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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Kawji Y, Almoaswes H, Bise C, Kawji L, Murphy A, Reed TD, Klapper RJ, Ahmadzadeh S, Shekoohi S, Cornett EM, Kaye AD. Electronic Health Record Recording of Patient Pain: Challenges and Discrepancies. Curr Pain Headache Rep 2023; 27:737-745. [PMID: 37740879 DOI: 10.1007/s11916-023-01170-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE OF REVIEW In the present review, various categories of pain, clinician-observed pain scales, and patient-reported pain scales are evaluated to better understand factors that impact patient pain perceptions. Additionally, the expansion of areas that require further research to determine the optimal way to evaluate pain scale data for treatment and management are discussed. RECENT FINDINGS Electronic health record (EHR) data provides a starting point for evaluating whether patient predictors influence postoperative pain. There are several ways to assess pain and choosing the most effective form of pain treatment. Identifying individuals at high risk for severe postoperative pain enables more effective pain treatment. However, there are discrepancies in patient pain reporting dependent on instruments used to measure pain and their storage in the EHR. Additionally, whether administered by a physician or another healthcare practitioner, differences in patient pain perception occur. While each scale has distinct advantages and limitations, pain scale data is a valuable therapeutic tool for assisting clinicians in providing patients with optimal pain control. Accurate assessment of patient pain perceptions by data extraction from electronic health records provides a potential for pain alleviation improvement. Predicting high-risk postoperative pain syndromes is a difficult clinical challenge. Numerous studies have been conducted on factors that impact pain prediction. Postoperative pain is significantly predicted by the kind of operation, the existence of prior discomfort, patient anxiety, and age.
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Affiliation(s)
- Yasmeen Kawji
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, 433 Bolivar Street, New Orleans, LA, 70112, USA
| | - Hanna Almoaswes
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, 433 Bolivar Street, New Orleans, LA, 70112, USA
| | - Claire Bise
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, 433 Bolivar Street, New Orleans, LA, 70112, USA
| | - Lena Kawji
- Department of Internal Medicine, School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Adrienne Murphy
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, 433 Bolivar Street, New Orleans, LA, 70112, USA
| | - Tanner D Reed
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, 433 Bolivar Street, New Orleans, LA, 70112, USA
| | - Rachel J Klapper
- Department of Radiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
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Mimoglu E, Joyce K, Mohamed B, Sathiyamurthy S, Banerjee J. Variability of neonatal premedication practices for endotracheal intubation and LISA in the UK (NeoPRINT survey). Early Hum Dev 2023; 183:105808. [PMID: 37343322 DOI: 10.1016/j.earlhumdev.2023.105808] [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] [Received: 04/18/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE The NeoPRINT Survey was designed to assess premedication practices throughout UK NHS Trusts for both neonatal endotracheal intubation and less invasive surfactant administration (LISA). DESIGN An online survey consisting of multiple choice and open answer questions covering preferences of premedication for endotracheal intubation and LISA was distributed over a 67-day period. Responses were then analysed using STATA IC 16.0. SETTING Online survey distributed to all UK Neonatal Units (NNUs). PARTICIPANTS The survey evaluated premedication practices for endotracheal intubation and LISA in neonates requiring these procedures. MAIN OUTCOME MEASURES The use of different premedication categories as well as individual medications within each category was analysed to create a picture of typical clinical practice across the UK. RESULTS The response rate for the survey was 40.8 % (78/191). Premedication was used in all hospitals for endotracheal intubation but overall, 50 % (39/78) of the units that have responded, use premedications for LISA. Individual clinician preference had an impact on premedication practices within each NNU. CONCLUSION The wide variability on first-line premedication for endotracheal intubation noted in this survey could be overcome using best available evidence through consensus guidance driven by organisations such as British Association of Perinatal |Medicine (BAPM). Secondly, the divisive view around LISA premedication practices noted in this survey requires an answer through a randomised controlled trial.
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Affiliation(s)
- Ecem Mimoglu
- School of Medicine, Imperial College London, London, UK
| | - Katie Joyce
- School of Medicine, Imperial College London, London, UK
| | - Basma Mohamed
- St George's University Hospitals NHS Foundation Trust, London, UK; Department of Neonatology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Jay Banerjee
- Department of Neonatology, Imperial College Healthcare NHS Trust, London, UK; Institute of Reproductive and Developmental Biology, Imperial College London, Biomedical Research Centre, Imperial College Healthcare NHS Trust, London, UK; Centre for Paediatrics and Child Health, Imperial College London, London, UK.
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Arabiat D, Mörelius E, Hoti K, Hughes J. Pain assessment tools for use in infants: a meta-review. BMC Pediatr 2023; 23:307. [PMID: 37337167 DOI: 10.1186/s12887-023-04099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 05/28/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Identifying pain in infants is challenging due to their inability to self-report pain, therefore the availability of valid and reliable means of assessing pain is critical. OBJECTIVE This meta-review sought to identify evidence that could guide the selection of appropriate tools in this vulnerable population. METHODS We searched Scopus, Medline, Embase, CINAHL, MIDRIS, EMCare and Google Scholar for eligible systematic reviews. Eligible reviews documented psychometric properties of available observational tools used to assess pain in infants. RESULTS A total of 516 reviews were identified of which 11 met our inclusion criteria. We identified 36 pain assessment tools (evaluated in 11 reviews) of which seven were reported in at least three reviews. The level of evidence reported on the psychometric properties of pain assessment tools varied widely ranging from low to good reliability and validity, whilst there are limited data on usability and clinical utility. CONCLUSIONS Currently, no observer administered pain assessment tool can be recommended as the gold standard due to limited availability and quality of the evidence that supports their validity, reliability and clinical utility. This meta-review attempts to collate the available evidence to assist clinicians to decide on what is the most appropriate tool to use in their clinical practice setting. It is important that researchers adopt a standard approach to evaluating the psychometric properties of pain assessment tools and evaluations of the clinical utility in order that the highest level of evidence can be used to guide tool selection.
