollegeLondonUK
- Oldenburg UniversityOldenburgGermany
| | | | | | - PLAN
- Pan‐London Peri‐operative Audit and Research NetworkUK
| | - SEARCH
- South‐East Anaesthetic Research ChainUK
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Adherence to All Steps of a Pain Management Protocol in Intensive Care Patients after Cardiac Surgery Is Hard to Achieve. Pain Res Manag 2017; 2017:7187232. [PMID: 28298879 PMCID: PMC5337384 DOI: 10.1155/2017/7187232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/23/2017] [Indexed: 11/17/2022]
Abstract
Purpose. To investigate adherence to our pain protocol considering analgesics administration, number and timing of pain assessments, and adjustment of analgesics upon unacceptably high (NRS ≥ 4) and low (NRS ≤ 1) pain scores. Material and Methods. The pain protocol for patients in the intensive care unit (ICU) after cardiac surgery consisted of automated prescriptions for paracetamol and morphine, automated reminders for pain assessments, a flowchart to guide interventions upon high and low pain scores, and reassessments after unacceptable pain. Results. Paracetamol and morphine were prescribed in all 124 patients. Morphine infusion was stopped earlier than protocolized in 40 patients (32%). During the median stay of 47 hours [IQR 26 to 74 hours], 702/706 (99%) scheduled pain assessments and 218 extra pain scores were recorded. Unacceptably high pain scores accounted for 96/920 (10%) and low pain scores for 546/920 (59%) of all assessments. Upon unacceptable pain additional morphine was administered in 65% (62/96) and reassessment took place in 15% (14/96). Morphine was not tapered in 273 of 303 (90%) eligible cases of low pain scores. Conclusions. Adherence to automated prescribed analgesics and pain assessments was good. Adherence to nonscheduled, flowchart-guided interventions was poor. Improving adherence may refine pain management and reduce side effects.
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Gorawara-Bhat R, Wong A, Dale W, Hogan T. Nurses' perceptions of pain management for older-patients in the Emergency Department: A qualitative study. PATIENT EDUCATION AND COUNSELING 2017; 100:231-241. [PMID: 27591825 DOI: 10.1016/j.pec.2016.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES 1) Identify themes arising from nurses' perceptions of assessing older-patients' pain; 2) use themes to guide development of optimal interventions to improve quality of pain assessment in the emergency department (ED). METHODS Nurse interviews (n=20) were conducted until theme saturation. They were transcribed, coded, and analyzed using qualitative methodology. RESULTS Two major themes-nurse 'challenges' and 'strategies' to overcome challenges, and their subthemes - classified as 'patient-related' or 'system-related,' were salient in nurses' perceptions. Strategies nurses reported for managing challenges were based in their own professional lived experiences. DISCUSSION AND CONCLUSION A 2×2 framework was developed to conceptualize challenges, strategies, subthemes and their classifications, yielding 4 typologies comprising challenge types matched with appropriate strategy types. While emergent challenges and strategies are corroborated in the literature, the present study is the first to develop a scheme of typologies beneficial for guiding the development of optimal interventions to improve the quality of assessing pain in older-patients. PRACTICE IMPLICATIONS The typology framework can guide the development of pain assessment tools and the needed combinations for assessing multidimensional pain in older-patients. Using the present findings, a new clinical intervention was shown to significantly improve pain management for older-patients in the ED.
