Improving Acute Postoperative Pain Management for the Pediatric Patient: Guidelines on the Use of Intravenous Dexmedetomidine

Inadequately treated surgical pain in children leads to risky complications, such as longer recovery times, infection, prolonged hospitalizations, readmissions, altered pain sensitivity, neurophysiological changes, and cognitive-behavioral abnormalities (Campbell, 2013; Ibrahim, Jones, Lai, & Tan, 2016). Review of the literature indicated intravenous dexmedetomidine, as an adjunct, may lead to improved outcomes and a reduction in postoperative pain in children undergoing surgical intervention. An evidenced-based educational presentation introduced intravenous dexmedetomidine in children to anesthesia professionals, pharmacy staff, and the pediatric care team at a tertiary care center. Concluding the educational presentation, participants completed a voluntary survey evaluating the effectiveness of the presentation. Results suggested the educational presentation increased the knowledge and likelihood anesthesia providers will use dexmedetomidine in children during the perioperative period, potentially improving postoperative pain management. This project can be expanded upon through education of the post-anesthesia recovery unit, as well as the pediatric intensive care unit to promote dexmedetomidine as an adjunct to a multimodal pain management protocol

Kivunhoidon arvioiminen ja kirjaaminen tehohoidossa

Tämän opinnäytetyön tarkoituksena oli selvittää tapoja, joilla kivun arvioimisen käytäntöjä on pyritty kehittämään tehohoidossa. Opinnäytetyö tehtiin systemaattista kirjallisuuskatsausta (n=13) soveltaen. Tavoitteena oli auttaa kehittämään tapoja, joilla voidaan yhtenäistää kivunarvioimiskäytäntöjä teho-osastolla. Kipua mitataan teho-osastoilla vaihtelevasti. Yhdenmukaista käytäntöä kivun arvioimiseen ei ole käytössä. Vaikka viimeisten 30 vuoden aikana on tapahtunut suurta edistystä kriittisesti sairaiden potilaiden kivun hoitotyössä, kipu on säilynyt ongelmana. Julkaisujen haku suoritettiin 2007- 2018 julkaistuista tutkimuksista ARTO-, CINAHL-, MEDIC-, Pub Med- ja Science direct tietokannoista. Kirjallisuuskatsauksen aineistoksi valikoitui tutkimuskysymysten perusteella kolmetoista artikkelia. Tutkimusten aihepiiri voitaneen jakaa kolmeen luokkaan: Kipumittareiden käyttöönoton vaikutus kivunhoidon laatuun teho-osastolla, kivun arviointiin liittyvät uskomukset, jotka vaikuttavat tehtyihin hoitopäätöksiin ja hoitokirjauksiin sekä tutkimukset muista kivun indikaattoreista, joita voisi käyttää kivunarvioinnin pohjana. Opinnäytetyössä saatujen tulosten perusteella voidaan sanoa seuraavaa. Systemaattinen kivun arviointi parantaa potilaiden hoidon laatua ja lyhentää hoitoaikaa teho-osastolla. Riittävä kivun arviointi yhtenäisellä menetelmällä ja sen dokumentointi on edellytys riittävälle kivunhoidolle. Hoitajien perehdytys kipumittareiden käyttöön lisäsi sairaanhoitajien kykyä arvioida hoidon tarvetta sekä hoidon tuloksia ja paransi täten myös potilasturvallisuutta.The purpose of this thesis was to find out how pain registration practices has been developed in intensive care and also investigate, what kind of evidence based research has been made of pain assessment in intensive care of adult patients. This research has been made by using a systematic literature (n=13) review. The aim was to improve pain registration practices in inten-sive care and make them more coherent. Pain is measured to varying degrees in intensive care and there is no congruent manner to do it. Even though there has been major progress in nursing critically ill patients during the last 30 years, the pain has still remained a problem. The literature search was done among researches published in 2007-2018 in ARTO-, CINAHI-, MEDIC-, Pub Med-, and Science direct -databases. Thirteen articles were selected to the mate-rial of this review on the basis of research questions. The theme of the review can be divided into three categories: The influence of using pain scales in intensive care to the quality of pain management, nurses beliefs of pain management and their evaluation of pain, which may influ-ence to treatment decisions and recording of treatment and publications about other pain indicators, which could be used as a basis for evaluation of pain. According to results from this review systematic pain evaluation reported either by the patient or as a result of using pain scales, improves the quality of treatment experienced by the patient. Sufficient evaluation of pain with a coherent method and pain registration are precondi-tions to sufficient pain management. When nurses were orientated to using pain scales, they were more confident with their ability in evaluating pain management. Usage of pain scales and other pain indicators has increased the patient safety and helped the health care workers to operate with pain managemen

Practice of Postoperative Pain Management in Under-Five Children in A Tertiary Hospital: A Prospective Crossectional Study