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Affiliation(s)
- Diana Arabiat
- Maternal and Child Nursing Department, Faculty of Nursing, The University of Jordan, Amman, Jordan.
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia.
| | - Evalotte Mörelius
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kreshnik Hoti
- Faculty of Medicine, University of Prishtina, Pristina, Kosovo
| | - Jeffery Hughes
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
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[Evidence-based guideline for neonatal pain management in China (2023)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:109-127. [PMID: 36854686 PMCID: PMC9979385 DOI: 10.7499/j.issn.1008-8830.2210052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/06/2022] [Indexed: 03/02/2023]
Abstract
Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.
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Menegol NA, Ribeiro SNS, de Paula AC, Montemezzo D, Sanada LS. A Cross-Cultural Adaptation and Content Validity of COMFORTneo Scale into Brazilian Portuguese. J Pain Symptom Manage 2022; 64:e323-e330. [PMID: 35985550 DOI: 10.1016/j.jpainsymman.2022.08.006] [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] [Received: 06/03/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT The instrument used to assess neonatal pain must be adequate regarding the type of pain, population, country, and language to provide the best evidence-based clinical strategies; however, few neonatal pain instruments have been translated and validated for the Brazilian population. OBJECTIVE The aim was to perform a cross-cultural adaptation of the COMFORTneo scale into Brazilian Portuguese and to evaluate the content validity of the adapted scale. METHODS The cross-cultural adaptation process followed six main steps: translation, synthesis of the translations, back-translation, submission to the expert committee, final version pretest, being that 65 individuals participated in this stage, including both healthcare professionals and students, and submission to the committee for process appraisal. Additionally, an equivalence form composed of a four-point Likert scale was sent to each committee participant to calculate the content validity index (CVI). The CVI was obtained as the sum of the items ranked as three or four by the experts divided by the total number of experts. RESULTS No difficulties were reported in the production of translated versions. The CVI for the final version of the translated instrument was 0.99. The final version was reviewed to correct any possible grammatical errors. The layout was modified as necessary, and instructions on scale scoring were added to facilitate the application, resulting in the COMFORTneo Brazil scale. CONCLUSION The COMFORTneo scale was properly and cross-culturally adapted into Brazilian Portuguese, reaching semantic, idiomatic, experimental, and conceptual equivalence with the original instrument, and a good CVI.
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Affiliation(s)
- Natália Alves Menegol
- Department of Physical Therapy (N.A.M., D.M., L.S.S.), Universidade do Estado de Santa Catarina, Florianópolis, SC, Brazil
| | - Simone Nascimento Santos Ribeiro
- Faculdade Ciências Médicas de Minas Gerais (S.N.S.R.), Instituto de Previdência dos Servidores do Estado de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Dayane Montemezzo
- Department of Physical Therapy (N.A.M., D.M., L.S.S.), Universidade do Estado de Santa Catarina, Florianópolis, SC, Brazil
| | - Luciana Sayuri Sanada
- Department of Physical Therapy (N.A.M., D.M., L.S.S.), Universidade do Estado de Santa Catarina, Florianópolis, SC, Brazil.
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McBride CA, Rahiman S, Schlapbach LJ, Schults JA, Kleidon TM, Kennedy M, Paterson RS, Byrnes J, Ware RS, Ullman AJ. Comparing ivWatch biosensor to standard care to identify extravasation injuries in the paediatric intensive care: a protocol for a randomised controlled trial. BMJ Open 2022; 12:e047765. [PMID: 35190407 PMCID: PMC8862432 DOI: 10.1136/bmjopen-2020-047765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Peripheral intravenous catheters (PIVCs) frequently fail during therapy administration, resulting in infusates pooling in the surrounding tissue. These extravasation injuries can cause significant pain, tissue destruction and scarring. ivWatch is a biosensor that uses visible and near-infrared light to measure tissue changes surrounding the PIVC and alert clinicians when extravasation may occur. The effectiveness of ivWatch, in comparison to clinical observation, in decreasing injury severity is unknown. The present study aims to investigate whether using ivWatch may potentially detect injury earlier and decrease the severity of PIVC extravasation injuries. METHODS AND ANALYSIS A single centre, parallel group, open-label superiority randomised controlled trial comparing (a) standard care (clinical observation) to (b) ivWatch monitoring in addition to standard care, to decrease the severity of extravasation injuries. 200 children with PIVCs inserted in the distal half of the limb, receiving intermediate-risk to high-risk infusates for ≥24 hours, will be consecutively recruited at a paediatric intensive care unit in Queensland, Australia. The primary outcome is extravasation severity, measured by the Cincinnati Children's Extravasation Harm Scale. Secondary outcomes include severity assessed with three-dimensional camera imaging, extravasation volume, treatment sequelae, the number of PIVCs used and dwell time, quality of life and healthcare costs. The between treatment difference in extravasation severity will be compared using ordinal logistic regression, with the treatment group included as the main effect, and reported with corresponding 95% CIs. Estimates of value will be presented as net monetary benefits and cost per reduction in extravasation injury severity, both presented with corresponding 95% credible intervals. ETHICS AND DISSEMINATION This study received approval from the Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (reference number: HREC/20/QCHQ/60867) and the Griffith University HREC (reference number: 2020/310) and will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12620000317998.
