Céline Gélinas

Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002. Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks® database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (–) an intervention. A strong recommendation (either for or against) indicated that the intervention’s desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase “We recommend …” is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase “We suggest …” is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. Conclusion:These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Creating a Healthy Workplace for New-Generation Nurses

PURPOSE To examine dimensions of the psychosocial work environment that influence the psychological health of new-generation nurses. BACKGROUND While much work has been done concerning the health of nurses in general, research on the relationship between the nursing work environment and the psychological well-being of new-generation nurses at the start of their careers is limited. DESIGN A correlational descriptive design was used for this quantitative study. Survey data were collected from new nurses (N=309) whose names were obtained from a provincial licensing registry in Quebec, Canada. FINDINGS Among new nurses, 43.4% stated that they have a high level of psychological distress. These nurses were significantly more likely to perceive an imbalance between effort expended on the job and rewards received, low decisional latitude, high psychological demands, high job strain, as well as low social support from colleagues and superiors (p < or = 0.05). CONCLUSIONS Understanding the relationship between the work environment and health as experienced by new-generation nurses is imperative for creating interventions to successfully recruit and retain these young nurses. CLINICAL RELEVANCE Generation Y nurses in Quebec, faced with high levels of psychological distress because of their exposure to difficult nursing work environments, might leave the profession thereby exacerbating an already salient nursing shortage.

A brief intervention for fatigue management in breast cancer survivors.

The purpose of this randomized control trial was to verify the effectiveness of a brief group intervention that combines stress management psycho-education and physical activity (ie, independent variable) intervention in reducing fatigue and improving energy level, quality of life (mental and physical), fitness (VO2submax), and emotional distress (ie, dependent variables) in breast cancer survivors. This study applied Lazarus and Folkman stress-coping theoretical framework, as well as Salmons unifying theory of physical activity. Eighty-seven French-speaking women who had completed their treatments for nonmetastatic breast cancer at a university hospital in Quebec City, Canada, were randomly assigned to either the group intervention (experimental) or the usual-care (control) condition. Data were collected at baseline, postintervention, and at 3-month follow-up. The 4-week group intervention was cofacilitated by 2 nurses. Results showed that participants in the intervention group showed greater improvement in fatigue, energy level, and emotional distress at 3-month follow-up, and physical quality of life at postintervention, compared with the participants in the control group. These results suggest that a brief psycho-educational group intervention focusing on active coping strategies and physical activity is beneficial to cancer survivors after breast cancer treatments.

Validation evidence for the French Canadian adaptation of the Multidimensional Fatigue Inventory as a measure of cancer-related fatigue.

Cancer-related fatigue is the most reported symptom among patients with cancer. Researchers in the field of psychooncology have encouraged the development of short instruments, which allow for easier completion by clinical populations while still maintaining solid psychometric properties. The current study examined the validity and reliability of the French Canadian adaptation of the Multidimensional Fatigue Inventory (MFI) among women (n = 277) and men (n = 327) undergoing therapy for breast or prostate cancer, respectively. An exploratory factor analysis of the selected 15-item MFI yielded the following four factors: general/physical, mental, reduced motivation, and reduced activity. This was supported by a confirmatory factor analysis. The reliability, as evaluated by test-retest and Cronbach alpha internal consistency reliability coefficients of the French Canadian shortened MFI, was acceptable. In addition, the four factor-based scores correlated in a theoretically meaningful manner with existing measures of mood disturbance (Profile of Mood States and Hospital Anxiety and Depression Scale), cancer-related stressors (Inventory of Recent Life Experiences), coping with illness (Coping with Health Injuries and Problems Scale), quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire), and insomnia (Insomnia Severity Index), suggesting good construct, convergent, and concurrent criterion validity. Although further validation is recommended, the results for the French Canadian MFI in assessing cancer-related fatigue in both women and men undergoing cancer treatments showed good psychometric qualities.