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Affiliation(s)
| | - Alexandra Wong
- Section of Geriatrics and Palliative Medicine, Chicago, IL, USA
| | - William Dale
- Section of Geriatrics and Palliative Medicine, Chicago, IL, USA
| | - Teresita Hogan
- Section of Geriatrics and Palliative Medicine, Chicago, IL, USA; Section of Emergency Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Zimmerman KO, Smith PB, Benjamin DK, Laughon M, Clark R, Traube C, Stürmer T, Hornik CP. Sedation, Analgesia, and Paralysis during Mechanical Ventilation of Premature Infants. J Pediatr 2017; 180:99-104.e1. [PMID: 27522446 PMCID: PMC5183489 DOI: 10.1016/j.jpeds.2016.07.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/31/2016] [Accepted: 07/01/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To characterize administration of sedatives, analgesics, and paralytics in a large cohort of mechanically ventilated premature infants. STUDY DESIGN Retrospective cohort study including all infants <1500 g birth weight and <32 weeks gestational age (GA) mechanically ventilated at 348 Pediatrix Medical Group neonatal intensive care units from 1997 to 2012. The primary outcome is the proportion of mechanically ventilated days in which infants were administered drugs of interest. Multivariable logistic regression was used to evaluate the predictors of administration of drugs of interest. RESULTS We identified 85 911 mechanically ventilated infants. Infants received a drug of interest (opioids, benzodiazepines, other sedatives, and paralytics) on 433 587/1 305 413 (33%) of mechanically ventilated infant days. The administration of opioids increased during the study period from 5% of infant days in 1997 to 32% in 2012. The administration of benzodiazepines increased during the study period from 5% of infant days in 1997 to 24% in 2012. Use of paralytics and other drugs remained ≤1% throughout the study period. Predictors of drug administration included younger GA, small for GA status, male sex, presence of a major congenital anomaly, older postnatal age at intubation, exposure to high-frequency ventilation, exposure to inotropes, more recent year of discharge, and neonatal intensive care unit site. CONCLUSIONS Administration of opioids and benzodiazepines in mechanically ventilated premature infants increased over time. Because infant characteristics were unchanged, site-specific differences in practice likely explain our observations. Increased administration over time is concerning given limited evidence of benefit and potential for harm.
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Affiliation(s)
- Kanecia O Zimmerman
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Matthew Laughon
- Department of Pediatrics, Division of Neonatology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Chani Traube
- Department of Pediatrics, Division of Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christoph P Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC.
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The Challenges of Providing Effective Pain Management for Children in the Pediatric Intensive Care Unit. Pain Manag Nurs 2016; 17:372-383. [DOI: 10.1016/j.pmn.2016.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 11/20/2022]
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Aktaş YY, Karabulut N. A Turkish Version of the Critical-Care Pain Observation Tool: Reliability and Validity Assessment. J Perianesth Nurs 2016; 32:341-351. [PMID: 28739066 DOI: 10.1016/j.jopan.2015.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 10/20/2022]
Abstract
PURPOSE The study aim was to evaluate the validity and reliability of the Critical-Care Pain Observation Tool in critically ill patients. DESIGN A repeated measures design was used for the study. METHODS A convenience sample of 66 patients who had undergone open-heart surgery in the cardiovascular surgery intensive care unit in Ordu, Turkey, was recruited for the study. The patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (suctioning), and 20 minutes after the procedure while they were conscious and intubated after surgery. FINDING The Turkish version of the Critical-Care Pain Observation Tool has shown statistically acceptable levels of validity and reliability. Inter-rater reliability was supported by moderate-to-high-weighted κ coefficients (weighted κ coefficient = 0.55 to 1.00). For concurrent validity, significant associations were found between the scores on the Critical-Care Pain Observation Tool and the Behavioral Pain Scale scores. Discriminant validity was also supported by higher scores during suctioning (a nociceptive procedure) versus non-nociceptive procedures. The internal consistency of the Critical-Care Pain Observation Tool was 0.72 during a nociceptive procedure and 0.71 during a non-nociceptive procedure. CONCLUSIONS The validity and reliability of the Turkish version of the Critical-Care Pain Observation Tool was determined to be acceptable for pain assessment in critical care, especially for patients who cannot communicate verbally.