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Affiliation(s)
- Craig Antony McBride
- Surgical Team: Infants, Toddlers, Children (STITCh), Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Nathan, Queensland, Australia
- Pegg Leditschke Children's Burns Centre, Children's Health Queensland, South Brisbane, Queensland, Australia
| | - Sarfaraz Rahiman
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Luregn J Schlapbach
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Neonatology, Children's Research Center, University Children's Hospital Zürich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Jessica A Schults
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Nathan, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
- Herston Infectious Disease Institute, Metro North Health, Herston, Queensland, Australia
| | - Tricia M Kleidon
- Surgical Team: Infants, Toddlers, Children (STITCh), Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Nathan, Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
| | - Melanie Kennedy
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Rebecca S Paterson
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
| | - Joshua Byrnes
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Nathan, Queensland, Australia
- Centre for Applied Health Economics, Menzies Health Institute, Griffith University, Southport, Queensland, Australia
| | - Robert S Ware
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Nathan, Queensland, Australia
- Centre for Applied Health Economics, Menzies Health Institute, Griffith University, Southport, Queensland, Australia
| | - Amanda Judith Ullman
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Nathan, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
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Tapia R, López-Herce J, Arias Á, del Castillo J, Mencía S. Validity and Reliability of the Richmond Agitation-Sedation Scale in Pediatric Intensive Care Patients: A Multicenter Study. Front Pediatr 2022; 9:795487. [PMID: 35047463 PMCID: PMC8762108 DOI: 10.3389/fped.2021.795487] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/29/2021] [Indexed: 12/14/2022] Open
Abstract
Background: There is limited data about the psychometric properties of the Richmond Agitation-Sedation Scale (RASS) in children. This study aims to analyze the validity and reliability of the RASS in assessing sedation and agitation in critically ill children. Methods: A multicenter prospective study in children admitted to pediatric intensive care, aged between 1 month and 18 years. Twenty-eight observers from 14 PICUs (pediatric intensive care units) participated. Every observation was assessed by 4 observers: 2 nurses and 2 pediatric intensivists. We analyzed RASS inter-rater reliability, construct validity by comparing RASS to the COMFORT behavior (COMFORT-B) scale and the numeric rating scale (NRS), and by its ability to distinguish between levels of sedation, and responsiveness to changes in sedative dose levels. Results: 139 episodes in 55 patients were analyzed, with a median age 3.6 years (interquartile range 0.7-7.8). Inter-rater reliability was excellent, weighted kappa (κw) 0.946 (95% CI, 0.93-0.96; p < 0.001). RASS correlation with COMFORT-B scale, rho = 0.935 (p < 0.001) and NRS, rho = 0.958 (p < 0.001) was excellent. The RASS scores were significantly different (p < 0.001) for the 3 sedation categories (over-sedation, optimum and under-sedation) of the COMFORT-B scale, with a good agreement between both scales, κw 0.827 (95% CI, 0.789-0.865; p < 0.001), κ 0.762 (95% CI, 0.713-0.811, p < 0.001). A significant change in RASS scores (p < 0.001) was recorded with the variance of sedative doses. Conclusions: The RASS showed good measurement properties in PICU, in terms of inter-rater reliability, construct validity, and responsiveness. These properties, including its ability to categorize the patients into deep sedation, moderate-light sedation, and agitation, makes the RASS a useful instrument for monitoring sedation in PICU.
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Affiliation(s)
- Rocío Tapia
- Pediatric Intensive Care Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (“IRYCIS”), Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Maternal and Child Health Department (“Red SAMID”), Universidad Complutense, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Ángel Arias
- Research Support Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | - Jimena del Castillo
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Santiago Mencía
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Maternal and Child Health Department (“Red SAMID”), Universidad Complutense, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
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Treiman-Kiveste A, Pölkki T, Kalda R, Kangasniemi M. Nurses' perceptions of infants' procedural pain assessment and alleviation with non-pharmacological methods in Estonia. J Pediatr Nurs 2022; 62:e156-e163. [PMID: 34561132 DOI: 10.1016/j.pedn.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/05/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to describe nurses perceptions of infants' procedural pain assessment and alleviation with non-pharmacological methods including parental guidance in departments of neonatal and infant medicine and Neonatal Intensive Care (NICUs). DESIGN AND METHODS A descriptive cross-sectional survey was carried out among all nurses (n= 149) who were working in neonatal and infant departments or NICUs in Estonian hospitals. Altogether, 128 questionnaires were returned and 111 respondents were eligible (75% response rate). The data were analysed using statistical methods. RESULTS More than half of the nurses agreed that systematic documentation of the measurement of pain is necessary for nursing care and that it affects pain alleviation in infants. Half of the respondents (51%) confirmed that pain scales are important in the measurement of infants' pain, but 58% claimed they were able to assess pain in a reliable way without using pain assessment scales. Nurses also reported that they were unfamiliar with most pain scales and they were not routinely used in everyday practice. Nurses said that the most useful non-pharmacological pain alleviation methods were touching (83%) and positioning infants (78%), the most rarely used were skin-to-skin care (12%) and encouraging mothers to breastfeed the infant (34%). The majority of respondents (79%) reported that they do not know or do not have written instructions on pain assessment in their workplace, and only a few (10%) reported that they have participated in pain management courses during the last year. CONCLUSIONS There is a need to increase the use of pain assessment scales and pain documentation in everyday practice in those hospitals in Estonia. The use of scales in pain assessment was valued by few nurses. It seems that there is a lack of knowledge on non-pharmacological methods, and nurses reported using only a few non-pharmacological pain alleviation methods and guided parents on using them. PRACTICE IMPLICATIONS Nurses need pain management guidelines for everyday work, and in addition to nurses, written guidelines for parents are needed.
