Anne-Sylvie Ramelet

The effectiveness of a standardised preoperative preparation in reducing child and parent anxiety: a single‐blind randomised controlled trial

AIMS To evaluate the effect of a structured preoperative preparation on child and parent state anxiety, child behavioural change and parent satisfaction. BACKGROUND It is estimated that around 50-70% of hospitalised children experience severe anxiety and distress prior to surgery. Children who are highly anxious and distressed preoperatively are likely to be distressed on awakening and have negative postoperative behaviour. Although education before surgery has been found to be useful mostly in North America, the effectiveness of preoperative preparation programme adapted to the Australian context remains to be tested. DESIGN This single-blind randomised controlled study was conducted at a tertiary referral hospital for children in Western Australia. METHODS Following ethics approval and parental consent, 73 children and one of their carers (usually a parent) were randomly assigned into two groups. The control group had standard practice with no specific preoperative education and the experimental group received a preoperative preparation, including a photo file, demonstration of equipment using a role-modelling approach and a tour. RESULTS The preoperative preparation reduced parent state anxiety significantly (-2·32, CI -4·06 to -0·56, p = 0·009), but not child anxiety (-0·59, CI -1·23 to 0·06, p = 0·07). There was no significant difference in child postoperative behaviour or parent satisfaction between the groups. There was a significant two-point pain score reduction in the preoperative preparation group, when compared with the control group median 2 (IQR 5) and 4 (IQR 4), respectively (p = 0·001). CONCLUSIONS Preoperative preparation was more efficient on parent than child. Although the preoperative preparation had limited effect on child anxiety, it permitted to decrease pain experience in the postoperative period. RELEVANCE TO CLINICAL PRACTICE Parents should be actively involved in their child preoperative preparation.

The challenges of pain measurement in critically ill young children: A comprehensive review

This article addresses the issues in measuring pain in critically ill children, provides a comprehensive review of the pain measures for children aged between 0 and 3 years, and discusses their applicability to this group of children. When children are critically ill, pain can only exacerbate the stress response that already exists, to the extent that homeostasis cannot be maintained. Severity of illness is thus likely to affect physiologic and behavioural pain responses that would normally be demonstrated in healthy children. The problem of differentiating pain from other constructs adds to the complexity of assessing pain in non-verbal children. A pain measure to be useful clinically must be adapted to the developmental age of the target population. Search of electronic databases and other electronic sources was supplemented by hand review of relevant journals to identify published and unpublished pain measures for use in children aged between 0 and 3 years. Twenty eight pain measures were identified in the literature; 11 for neonates only, 11 for children aged between 0 and 3 years, and six for children more than 12 months. These measures vary in relation to their psychometric properties, clinical utility and the context in which the study was performed. These measures may not be suitable for the critically ill young child, because the items included were derived from observations of healthy or moderately sick children, and may not reflect pain behaviour in those who are critically ill. It is therefore recommended to develop new pain scales for this population of compromised children.

Clinical validation of the Multidimensional Assessment of Pain Scale

Background:  The Multidimensional Assessment Pain Scale (MAPS), was developed to measure postoperative pain in critically ill preverbal children. Following preliminary psychometric testing, additional validation of this 5‐category 10‐point scale was required. This article reports the results of a follow‐up validation study that aimed to evaluate the clinical validity and utility of the MAPS.

Research priorities for nursing care of infants, children and adolescents: a West Australian Delphi study