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Severgnini P, Pelosi P, Contino E, Serafinelli E, Novario R, Chiaranda M. Accuracy of Critical Care Pain Observation Tool and Behavioral Pain Scale to assess pain in critically ill conscious and unconscious patients: prospective, observational study. J Intensive Care 2016; 4:68. [PMID: 27833752 PMCID: PMC5100216 DOI: 10.1186/s40560-016-0192-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 10/28/2016] [Indexed: 12/15/2022] Open
Abstract
Background Critically ill patients admitted to intensive care unit (ICU) may suffer from different painful stimuli, but the assessment of pain is difficult because most of them are almost sedated and unable to self-report. Thus, it is important to optimize evaluation of pain in these patients. The main aim of this study was to compare two commonly used scales for pain evaluation: Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS), in both conscious and unconscious patients. Secondary aims were (1) to identifying the most relevant parameters to determine pain scales changes during nursing procedures, (2) to compare both pain scales with visual analog scale (VAS), and (3) to identify the best combination of scales for evaluation of pain in patients unable to communicate. Methods In this observational study, 101 patients were evaluated for a total of 303 consecutive observations during 3 days after ICU admission. Measurements with both scales were obtained 1 min before, during, and 20 min after nursing procedures in both conscious (n.41) and unconscious (n.60) patients; furthermore, VAS was recorded when possible in conscious patients only. We calculated criterion and discriminant validity to both scales (Wilcoxon, Spearman rank correlation coefficients). The accuracy of individual scales was evaluated. The sensitivity and the specificity of CPOT and BPS scores were assessed. Kappa coefficients with the quadratic weight were used to reflect agreement between the two scales, and we calculated the effect size to identify the strength of a phenomenon. Results CPOT and BPS showed a good criterion and discriminant validity (p < 0.0001). BPS was found to be more specific (91.7 %) than CPOT (70.8 %), but less sensitive (BPS 62.7 %, CPOT 76.5 %). COPT and BPS scores were significantly correlated with VAS (p < 0.0001). The combination of BPS and CPOT resulted in better sensitivity 80.4 %. Facial expression was the main parameter to determine pain scales changes effect size = 1.4. Conclusions In critically ill mechanically ventilated patients, both CPOT and BPS can be used for assessment of pain intensity with different sensitivity and specificity. The combination of both BPS and CPOT might result in improved accuracy to detect pain compared to scales alone. Trial registration NCT01669486
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Affiliation(s)
- Paolo Severgnini
- Department of Biotechnologies and Sciences of Life, Intensive Care Unit-ASST Sette Laghi-Ospedale di Circolo Fondazione Macchi, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | | | - Elena Contino
- Department of Biotechnologies and Sciences of Life, Intensive Care Unit-ASST Sette Laghi-Ospedale di Circolo Fondazione Macchi, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Elisa Serafinelli
- Department of Biotechnologies and Sciences of Life, Intensive Care Unit-ASST Sette Laghi-Ospedale di Circolo Fondazione Macchi, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Raffaele Novario
- Department of Biotechnologies and Sciences of Life, Intensive Care Unit-ASST Sette Laghi-Ospedale di Circolo Fondazione Macchi, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Maurizio Chiaranda
- Department of Biotechnologies and Sciences of Life, Intensive Care Unit-ASST Sette Laghi-Ospedale di Circolo Fondazione Macchi, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
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Ehieli E, Yalamuri S, Brudney CS, Pyati S. Analgesia in the surgical intensive care unit. Postgrad Med J 2016; 93:38-45. [PMID: 27777355 DOI: 10.1136/postgradmedj-2016-134047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/10/2016] [Accepted: 08/27/2016] [Indexed: 01/30/2023]
Abstract
Critically ill patients are a heterogeneous group with diverse comorbidities and physiological derangements. The management of pain in the critically ill population is emerging as a standard of care in the intensive care unit (ICU). Pain control of critically ill patients in the ICU presents numerous challenges to intensivists. Inconsistencies in pain assessment, analgesic prescription and variation in monitoring sedation and analgesia result in suboptimal pain management. Inadequate pain control can have deleterious effects on several organ systems in critically ill patients. Therefore, it becomes incumbent on physicians and nurses caring for these patients to carefully evaluate their practice on pain management and adopt an optimal pain management strategy that includes a reduction in noxious stimuli, adequate analgesia and promoting education regarding sedation and analgesia to the ICU staff. Mechanistic approaches and multimodal analgesic techniques have been clearly demonstrated to be the most effective pain management strategy to improve outcomes. For example, recent evidence suggests that the use of short acting analgesics and analgesic adjuncts for sedation is superior to hypnotic based sedation in intubated patients. This review will address analgesia in the ICU, including opioid therapy, adjuncts, regional anaesthesia and non-pharmacological options that can provide a multimodal approach to treating pain.