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Affiliation(s)
- Airin Treiman-Kiveste
- Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Ravila 19, 50412 Tartu, Estonia; Tartu Health Care College, Estonia.
| | - Tarja Pölkki
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu University Hospital, Medical Research Center, Oulu, Finland
| | - Ruth Kalda
- Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Estonia
| | - Mari Kangasniemi
- Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Estonia; University of Turku, Faculty of Medicine, Department of Nursing Science, Finland
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Behavioral Observation of Infants With Life-Threatening or Life-Limiting Illness in the Neonatal Intensive Care Unit. Nurs Res 2021; 69:S29-S35. [PMID: 32555012 DOI: 10.1097/nnr.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Infants in the neonatal intensive care unit experience aversive stimuli that cause pain and distress. Maintaining adequate relief from pain and distress is challenging because of infants' varying ages and stages of development and their nonverbal status. Thus, pain and distress must be interpreted by a healthcare provider or other proxy from their own observations or perceptions. There is no standard research or clinical measure for pain and distress in infants. OBJECTIVE The purpose of this analysis was to evaluate the use of the COMFORT Behavior (COMFORT-B) Scale as a measure of pain and distress in infants diagnosed with life-threatening or life-limiting illnesses in the neonatal intensive care unit in comparison with the nurse-documented Neonatal Pain, Agitation and Sedation Scale; the infants' Technology Dependence Scale; and the mothers' report of total perceived symptom scores. METHODS Infants diagnosed with life-threatening or life-limiting illnesses and hospitalized in a Level IV neonatal intensive care unit in the Midwestern United States and their parents were included. Measurement of pain and distress in infants was collected weekly from enrollment through 12 weeks or until discharge, whichever occurred first. Observations for the COMFORT-B Scale were conducted before and after standard caregiving activities. Pearson r correlations were used to compare means between pain and distress, technology dependence, and mothers' total perceived symptom scores over time. RESULTS Data from 78 infants (46 male and 32 female infants) of ages 23-41 weeks of gestation at birth were analyzed. No correlations were found among the COMFORT-B Scale; the Neonatal Pain, Agitation and Sedation Scale; and mothers' total perceived symptom scores. Moderate correlations were found among the Technology Dependence Scale; mothers' total perceived symptom scores; and the Neonatal Pain, Agitation and Sedation Scale. DISCUSSION Performing COMFORT-B observations can be challenging, and it is unclear whether the information obtained from the COMFORT-B Scale added to the assessment of the infant's pain and distress that is typically recorded in the health record or from parents. Further evaluation is needed to determine if it is more reliable to collect the Neonatal Pain, Agitation and Sedation Scale scores rather than conduct observations using the COMFORT-B Scale in studies of infants with life-threatening and life-limiting illnesses in the neonatal intensive care unit.
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11
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Geven BM, Maaskant JM, Ward CS, van Woensel JBM. Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children. Crit Care Nurse 2021; 41:e17-e23. [PMID: 33560432 DOI: 10.4037/ccn2021462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Iatrogenic withdrawal syndrome is a well-known adverse effect of sedatives and analgesics commonly used in patients receiving mechanical ventilation in the pediatric intensive care unit, with an incidence of up to 64.6%. When standard sedative and analgesic treatment is inadequate, dexmedetomidine may be added. The effect of supplemental dexmedetomidine on iatrogenic withdrawal syndrome is unclear. OBJECTIVE To explore the potentially preventive effect of dexmedetomidine, used as a supplement to standard morphine and midazolam regimens, on the development of iatrogenic withdrawal syndrome in patients receiving mechanical ventilation in the pediatric intensive care unit. METHODS This retrospective observational study used data from patients on a 10-bed general pediatric intensive care unit. Iatrogenic withdrawal syndrome was measured using the Sophia Observation withdrawal Symptoms-scale. RESULTS In a sample of 102 patients, the cumulative dose of dexmedetomidine had no preventive effect on the development of iatrogenic withdrawal syndrome (P = .19). After correction for the imbalance in the baseline characteristics between patients who did and did not receive dexmedetomidine, the cumulative dose of midazolam was found to be a significant risk factor for iatrogenic withdrawal syndrome (P < .03). CONCLUSION In this study, supplemental dexmedetomidine had no preventive effect on iatrogenic withdrawal syndrome in patients receiving sedative treatment in the pediatric intensive care unit. The cumulative dose of midazolam was a significant risk factor for iatrogenic withdrawal syndrome.
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Affiliation(s)
- Barbara M Geven
- Barbara M. Geven is a pediatric intensive care nurse and clinical epidemiologist, Amsterdam UMC/Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Jolanda M. Maaskant is a senior nurse researcher and clinical epidemiologist, Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam UMC/University of Amsterdam
| | - Catherine S Ward
- Catherine S. Ward is a general and pediatric anesthesiologist, Amsterdam UMC/Emma Children's Hospital
| | - Job B M van Woensel
- Job B.M. van Woensel is medical director of the pediatric intensive care unit, Amsterdam UMC/Emma Children's Hospital
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12
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Peterson J, den Boer MC, Roehr CC. To Sedate or Not to Sedate for Less Invasive Surfactant Administration: An Ethical Approach. Neonatology 2021; 118:639-646. [PMID: 34628413 DOI: 10.1159/000519283] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022]
Abstract
Less invasive surfactant administration (LISA) is an effective, minimally invasive technique of administering surfactant to infants with respiratory distress syndrome. While termed less invasive, LISA still requires airway instrumentation with direct laryngoscopy, thus may be considered painful. However, the issue of whether or not to routinely sedate infants for LISA remains contentious, with significant variation in practice between centres. Proponents for giving pharmacological analgesia and/or sedation predominantly focus on patient comfort during the procedure. However, those who favour non-pharmacological measures of pain management focus on the potential for procedural success without the risk of adverse events, such as respiratory depression and potentially the need for escalation to intubation, which may occur with pharmacological agents. The neonatal population who may benefit from LISA is varied. Due to this variety in presentation type, gestational age, and unit experience, there is a need to provide an individualized, tailored approach to sedation and analgesia for these infants. Using a blanket approach to sedation will lead to infants being exposed to sedative medications on the assumption of potential distress, rather than in response to signs of actual distress. This places the infant at risk of the adverse reactions, potentially without them ever having needed the beneficial effect of the medications. This seems an unnecessary risk. This article explores the ethical arguments pertaining to analgesia and sedation during the LISA technique, concluding that a standardized approach to the usage of pharmacological sedation is undesirable. Moreover, we maintain that procedural analgesia and sedation should be based on individualized, infant-centred assessment, rather than on a rigid, standardized approach.