A Validated Approach to Evaluating Psychometric Properties of Pain Assessment Tools for Use in Nonverbal Critically Ill Adults

A valid pain assessment is the foundation of adequate pain management. Pain assessment can be challenging, especially in adult intensive care unit (ICU) patients who are unable to self-report. In such situations, relying on observational assessment tools is an alternative strategy. This review describes and analyzes the development and psychometric properties of pain assessment tools developed for use with nonverbal critically ill adults. A total of 32 relevant papers that described the psychometric properties of eight pain assessment tools were included. The scale development process, psychometric properties (i.e., reliability and validity), and feasibility of pain assessment tools were analyzed using a 0 to 20 scoring system. Each pain assessment tool was scored independently by two reviewers. Of the eight behavioral pain scales developed for use in adult ICU patients, the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are considered to be the most valid and reliable for this purpose, according to the available evidence. Behavioral pain scales may be viable alternatives to assessing pain in ICU patients who are unable to self-report, but only valid, reliable, and feasible scales should be used for this purpose.

Factors related to persistent fatigue following completion of breast cancer treatment.

PURPOSE/OBJECTIVES To verify the predictive capacity of the stress-process theory to emeanplain persistent fatigue following completion of breast cancer treatments; to verify the relationship between interleukin-1b and fatigue. DESIGN Correlational. SETTING Tertiary medical center in Quebec City, Canada. SAMPLE A systematic sample of 103 women in remission from breast cancer was recruited. The mean age was 54 years. Participants with a depressive mood, insomnia, or stage IV cancer were emeancluded. METHODS Participants were met during their follow-up appointment after the end of radiation therapy. Questionnaires on fatigue, stress variables, and other confounding variables were completed by telephone interview. Blood samples also were collected to measure the serum level of interleukin-1b. MAIN RESEARCH VARIABLES Fatigue, several variables from the stress-process theory, pain, menopausal symptoms, and demographic and medical variables. FINDINGS Fatigue was related theoretically and coherently to many stress-process variables. By controlling for pain, the final regression model included cancer stressors and passive and active coping as predictors, which accounted for 41% of the variance in fatigue. No relationship was found between fatigue and interleukin-1b. CONCLUSIONS The results supported the relevance of the stress-process theory for emeanplaining cancer-related fatigue. IMPLICATIONS FOR NURSING Nursing interventions based on this theoretical framework could be developed. In addition, further clinical research that tests the efficacy of these psycho-educative interventions in preventing persistent fatigue and improving the quality of life of women with breast cancer is recommended.

Critical Care Nurses’ Pain Assessment and Management Practices: A Survey in Canada

BACKGROUND Regular pain assessment can lead to decreased incidence of pain and shorter durations of mechanical ventilation and stays in the intensive care unit. OBJECTIVES To document knowledge and perceptions of pain assessment and management practices among Canadian intensive care unit nurses. METHODS A self-administered questionnaire was mailed to 3753 intensive care unit nurses identified through the 12 Canadian provincial/territorial nursing associations responsible for professional regulation. RESULTS A total of 842 nurses (24%) responded, and 802 surveys could be evaluated. Nurses were significantly less likely (P < .001) to use a pain assessment tool for patients unable to communicate (267 nurses, 33%) than for patients able to self-report (712 nurses, 89%). Significantly fewer respondents (P < .001) rated behavioral pain assessment tools as moderately to extremely important (595 nurses, 74%) compared with self-report tools (703 nurses, 88%). Routine (>50% of the time) discussion of pain scores during nursing handover was reported by 492 nurses (61%), and targeting of analgesia to a pain score or other assessment parameters by physicians by 333 nurses (42%). Few nurses (n = 235; 29%) were aware of professional society guidelines for pain assessment and management. Routine use of a behavioral pain tool was associated with awareness of published guidelines (odds ratio, 2.5; 95% CI, 1.7-3.7) and clinical availability of the tool (odds ratio, 2.6; 95% CI, 1.6-4.3). CONCLUSIONS A substantial proportion of intensive care unit nurses did not use pain assessment tools for patients unable to communicate and were unaware of pain management guidelines published by professional societies.