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Affiliation(s)
- Eric Ehieli
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Suraj Yalamuri
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Charles S Brudney
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Ibrahim M, Jones LJ, Lai NM, Tan K. Dexmedetomidine for analgesia and sedation in newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev 2016; 2016:CD012361. [PMCID: PMC6457690 DOI: 10.1002/14651858.cd012361] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the overall effectiveness and safety of dexmedetomidine for sedation and analgesia in newborn infants receiving mechanical ventilation compared with other non‐opioids, opioids or placebo. We will perform subgroup analyses according to method of dexmedetomidine administration; dose of dexmedetomidine; age of initiation of dexmedetomidine; indication for mechanical ventilation; gestational age; and duration of treatment.
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Affiliation(s)
- Masitah Ibrahim
- Monash Medical CentreMonash Newborn246 Clayton RoadClayton, MelbourneAustralia3168
| | - Lisa J Jones
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologySydneyAustralia
| | - Nai Ming Lai
- Taylor's UniversitySchool of MedicineSubang JayaMalaysia
| | - Kenneth Tan
- Monash UniversityDepartment of Paediatrics246 Clayton RoadClaytonMelbourneAustraliaVIC 3168
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Seaman JB, Evans AC, Sciulli AM, Barnato AE, Sereika SM, Happ MB. Abstracting ICU Nursing Care Quality Data From the Electronic Health Record. West J Nurs Res 2016; 39:1271-1288. [PMID: 27605024 DOI: 10.1177/0193945916665814] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen's kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.
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Kiavar M, Azarfarin R, Totonchi Z, Tavakoli F, Alizadehasl A, Teymouri M. Comparison of Two Pain Assessment Tools, "Facial Expression" and "Critical Care Pain Observation Tool" in Intubated Patients After Cardiac Surgery. Anesth Pain Med 2016; 6:e33434. [PMID: 27110536 PMCID: PMC4834529 DOI: 10.5812/aapm.33434] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 10/09/2015] [Accepted: 10/17/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Critical-care patients are at higher risk of untreated pain, because they are often unable to communicate owing to altered mental status, tracheal intubation and sedation. OBJECTIVES This study compared two pain assessment tools on tracheal intubated critically ill patients in a cardiac post-anesthesia care unit, who were unable to communicate verbally. The studied tools were "critical-care pain observation tool (CPOT)" and "facial expression (FE)". PATIENTS AND METHODS This was a prospective study based on diagnostic test evaluation. A sample of 91 intubated patients was selected from cardiac post-anesthesia care unit. Collected data were demographic characteristics, vital signs, FE and CPOT tools' scale. Pain was assessed with CPOT and FE scores five times. The first assessment was performed in at least 3 hours after admission of patients to ICU. Then, the pain intensity was reassessed every 30 minutes. In addition, blood pressure, heart rate, respiratory rate and oxygen saturation were measured simultaneously. RESULTS At the first period, the frequency of "severe" pain intensity using the CPOT was 58.2% and with the FE tool was 67% (P = 0.001). Both tools demonstrated reduction in severity of pain on second and third assessment times. Significantly increasing level of pain and blood pressure due to nursing painful procedures (endo-tracheal suctioning, changing patient's position, etc.), were obtained by CPOT in fourth assessment. FE was not able to detect such important findings (κ = 0.249). In the fifth step, pain intensity was reduced. The most agreement between the two tools was observed when the reported pain was "severe" (κ = 0.787, P < 0.001) and "mild" (κ = 0.851, P < 0.001). CONCLUSIONS The sensitivity of CPOT was higher for detection and evaluation of pain in intubated postoperative patients compared with "Facial Expression". Best agreement between these tools was observed in two extremes of pain intensity.