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Affiliation(s)
- Jennifer Peterson
- Neonatal Unit, St Mary's Maternity Hospital, Manchester Foundation Trust, Manchester, United Kingdom,
| | - Maria C den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Charles Christoph Roehr
- Neonatal Intensive Care Unit, Southmead Hospital, North Bristol Trust, Bristol, United Kingdom.,Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom.,National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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13
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Mencía S, Cieza R, Del Castillo J, López-Herce J. MONISEDA Project: Improving Analgosedation Monitoring in Spanish Pediatric Intensive Care Units. Front Pediatr 2021; 9:781509. [PMID: 34950619 PMCID: PMC8691263 DOI: 10.3389/fped.2021.781509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Analgosedation (AS) assessment using clinical scales is crucial to follow the international recommendations about analgosedation. The Analgosedation workgroup of the Spanish Society of Pediatric Intensive Care (SECIP) carried out two surveys in 2008 and 2015, which verified the gap in analgosedation assessment in Spanish pediatric intensive care unit (PICUs). The objective of the study was to analyze how analgosedation assessment by clinical scales changed after a multicenter intervention program. Methods: This is a multicenter pre-post study comparing the use of sedation, analgesia, withdrawal, and delirium scales before and after the MONISEDA project. Results were also compared with a control group formed by non-participating units. A survey about analgosedation management and monitoring was filled out before (year 2015) and after (year 2020) the implementation of the MONISEDA project in 2016. Results were compared not only between those periods of time but also between participant and non-participant PICUs in the MONISEDA project (M-group and non-M group, respectively). Data related to analgosedation of all patients admitted to a MONISEDA-participant PICU were also collected for 2 months. Results: Fifteen Spanish PICUs were enrolled in the MONISEDA project and another 15 non-participant PICUs formed the control group. In the M-group, the number of PICUs with a written analgosedation protocol increased from 53 to 100% (p = 0.003) and withdrawal protocol from 53 to 100% (p = 0.003), whereas in the non-M group, the written AS protocol increased from 80 to 87% and the withdrawal protocol stayed on 80%. The number of PICUs with an analgosedation team increased from 7 to 47% in the M-group (p = 0.01) and from 13 to 33% in the non-M group (p = 0.25). In the M-group, routine use of analgosedation clinical scales increased from 7 to 100% (p < 0.001), withdrawal scales from 7% to 86% (p = 0.001), and delirium scales from 7 to 33% (p = 0.125). In the non-M group, the number of PICUs using AS scales increased from 13 to 100% (p < 0.001), withdrawal scales from 7 to 27% (p = 0.125), and delirium scales from 0 to 7% (p = 1). Conclusions: The development of a specific training program improves monitoring and management of analgosedation in PICUs.
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Affiliation(s)
- Santiago Mencía
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
| | - Raquel Cieza
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
| | - Jimena Del Castillo
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
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Bosch-Alcaraz A, Jordan I, Guàrdia Olmos J, Falcó-Pegueroles A. Adaptación transcultural y características de la versión española de la escala COMFORT Behavior Scale en el paciente crítico pediátrico. Med Intensiva 2020; 44:542-550. [DOI: 10.1016/j.medin.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/07/2019] [Accepted: 07/02/2019] [Indexed: 11/26/2022]
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15
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Popowicz H, Kwiecień-Jaguś K, Olszewska J, Mędrzycka-Dąbrowska WA. Pain Scales in Neonates Receiving Mechanical Ventilation in Neonatal Intensive Care Units - Systematic Review. J Pain Res 2020; 13:1883-1897. [PMID: 32801846 PMCID: PMC7399469 DOI: 10.2147/jpr.s248042] [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: 02/01/2020] [Accepted: 06/24/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Recently, interest in the problem of proper prevention and monitoring of pain, especially acute, has been increasing in relation to various age groups. Greater awareness of the problem prompts discussion about the purpose of analgesia in newborns treated with mechanical ventilation. AIM The purpose of the systematic review was to analyze current research on the use of pain scales in newborns treated with mechanical ventilation in the Neonatal Intensive Care Unit. METHODS Medline databases: PubMed, OVID, EBSCO, Web of Science and Cochrane Library were traced using the appropriate keywords. The search was limited to studies in English. The review took into account the years 2006-2019. Considering the criteria, 12 articles were included in further analysis, to which full access was obtained. RESULTS The analyzed scientific research showed differences in beliefs about the validity and credibility of the scales used. Researchers indicated that staff with practical experience in using scales in their daily practice was very skeptical of the results obtained on their basis. CONCLUSION Based on this review, no explicit evidence can be obtained to support the use of one proper scale in pain assessment. It can be inferred that the COMFORT and N-PASS scales are effective for pain assessment and for determining the need for analgesics in mechanically ventilated neonates. These scales may be equally effective in assessing chronic pain, especially in mechanically ventilated children. On the other hand, the PIPP and CRIES scales are most commonly recommended for assessing acute and postoperative pain.