Exploring the validity of the bispectral index, the Critical-Care Pain Observation Tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: A pilot study

This pilot study aimed to explore the validity of the bispectral (BIS) index, the Critical-Care Pain Observation Tool (CPOT) score, and vital signs (mean arterial pressure, heart rate) during rest and painful procedures in sedated and mechanically ventilated ICU adults. A convenience sample of nine patients with various diagnoses participated in this observational repeated measures study. Patients were observed during 2 minute periods at rest (baseline), and during procedures known to be painful: turning and endotracheal suctioning. Both the BIS index and the CPOT score were found to increase when patients were exposed to procedures compared with rest, and were found to be more sensitive to procedures compared with vital signs. Indeed, vital signs remained quite stable during procedures in this sample. Results from this study support the recommendation that behavioural indicators (i.e. in this case, the use of a behavioural pain scale called the CPOT) be used for the detection of pain in nonverbal ICU patients. However, in some situations (e.g. deep sedation, use of blocking agents), behavioural indicators may no longer be observable, and all that is left are physiologic signs. The BIS seems to be an interesting technique and further research is required in order to establish if it could be used to guide clinicians for the detection of pain in this vulnerable population.

Psychometric analysis of subjective sedation scales in critically ill adults.

Objective:To describe and analyze the development and psychometric properties of subjective sedation scales developed for critically ill adult patients. Data Sources:PubMed, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, ISI Web of Science, and the International Pharmaceutical Abstracts. Study Selection:English-only publications through December 2012 with at least 30 patients older than 18 years, which included the key words of adult, critically ill, subjective sedation scale, sedation scale, validity, and reliability. Data Extraction:Two independent reviewers evaluated the psychometric properties using a standardized sedation scale psychometric scoring system. Data Synthesis:Among the 19,000+ citations extracted for the 2013 Society of Critical Care Medicine’s Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium and from December 2010 to 2012, 36 articles were identified compassing 11 sedation scales. The scale development process, psychometric properties, feasibility, and implementation of sedation scales were analyzed using a 0–20 scoring system. Two scales demonstrated scores indicating “very good” published psychometric properties: Richmond Agitation-Sedation Scale (19.5) and the Sedation-Agitation Scale (19). Scores with “moderate” properties include the Vancouver Interaction and Calmness Scale (14.3), Adaptation to the Intensive Care Environment (13.7), Ramsay Sedation Scale (13.2), Minnesota Sedation Assessment Tool (13), and the Nursing Instrument for the Communication of Sedation (12.8). Scales with “low” properties included the Motor Activity Assessment Scale (11.5) and the Sedation Intensive Care Score (10.5). The New Sheffield Sedation Scale (8.5) and the Observer’s Assessment of Alertness/Sedation Scale (3.7) demonstrated “very low” published properties. Conclusions:Based on the current literature, and using a predetermined psychometric scoring system, the Richmond Agitation-Sedation Scale and the Sedation-Agitation Scale are the most valid and reliable subjective sedation scales for use in critically ill adult patients.

Pain, Sedation, and Delirium Management in the Neurocritically Ill: Lessons Learned from Recent Research

Critically ill patients with a primary neurological injury or illness pose unique challenges for pain, agitation, and delirium management in intensive care units (ICUs). Detection and monitoring can be limited by contextual level of consciousness (LOC) alterations, cognition, expression, or language deficits. Recent data suggest that existing pain assessment tools may not be applicable to all neurocritically ill patients, especially in those with LOC alterations and atypical pain-associated behaviors. Targeted sedation goals may be neurologically disease specific; for instance, intracranial pressure (ICP) targets will supersede sedation titration by other criteria. Technology such as bispectral index (BIS) may be beneficial in avoiding excessive medication administration in deeply sedated neurologically injured ICU patients. Given the wide variety of pathology in the neurocritically ill patients, it is unclear if delirium can be diagnosed and unequivocally differentiated from symptoms of the underlying neurological pathology. However, delirium symptoms may herald life-threatening primary insult progression or result from a new secondary neurological injury and should be monitored. Patients with neurological injury or illness are often excluded from ICU studies addressing pain, sedation, and delirium, but this need not be the case. We review what is understood in this area based on current evidence.