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Affiliation(s)
- Majid Kiavar
- Cardiology Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Azarfarin
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ziae Totonchi
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Tavakoli
- Cardiac Anesthesia Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azin Alizadehasl
- Cardiology Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mitra Teymouri
- Cardiology Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Kizza IB, Muliira JK, Kohi TW, Nabirye RC. Nurses’ knowledge of the principles of acute pain assessment in critically ill adult patients who are able to self-report. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2016. [DOI: 10.1016/j.ijans.2016.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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The Impact of Pain Assessment on Critically Ill Patients' Outcomes: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2015; 2015:503830. [PMID: 26558273 PMCID: PMC4628961 DOI: 10.1155/2015/503830] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/04/2015] [Indexed: 01/31/2023]
Abstract
In critically ill patients, pain is a major problem. Efficient pain management depends on a systematic, comprehensive assessment of pain. We aimed to review and synthesize current evidence on the impact of a systematic approach to pain assessment on critically ill patients' outcomes. A systematic review of published studies (CINAHL, PUBMED, SCOPUS, EMBASE, and COCHRANE databases) with predetermined eligibility criteria was undertaken. Methodological quality was assessed by the EPHPP quality assessment tool. A total of 10 eligible studies were identified. Due to big heterogeneity, quantitative synthesis was not feasible. Most studies indicated the frequency, duration of pain assessment, and types of pain assessment tools. Methodological quality assessment yielded “strong” ratings for 5/10 and “weak” ratings for 3/10 studies. Implementation of systematic approaches to pain assessment appears to associate with more frequent documented reports of pain and more efficient decisions for pain management. There was evidence of favorable effects on pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, and complications. This systematic review demonstrates a link between systematic pain assessment and outcome in critical illness. However, the current level of evidence is insufficient to draw firm conclusions. More high quality randomized clinical studies are needed.
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Latorre-Marco I, Solís-Muñoz M, Acevedo-Nuevo M, Hernández-Sánchez ML, López-López C, Sánchez-Sánchez MDM, Wojtysiak-Wojcicka M, De las Pozas-Abril J. Validation of the Behavioural Indicators of Pain Scale ESCID for pain assessment in non-communicative and mechanically ventilated critically ill patients: a research protocol. J Adv Nurs 2015; 72:205-16. [PMID: 26358885 DOI: 10.1111/jan.12808] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/29/2022]
Abstract
AIM To investigate the validity and reliability of the Behavioural Indicators of Pain Scale (ESCID) in medically and surgically non-communicative and mechanically ventilated critical patients. BACKGROUND Scales based on behavioural indicators of pain are suggested to measure pain in non-communicative critically ill patients. Scales proposed thus far have a range not comparable to those used with patients who can report their pain. A scale with a 0-10 range and more behavioural indicators is proposed to improve the detection and measurement of pain. DESIGN A multicentre prospective observational design to validate a scale-measuring instrument. METHODS Three hundred non-communicative and mechanically ventilated critical patients from 20 different intensive care units will be observed for 5 minutes before, during and 15 minutes after three procedures: turning, tracheal suctioning and soft friction with gauze on healthy tissue. Two independent observers will assess the pain of subjects with the Behavioural Pain Scale and the ESCID scale simultaneously. Descriptive and inferential statistics will be used. Student's t-test will be used to compare components of the twos scales. Inter-rater and intrarater agreement will be investigated. The reliability scale will be measured using Cronbach's alpha. Approval date for this protocol was January 2012. DISCUSSION A greater number of behavioural indicators in the ESCID scale than in previously validated scales, with a 0-10 score range, can improve the detection and measurement of pain in non-communicative and mechanically ventilated critical patients. Funding granted in 2011 by the Spanish Health Research Fund (PI 11/00766, Health Ministry). TRIAL REGISTRATION Study registered with www.clinicaltrials.gov (NCT01744717).