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Affiliation(s)
- Hanna Popowicz
- Department of Obstetric and Gynaecological Nursing, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Kwiecień-Jaguś
- Department of Anaesthesiology Nursing and Intensive Care, Medical University of Gdansk, Gdansk, Poland
| | - Jolanta Olszewska
- Department of Obstetric and Gynaecological Nursing, Medical University of Gdansk, Gdansk, Poland
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Bosch-Alcaraz A, Jordan I, Benito-Aracil L, Saz-Roy MÁ, Falcó-Pegueroles A. Discomfort of the critically ill paediatric patient and correlated variables. Aust Crit Care 2020; 33:504-510. [PMID: 32605846 DOI: 10.1016/j.aucc.2020.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 02/07/2020] [Accepted: 02/17/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The care of critically ill children is usually invasive and aggressive, requiring numerous traumatic procedures that may cause fear, pain, and discomfort. OBJECTIVES The aim of this study was to analyse the level of discomfort of patients admitted to the paediatric intensive care unit of a specialist children's hospital and to determine the sociodemographic and clinical variables that influence the degree of discomfort experienced by critically ill paediatric patients. METHODS We performed a descriptive observational cross-sectional study that included a total of 311 children with a median age of 5.07 y (interquartile range = 0.9-11.7). A team of 10 paediatric critical care nurses assessed the degree of discomfort once for each shift (morning, afternoon, and night) on 2 successive days using the COMFORT Behavior Scale-Spanish version. RESULTS In total, 49.8% (n = 155) of the patients were free of discomfort (score ≤10 points) vs. 50.2% (n = 156) who experienced discomfort. There was a significant negative correlation between discomfort and the length of stay in days (Rho = 0.16; p = 0.02), that is, the longer the stay, the less discomfort the patient felt. The correlation between age and degree of discomfort was found to be both positive and significant (Rho = 0.230, p < 0.001); the greater the age, the greater the discomfort. In comparison of all children who received analgosedation (n = 205), with discomfort levels of 10.77 ± 2.94, with those who did not receive analgosedation (n = 106), with discomfort levels of 11.96 ± 2.80, we did find a statistically significant difference (χ2 = -4.05; p < 0.001). CONCLUSIONS Half of the patients admitted to the paediatric intensive care unit experienced discomfort. Age and analgosedation were the two most important variables involved with a high degree of discomfort. Clinical care practices must consider these factors and try to plan activities designed to relieve discomfort in all critically ill paediatric patients.
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Affiliation(s)
- Alejandro Bosch-Alcaraz
- Pediatric Nurse, Hospital Sant Joan de Déu, Barcelona, Spain; Department of Public Health, Mental Health, and Maternity/Childhood Nursing, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.
| | - Iolanda Jordan
- Pediatric Intensive Care Specialist, Hospital Sant Joan de Déu, Barcelona, Spain; Medicine Unit of Training and Research, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Llúcia Benito-Aracil
- Department of Fundamental Care and Medical-Surgical Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Spain
| | - Mª Ángeles Saz-Roy
- Department of Public Health, Mental Health, and Maternity/Childhood Nursing, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Anna Falcó-Pegueroles
- Department of Fundamental Care and Medical-Surgical Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Spain; Consolidated Research Group SGR 269 Quantitative Psychology, University of Barcelona, Barcelona, Spain
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17
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Suprawoto DN, Nurhaeni N, Waluyanti FT. COMFORT Behavior Scale instrument: validity and reliability test for critically ill pediatric patients in Indonesia. Pediatr Rep 2020; 12:8690. [PMID: 32905068 PMCID: PMC7463139 DOI: 10.4081/pr.2020.8690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Indexed: 11/23/2022] Open
Abstract
The COMFORT Behavior Scale (CBS) is an instrument that has been validated in several languages to assess the levels of sedation in children. This project was implemented to identify the validity and reliability of CBS. The design used was an analytic descriptive cross-sectional approach. Fifty-one children aged 1 month to 18 years who received analgesic and/or sedation therapy were purposively selected and assessed for their sedation levels using CBS and the Nurse Interpretation of Sedation Score (NISS). The data were analyzed using the Mann-Whitney U test to measure the concurrent validity; each item was analyzed using Pearson correlation; inter-rater reliability was measured by the Kappa coefficient; and the internal consistency was measured by Cronbach's alpha. The results showed there was no significant correlation between the levels of sedation assessed using CBS and NISS (P= 0.118; α= 0.05). Six items in the CBS instrument were found to be valid (r= 0.348-0.813). The Cronbach's alpha for CBS was 0.873. Thus, the Indonesian version of CBS is valid and reliable in assessing sedation levels in children.
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18
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Herr K, Coyne PJ, Ely E, Gélinas C, Manworren RCB. Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement. Pain Manag Nurs 2019; 20:404-417. [PMID: 31610992 DOI: 10.1016/j.pmn.2019.07.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/25/2019] [Accepted: 07/21/2019] [Indexed: 11/18/2022]
Abstract
Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.
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Affiliation(s)
- Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa.
| | - Patrick J Coyne
- Palliative Care Department, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Ely
- Department of Nursing Research, University of Chicago Hospitals, Chicago, Illinois
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS, Centre-West-Montréal, Montréal, Québec, Canada
| | - Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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19
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van den Hoogen NJ, de Kort AR, Allegaert KM, Joosten EA, Simons SHP, Tibboel D, van den Bosch GE. Developmental neurobiology as a guide for pharmacological management of pain in neonates. Semin Fetal Neonatal Med 2019; 24:101012. [PMID: 31221544 DOI: 10.1016/j.siny.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pain in newborn children should be prevented due to negative short- and long-term consequences. A good understanding of the development of the nociceptive system in newborns is necessary to enable optimal pain assessment, and most importantly to treat and prevent pain adequately in neonates. So far, preclinical juvenile animal studies have led to a tremendous amount of information regarding the development of the nociceptive system. In addition, they have made clear that the developmental stage of the nociceptive system may influence the mechanism of action of different classes of analgesics. Age specific analgesic therapy, based on post-menstrual age, should therefore be considered by incorporating information on the developmental stages of the nociceptive system in combination with knowledge from pharmacokinetic and -dynamic studies in neonates.