AIMS AND OBJECTIVES This paper describes a study that aimed to identify research priorities for the care of infants, children and adolescents at the sole tertiary referral hospital for children in Western Australia. The secondary aim was to stimulate nurses to explore clinical problems that would require further inquiry. BACKGROUND Planning for research is an essential stage of research development; involving clinicians in this exercise is likely to foster research partnerships that are pertinent to clinical practice. Nursing research priorities for the paediatric population have not previously been reported in Australia. DESIGN Delphi study. METHOD Over 12 months in 2005-2006, a three-round questionnaire, using the Delphi technique, was sent to a randomly selected sample of registered nurses. This method was used to identify and prioritise nursing research topics relevant to the patient and the family. Content analysis was used to analyse Round I data and descriptive statistics for Round II and III data. RESULTS In Round I, 280 statements were identified and reduced to 37 research priorities. Analysis of data in subsequent rounds identified the top two priority research areas as (1) identification of strategies to reduce medication incidents (Mean=6·47; SD 0·88) and (2) improvement in pain assessment and management (Mean=6; SD 1·38). Additional comments indicated few nurses access the scientific literature or use research findings because of a lack of time or electronic access. CONCLUSIONS Thirty-seven research priorities were identified. The identification of research priorities by nurses provided research direction for the health service and potentially other similar health institutions for children and adolescents in Australia and internationally. RELEVANCE TO CLINICAL PRACTICE The nurse participants showed concern about the safety of care and the well-being of children and their families. This study also enabled the identification of potential collaborative research and development of pain management improvement initiatives.

Development and preliminary psychometric testing of the Multidimensional Assessment of Pain Scale: MAPS

Background:  This study aimed to test the preliminary psychometric properties of the Multidimensional Assessment Pain Scale (MAPS), a clinical instrument developed for assessing postoperative pain in critically ill preverbal children.

Pain indicators in brain-injured critical care adults: An integrative review

INTRODUCTION Health professionals are confronted with the difficulty of adequately evaluating pain in critically ill, brain-injured patients, as these patients are often unable to self-report. In addition, their confused and stereotyped behaviours may change their responses to pain; the indicators and descriptors generally used to evaluate pain in the critically ill may therefore not be appropriate for brain-injured patients. AIM The aim of this integrative review was to identify clinically measurable and observable pain indicators and descriptors for brain-injured, critically ill adults. METHOD A search of electronic databases (Medline, CINAHL, Embase) combined with cross-referencing was performed. Articles were included if they described pain indicators in critically ill adults and included brain-injured patients in their population. RESULTS Seven articles met the inclusion criteria. They were critically appraised for their quality and their relevance for the population of brain-injured patients. Behavioural pain indicators such as facial expressions, body movements and muscle tension were found in all of the articles. However, the descriptions of the indicators differ from one article to another. The intensity and nature of behavioural pain responses vary according to the level of consciousness. Changes in physiological parameters have also been reported, but these results are inconclusive. CONCLUSION Additional research is needed to identify and better describe pain indicators that are specific to brain-injured patients in the ICU. Studies with large samples, different brain injury diagnoses and various levels of consciousness are warranted.

Analgesia and sedation in emergency situations and in the pediatric intensive care unit

OBJETIVO: Revisar as atuais estrategias de uso de analgesicos e sedativos em salas de emergencia e em unidades de tratamento intensivo pediatrico. FONTES DOS DADOS: Revisao de bibliografia realizada na base de dados da Medline, alem de capitulos de livros de terapia intensiva pediatrica e da experiencia dos servicos dos autores. SINTESE DOS DADOS: Apesar de todos os avancos e pesquisas no campo da dor, o uso de sedativos e analgesicos em unidades intensivas pediatricas continua deficitario. A dor e o desconforto associados a situacoes de urgencia, procedimentos invasivos e internacoes prolongadas ainda resultam em significativa morbidade aos pacientes pediatricos criticamente enfermos. A dificuldade de comunicacao do paciente pediatrico com a equipe medica, a grande quantidade de procedimentos invasivos necessarios a manutencao da vida, aliados a antiga premissa de que os mecanismos de dor nao estao bem desenvolvidos nas criancas, fazem desse tema um desafio nas unidades de terapia intensiva pediatrica. Neste estudo, revisamos as drogas mais utilizadas no manejo da dor e sedacao, apresentando novas opcoes terapeuticas mais largamente estudadas recentemente. CONCLUSOES: Nos ultimos dez anos, desenvolveu-se uma consciencia mais critica em relacao a necessidade de promover um adequado alivio da dor e da ansiedade inerentes aos ambientes de emergencia e de UTI, devendo ser esta uma prioridade no planejamento terapeutico de criancas extremamente doentes.