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Affiliation(s)
- Ignacio Latorre-Marco
- Intensive Care Unit, Puerta de Hierro Majadahonda University Hospital (HUPHM), Madrid, Spain
| | | | | | | | - Candelas López-López
- Emergency and Trauma Intensive Care Unit, 12 de Octubre University Hospital (HU12O), Madrid, Spain
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van der Hoeven SM, Binnekade JM, de Borgie CAJM, Bosch FH, Endeman H, Horn J, Juffermans NP, van der Meer NJM, Merkus MP, Moeniralam HS, van Silfhout B, Slabbekoorn M, Stilma W, Wijnhoven JW, Schultz MJ, Paulus F. Preventive nebulization of mucolytic agents and bronchodilating drugs in invasively ventilated intensive care unit patients (NEBULAE): study protocol for a randomized controlled trial. Trials 2015; 16:389. [PMID: 26329352 PMCID: PMC4557315 DOI: 10.1186/s13063-015-0865-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/14/2015] [Indexed: 01/09/2023] Open
Abstract
Background Preventive nebulization of mucolytic agents and bronchodilating drugs is a strategy aimed at the prevention of sputum plugging, and therefore atelectasis and pneumonia, in intubated and ventilated intensive care unit (ICU) patients. The present trial aims to compare a strategy using the preventive nebulization of acetylcysteine and salbutamol with nebulization on indication in intubated and ventilated ICU patients. Methods/Design The preventive nebulization of mucolytic agents and bronchodilating drugs in invasively ventilated intensive care unit patients (NEBULAE) trial is a national multicenter open-label, two-armed, randomized controlled non-inferiority trial in the Netherlands. Nine hundred and fifty intubated and ventilated ICU patients with an anticipated duration of invasive ventilation of more than 24 hours will be randomly assigned to receive either a strategy consisting of preventive nebulization of acetylcysteine and salbutamol or a strategy consisting of nebulization of acetylcysteine and/or salbutamol on indication. The primary endpoint is the number of ventilator-free days and surviving on day 28. Secondary endpoints include ICU and hospital length of stay, ICU and hospital mortality, the occurrence of predefined pulmonary complications (acute respiratory distress syndrome, pneumonia, large atelectasis and pneumothorax), and the occurrence of predefined side effects of the intervention. Related healthcare costs will be estimated in a cost-benefit and budget-impact analysis. Discussion The NEBULAE trial is the first randomized controlled trial powered to investigate whether preventive nebulization of acetylcysteine and salbutamol shortens the duration of ventilation in critically ill patients. Trial registration NCT02159196, registered on 6 June 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0865-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophia M van der Hoeven
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Jan M Binnekade
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | | | - Frank H Bosch
- Department of Intensive Care, Rijnstate, Arnhem, The Netherlands.
| | - Henrik Endeman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L E I C A), Amsterdam, The Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L E I C A), Amsterdam, The Netherlands.
| | - Nardo J M van der Meer
- Department of Intensive Care, Amphia Hospital, Breda, Oosterhout and Etten-Leur, The Netherlands. .,Tias/Tilburg University, Tilburg, The Netherlands.
| | | | - Hazra S Moeniralam
- Department of Intensive Care, Antonius Hospital, Nieuwegein, The Netherlands.
| | - Bart van Silfhout
- Department of Intensive Care, Antonius Hospital, Nieuwegein, The Netherlands.
| | - Mathilde Slabbekoorn
- Department of Intensive Care, Medical Center Haaglanden and Leidschendam, The Hague, The Netherlands.
| | - Willemke Stilma
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Jan Willem Wijnhoven
- Department of Intensive Care, Amphia Hospital, Breda, Oosterhout and Etten-Leur, The Netherlands.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L E I C A), Amsterdam, The Netherlands.