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Affiliation(s)
- Nynke J van den Hoogen
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Anne R de Kort
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Karel M Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, KU, Leuven, Leuven, Belgium
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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Fagioli D, Evangelista C, Gawronski O, Tiozzo E, Broccati F, Ravà L, Dall'Oglio I. Pain assessment in paediatric intensive care: the Italian COMFORT behaviour scale. Nurs Child Young People 2019; 30:27-33. [PMID: 30457241 DOI: 10.7748/ncyp.2018.e1081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Assessment of pain in paediatric intensive care units (PICUs) is crucial to minimise the risks of inadequate sedation. AIM To translate and validate the Italian version of the COMFORT behaviour scale (CBS) in a PICU in terms of its psychometric, construct, feasibility and reproducibility properties. METHOD Before and after tracheal suctioning, 71 observations were performed on 35 sedated and mechanically ventilated patients in three PICUs. Pain and distress were assessed using the CBS and the Nurse Interpretation of Sedation Score (NISS). RESULTS Interrater agreement and interrater reliability were high before the procedure and moderate after (pre: 100%, Cohen's kappa = 1; post: 79%, Cohen's kappa = 0.558). The scale's internal consistency was calculated before and after the procedure (Cronbach's alpha = 0.81 and 0.91). Agreement between the CBS and the NISS was low before and after the procedure (20% and 28%). The agreement between the tools was low because the NISS, a tool based on expert opinion, is not as precise as the CBS and could be affected by cultural biases. CONCLUSION The Italian version of the CBS proved to be valid and reproducible for the objective measurement of pain and distress in a wide age range of patients admitted to PICUs.
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Affiliation(s)
- Daniele Fagioli
- Clinical pharmacy unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Costanza Evangelista
- Respiratory unit, University Department of Paediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Orsola Gawronski
- Professional development, continuing education and nursing research service, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emanuela Tiozzo
- Continuing education and nursing research service, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Broccati
- Emergency department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lucilla Ravà
- Clinical epidemiology unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Immacolata Dall'Oglio
- Professional development, continuing education and nursing research service, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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- Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Cunningham ME, Vogel AM. Analgesia, sedation, and delirium in pediatric surgical critical care. Semin Pediatr Surg 2019; 28:33-42. [PMID: 30824132 DOI: 10.1053/j.sempedsurg.2019.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.
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Affiliation(s)
- Megan E Cunningham
- Texas Children's Hospital, Division of Pediatric Surgery, Department of Surgery, 6701 Fannin Street, Houston, TX 77030, USA.
| | - Adam M Vogel
- Texas Children's Hospital, Division of Pediatric Surgery, Department of Surgery, 6701 Fannin Street, Houston, TX 77030, USA; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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Loeffen EAH, Stinson JN, Birnie KA, van Dijk M, Kulkarni K, Rijsdijk M, Font-Gonzalez A, Dupuis LL, van Dalen EC, Mulder RL, Campbell F, Tissing WJE, van de Wetering MD, Gibson F. Measurement properties of instruments to assess pain in children and adolescents with cancer: a systematic review protocol. Syst Rev 2019; 8:33. [PMID: 30691495 PMCID: PMC6348667 DOI: 10.1186/s13643-019-0945-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 01/11/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Pain in children and adolescents with cancer has been identified as an area where many healthcare professionals seek guidance. This protocol details a systematic review whose aim is to explore current knowledge regarding measurement instruments to assess pain (and pain-related distress) in children and adolescents with cancer. After completion of the review, the information will be used in the development of a clinical practice guideline. METHODS We will search four electronic databases (MEDLINE via PubMed, CINAHL, PsycINFO and HaPI). Additional relevant studies will be identified by reference checking and expert consultation. All citations will be screened independently by two reviewers in a three-step approach: first selection based on title, second selection based on abstract, third selection based on full-text. Studies in children and adolescents with cancer that aimed to evaluate the clinimetric properties of an existing pain measurement instrument or to develop a new pain measurement instrument and that include at least one relevant outcome (reliability, validity, responsiveness, interpretability, clinical utility) are eligible for inclusion. For all steps of evidence selection, a detailed list with eligibility criteria will be determined a priori. Data extraction and quality assessment of included studies (according to the COnsensus-based Standards for the selection of health Measurement INstruments, COSMIN criteria) will be conducted independently by two authors. DISCUSSION This systematic review will provide an overview of the current literature regarding measurement instruments to assess pain in children and adolescents with cancer. This knowledge synthesis will be used to formulate recommendations for clinical practice. Also, by synthesizing existing evidence, knowledge gaps will be identified. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017072879.
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Affiliation(s)
- Erik A H Loeffen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Oncology/Hematology, Groningen, The Netherlands.