Assessment of pain and agitation in critically ill infants

Abstract Critically ill infants are subjected to many painful experiences that, if inadequately treated, can have severe physiological and psychological consequences. Optimal management of pain relies on the adequacy of nurses’ assessment; this, however, is complicated by another common condition, agitation. A multidimensional assessment is therefore necessary to adequately identify pain and agitation. The aim of this descriptive study was to identify the cues that nurses caring for critically ill infants use to assess pain and agitation. A questionnaire, developed from the literature, was distributed to all registered nurses (85) working in the neonatal and paediatric intensive care units of an Australian teaching hospital. Questionnaires were completed by 41 nurses (a 57 per cent response rate). Results revealed that, except for diagnosis, there were no significant differences between the cues participants used to assess pain and those to assess agitation. Nurses used numerous cues from various sources: most importantly, their own judgement (99 per cent); the parents’ judgement (90 per cent); the infants environment; documentation (78 per cent), and the infants cues (70 per cent). These findings demonstrate the relevance of the nurses role in assessment of pain and agitation in critically ill infants. Nurses used cues specific to the critically ill rather than the less sick infant. Results of this study also show the difficulty of differentiating between pain and agitation. Further research on ways of distinguishing between the construct of pain and agitation needs to be undertaken.

Capturing postoperative pain responses in critically ill infants aged 0 to 9 months

Objectives: The purpose of this study was to describe physiologic and behavioral pain behaviors in postoperative critically ill infants. A secondary aim was to identify how these pain responses vary over time. Design: This observational study was conducted in the pediatric intensive care unit at two tertiary referral hospitals. Using ethological methods of observation, video recordings of postoperative infants were viewed to depict different situations of pain and no pain and were then coded using a reliable checklist. Patients: A total of 803 recorded segments were generated from recordings of five critically ill infants aged between 0 and 9 months who had undergone major surgery. Measurements and Main Results: There was an 82% agreement between the two coders. Multivariate analyses showed that physiologic responses differed only when adjusted for time. Significant decreases in systolic and diastolic arterial pressure (p < .001 and p = .036, respectively) were associated with postoperative pain exacerbated by painful procedures on day 2. On day 3, however, heart rate, arterial pressure (systolic, diastolic, and mean), and central venous pressure significantly increased (p < .05) in response to postoperative pain. Indicators included vertical stretch of the mouth, hand twitching, and jerky leg movements for postoperative pain and increase in respiratory distress, frown, eyes tightly closed, angular stretch of the mouth, silent or weak cry, jerky head movements, fist, pulling knees up, and spreading feet for postoperative pain exacerbated by painful stimuli. Conclusions: Findings support the ability to capture different intensities of postoperative pain in critically ill infants beyond neonatal age. These pain indicators can be used for the development of a pain assessment tool forthis group of infants.

Paediatric end-of-life care needs in Switzerland: current practices, and perspectives from parents and professionals. A study protocol.

AIM To present a protocol for a multi-phase study about the current practice of end-of-life care in paediatric settings in Switzerland. BACKGROUND In Switzerland, paediatric palliative care is usually provided by teams, who may not necessarily have specific training. There is a lack of systematic data about specific aspects of care at the end of a childs life, such as symptom management, involvement of parents in decision-making and family-centred care and experiences and needs of parents, and perspectives of healthcare professionals. DESIGN This retrospective nationwide multicentre study, Paediatric End-of-LIfe CAre Needs in Switzerland (PELICAN), combines quantitative and qualitative methods of enquiry. METHODS The PELICAN study consists of three observational parts, PELICAN I describes practices of end-of-life care (defined as the last 4 weeks of life) in the hospital and home care setting of children (0-18 years) who died in the years 2011-2012 due to a cardiac, neurological or oncological disease, or who died in the neonatal period. PELICAN II assesses the experiences and needs of parents during the end-of-life phase of their child. PELICAN III focuses on healthcare professionals and explores their perspectives concerning the provision of end-of-life care. CONCLUSION This first study across Switzerland will provide comprehensive insight into the current end-of-life care in children with distinct diagnoses and the perspectives of affected parents and health professionals. The results may facilitate the development and implementation of programmes for end-of-life care in children across Switzerland, building on real experiences and needs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01983852.