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Liu Y, Li L, Herr K. Evaluation of Two Observational Pain Assessment Tools in Chinese Critically Ill Patients. PAIN MEDICINE 2015; 16:1622-8. [DOI: 10.1111/pme.12742] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Saadatmand V, Rejeh N, Heravi-Karimooi M, Tadrisi SD, Vaismoradi M, Jordan S. Effects of Natural Sounds on Pain: A Randomized Controlled Trial with Patients Receiving Mechanical Ventilation Support. Pain Manag Nurs 2015; 16:483-92. [PMID: 26092195 DOI: 10.1016/j.pmn.2014.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 09/06/2014] [Accepted: 09/08/2014] [Indexed: 11/17/2022]
Abstract
Nonpharmacologic pain management in patients receiving mechanical ventilation support in critical care units is under investigated. Natural sounds may help reduce the potentially harmful effects of anxiety and pain in hospitalized patients. The aim of this study was to examine the effect of pleasant, natural sounds on self-reported pain in patients receiving mechanical ventilation support, using a pragmatic parallel-arm, randomized controlled trial. The study was conducted in a general adult intensive care unit of a high-turnover teaching hospital, in Tehran, Iran. Between October 2011 and June 2012, we recruited 60 patients receiving mechanical ventilation support to the intervention (n = 30) and control arms (n = 30) of a pragmatic parallel-group, randomized controlled trial. Participants in both arms wore headphones for 90 minutes. Those in the intervention arm heard pleasant, natural sounds, whereas those in the control arm heard nothing. Outcome measures included the self-reported visual analog scale for pain at baseline; 30, 60, and 90 minutes into the intervention; and 30 minutes post-intervention. All patients approached agreed to participate. The trial arms were similar at baseline. Pain scores in the intervention arm fell and were significantly lower than in the control arm at each time point (p < .05). Administration of pleasant, natural sounds via headphones is a simple, safe, nonpharmacologic nursing intervention that may be used to allay pain for up to 120 minutes in patients receiving mechanical ventilation support.
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Affiliation(s)
- Vahid Saadatmand
- Department of Critical Care Unit, School of Nursing & Midwifery, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Nahid Rejeh
- Elderly Care Research Center, Shahed University, College of Nursing & Midwifery, Tehran, Iran.
| | - Majideh Heravi-Karimooi
- Elderly Care Research Center, Shahed University, College of Nursing & Midwifery, Tehran, Iran
| | | | | | - Sue Jordan
- College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, United Kingdom
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Bae KH, Jeong IS. [Pain perception of nurses and pain expression of patients in critical care units]. J Korean Acad Nurs 2015; 44:437-45. [PMID: 25231809 DOI: 10.4040/jkan.2014.44.4.437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE This study was done to identify pain perception (P-PER) by nurses and pain expression (P-EXP) by patients in critical care units (ICUs) and degree of agreement between nurses' P-PER and patients' P-EXP. METHODS Nurses' P-PER was measured with a self-administered questionnaire completed by 99 nurses working in ICUs during May, 2013. Patients' P-EXP was measured with the Critical Care Non-Verbal Pain Scale through observations of 31 ICU patients during nine nursing procedures (NPs) performed between May and July, 2013. RESULTS Nurses' P-PER was from 4.49 points for nasogastric tube (NGT) insertion to 0.83 for blood pressure (BP) measurement based on a 9-point scale, Patients' P-EXP was 4.48 points for NGT to 0.18 for BP measurement based on a 10-point scale. Eight NPs except oral care showed higher scores for nurses' P-PER than for patients' P-EXP. Position change (p=.019), subcutaneous injection (p<.001), blood sugar test (p<.001), and BP measurement (p<.001) showed significant differences between nurses' P-PER and patients' P-EXP. CONCLUSION Nasogastric tube (NGT) insertion was scored highest by both nurses and patients. Eight NPs except 'oral care' showed nurses' P-PER was higher or similar to patients' P-EXP, which indicates that nurses may overestimate procedural pain experienced by patients.
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Affiliation(s)
- Kyung Hee Bae
- Department of Nursing, Pusan National University Hospital, Busan, Korea
| | - Ihn Sook Jeong
- College of Nursing, Pusan National University, Yangsan, Korea.
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