| | - Jennifer N Stinson
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Monique van Dijk
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Ketan Kulkarni
- Division of Pediatric Hematology Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anna Font-Gonzalez
- Department of Pediatric Oncology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - L Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Elvira C van Dalen
- Department of Pediatric Oncology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Renée L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Wim J E Tissing
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Oncology/Hematology, Groningen, The Netherlands
| | - Marianne D van de Wetering
- Department of Pediatric Oncology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Faith Gibson
- Centre for Outcomes and Experiences Research in Children's Health, Illness, and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,University of Surrey, Guildford, UK
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Haslund-Krog SS, Hertel S, Dalhoff K, Poulsen S, Christensen U, Wilkins D, van den Anker J, Brink Henriksen T, Holst H. Interventional cohort study of prolonged use (>72 hours) of paracetamol in neonates: protocol of the PARASHUTE study. BMJ Paediatr Open 2019; 3:e000427. [PMID: 31206077 PMCID: PMC6542439 DOI: 10.1136/bmjpo-2018-000427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Anticipated or actual pain in neonates results in use of paracetamol for prolonged pain relief in many neonatal intensive care units. Clinical trials examining safety of paracetamol exposure in neonates have been of short duration (1-3 days) and hepatic biomarkers and paracetamol metabolism are rarely reported in the same studies.We aim to investigate the safety (hepatic tolerance) and effectiveness of prolonged paracetamol exposure in neonates by measuring hepatic biomarkers, plasma concentrations of paracetamol and its metabolites and pain scores. In addition, we study a possible interaction between ethanol and paracetamol. METHODS AND ANALYSIS A multicentre interventional cohort study.Neonates of any gestational age and up to 44 weeks postmenstrual age, treated with oral or intravenous paracetamol can be included.Alanine aminotransferase (ALT) and bilirubin are measured at baseline or within 24 hours after treatment initiation. P-paracetamol and metabolites are measured at steady state and every 2 days (opportunistically) together with ALT and bilirubin and lastly after discontinuation of treatment. COMFORT neo pain scores are collected longitudinally. COMFORT neo pain scores and population pharmacokinetic analysis of paracetamol samples will be analysed simultaneously using non-linear mixed effects models. One and two compartment models with first-order elimination will be tested for disposition. In addition, plasma ethanol is measured if the patient receives concomitant treatment with intravenous or oral phenobarbital containing ethanol as an excipient. ETHICS AND DISSEMINATION Inclusion of patients can be postponed 24 hours after the first paracetamol dose. This is intended to make the inclusion process less stressful for parents. This study uses standard dosing strategies. The potential risks are additional blood samples, which are collected opportunistically to reduce additional heel pricks. TRIAL REGISTRATIONNUMBER Ethics Comittee: H-17027244, EudraCT no: 2017-002724-25, BFH-2017-106, 05952.
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Affiliation(s)
| | - Steen Hertel
- Neonatal Intensive Care Unit, Rigshospitalet, Copenhagen, Denmark
| | - Kim Dalhoff
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Susanne Poulsen
- Neonatal Intensive Care Unit, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Christensen
- Department of Pediatrics, Neonatal Intensive Care Unit, Aarhus Universitetshospital, Aarhus, Denmark
| | - Diana Wilkins
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA.,Division of Pediatric Pharmacology and Pharmacometrics, Universitat Basel, Basel, BS, Switzerland
| | - Tine Brink Henriksen
- Department of Pediatrics, Neonatal Intensive Care Unit, Aarhus Universitetshospital, Aarhus, Denmark
| | - Helle Holst
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
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25
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Fagin A, Palmieri TL. Considerations for pediatric burn sedation and analgesia. BURNS & TRAUMA 2017; 5:28. [PMID: 29051890 PMCID: PMC5641993 DOI: 10.1186/s41038-017-0094-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/25/2017] [Indexed: 12/13/2022]
Abstract
Burn patients experience anxiety and pain in the course of their injury, treatment, and recovery. Hence, treatment of anxiety and pain is paramount after burn injury. Children, in particular, pose challenges in anxiety and pain management due to their unique physiologic, psychologic, and anatomic status. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. The purpose of this review is to describe the challenges associated with management of anxiety, pain, and sedation in burned children and to describe the different options for treatment of anxiety and pain in burned children.
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Affiliation(s)
- Alice Fagin
- Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR 72202 USA
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California and University of California Davis, 2425 Stockton Blvd, Suite 718, Sacramento, CA USA
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26
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Vink P, Lucas C, Maaskant JM, van Erp WS, Lindeboom R, Vermeulen H. Clinimetric properties of the Nociception Coma Scale (-Revised): A systematic review. Eur J Pain 2017; 21:1463-1474. [PMID: 28573825 PMCID: PMC5600098 DOI: 10.1002/ejp.1063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2017] [Indexed: 11/12/2022]
Abstract
The Nociception Coma Scale is a nociception behaviour observation tool, developed specifically for patients with disorders of consciousness (DOC) due to (acquired) brain injury. Over the years, the clinimetric properties of the NCS and its revised version (NCS‐R) have been assessed, but no formal summary of these properties has been made. Therefore, we performed a systematic review on the clinimetric properties (i.e. reliability, validity, responsiveness and interpretability) of the NCS(‐R). We systematically searched CENTRAL, CINAHL, Embase, PsycInfo and Web of Science until August 2015. Two reviewers independently selected the clinimetric studies and extracted data with a structured form. Included studies were appraised on quality with the COSMIN checklist. Eight studies were found eligible and were appraised with the COSMIN checklist. Although nearly all studies lacked sample size calculation, and were executed by the same group of authors, the methodological quality ranged from fair to excellent. Important aspects of reliability, construct validity and responsiveness have been studied in depth and with sufficient methodological quality. The overview of clinimetric properties in this study shows that the NCS and NCS‐R are both valid and useful instruments to assess nociceptive behaviour in DOC patients. The studies provide guidance for the choice in NCS‐R cut‐off value for possible pain treatment and cautions awareness of interprofessional differences in NCS‐R measurements. Significance This systematic review provides a structured overview of the clinimetric properties of the Nociception Coma Scale (‐Revised) and provides insights for a solid evidence‐based nociception behaviour assessment and treatment plan.
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Affiliation(s)
- P Vink
- Department of Neurology and Neurosurgery, Academic Medical Center (AMC), Amsterdam, The Netherlands.,Omni Cura Nursing Teaching Research, Amsterdam, The Netherlands
| | - C Lucas
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Medical Faculty (AMC), University of Amsterdam, The Netherlands
| | - J M Maaskant
- Emma Children's Hospital, Academic Medical Center Amsterdam, The Netherlands.,ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, The Netherlands
| | - W S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands.,Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Belgium
| | - R Lindeboom
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Medical Faculty (AMC), University of Amsterdam, The Netherlands
| | - H Vermeulen
- Department of Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands.,Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
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