BACKGROUND: Despite advancements in pain management, children have remained undertreated for postoperative pain. Data regarding the practice of post-operative pain management in paediatric patients remains less available in the developing world. This study was aimed at evaluating practice of postoperative pain management in under five children. METHODS: A prospective cross sectional one-year study was conducted on all paediatric patients who underwent major paediatric surgical procedures from February 1, 2020 to January31, 2021, at a tertiary hospital in Addis Ababa, Ethiopia. RESULT: A single type of analgesic medication was used in 67.1% patients. Analgesic medications were administered on standing base only in 64.4% of patients. Patients’ charts had no documentation of pain assessment both in the neonatal intensive care units and wards.32.89 % of assessed patients had moderate to severe pain record. CONCLUSION: Significant number of patients suffer from post-operative pain because of absence of proper pain assessment and inadequate administration of analgesic medication.   &nbsp

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

Implementing a hybrid cognitive-behavioural therapy for pain-related insomnia in primary care : lessons learnt from a mixed-methods feasibility study

Objectives: To test the feasibility of implementing a brief but intensive hybrid cognitive behavioural therapy (Hybrid CBT) for pain-related insomnia. Design: Mixed-methods, with qualitative process evaluation on a two-arm randomised controlled feasibility trial. Setting: Primary care. Participants: Twenty-five adult patients with chronic pain and insomnia. Intervention: Hybrid CBT or self-help control intervention. Primary and secondary outcome measures: Primary outcomes measures were the Insomnia Severity Index and interference scale of the Brief Pain Inventory (BPI). Secondary outcomes measures were the present pain intensity rating from the BPI, Multidimensional Fatigue Inventory, Hospital Anxiety and Depression Scale and EQ-5D-5L. Results: Fourteen participants were randomised to receive Hybrid CBT, 11 to receive the self-help control treatment. Of the 14 in the Hybrid CBT group, 9 (64%) completed all four treatment sessions (4 discontinued due to poor health; 1 due to time constraints). Adherence to the self-help control treatment was not monitored. The total number of participants completing the 12-week and 24-week follow-ups were 12 (6 in each group; Hybrid CBT: 43%; self-help: 55%) and 10 (5 in each group; Hybrid CBT: 36%; self-help: 45%). Based on the data available, candidate outcome measures appeared to be sensitive to changes associated with interventions. Thematic analysis of pre-postintervention interview data revealed satisfaction with treatment content among those who completed the Hybrid CBT, whereas those in the self-help control treatment wanted more contact hours and therapist guidance. Other practical suggestions for improvement included shortening the duration of each treatment session, reducing the amount of assessment paperwork, and minimising the burden of sleep and pain monitoring. Conclusion: Important lessons were learnt with regard to the infrastructure required to achieve better patient adherence and retention. Based on the qualitative feedback provided by a subset of treatment completers, future trials should also consider lowering the intensity of treatment and streamlining the data collection procedure. Trial registration number: ISRCTN17294365

Improving end-of-life care in acute geriatric hospital wards using the Care Programme for the Last Days of Life : study protocol for a phase 3 cluster randomized controlled trial

Background: The Care Programme for the Last Days of Life has been developed to improve the quality of end-of-life care in acute geriatric hospital wards. The programme is based on existing end-of-life care programmes but modeled to the acute geriatric care setting. There is a lack of evidence of the effectiveness of end-of-life care programmes and the effects that may be achieved in patients dying in an acute geriatric hospital setting are unknown. The aim of this paper is to describe the research protocol of a cluster randomized controlled trial to evaluate the effects of the Care Programme for the Last Days of Life. Methods and design: A cluster randomized controlled trial will be conducted. Ten hospitals with one or more acute geriatric wards will conduct a one-year baseline assessment during which care will be provided as usual. For each patient dying in the ward, a questionnaire will be filled in by a nurse, a physician and a family carer. At the end of the baseline assessment hospitals will be randomized to receive intervention (implementation of the Care Programme) or no intervention. Subsequently, the Care Programme will be implemented in the intervention hospitals over a six-month period. A one-year post-intervention assessment will be performed immediately after the baseline assessment in the control hospitals and after the implementation period in the intervention hospitals. Primary outcomes are symptom frequency and symptom burden of patients in the last 48 hours of life. Discussion: This will be the first cluster randomized controlled trial to evaluate the effect of the Care Programme for the Last Days of Life for the acute geriatric hospital setting. The results will enable us to evaluate whether implementation of the Care Programme has positive effects on end-of-life care during the last days of life in this patient population and which components of the Care Programme contribute to improving the quality of end-of-life care

Jefferson Digital Commons quarterly report: January-March 2020

This quarterly report includes: New Look for the Jefferson Digital Commons Articles COVID-19 Working Papers Educational Materials From the Archives Grand Rounds and Lectures JeffMD Scholarly Inquiry Abstracts Journals and Newsletters Master of Public Health Capstones Oral Histories Posters and Conference Presentations What People are Saying About the Jefferson the Digital Common

An Electronic Delphi Study to Establish Pediatric Intensive Care Nursing Research Priorities in Twenty European Countries*

OBJECTIVES:: To identify and to establish research priorities for pediatric intensive care nursing science across Europe. DESIGN:: A modified three-round electronic Delphi technique was applied. Questionnaires were translated into seven different languages. SETTING:: European PICUs. PARTICIPANTS:: The participants included pediatric intensive care clinical nurses, managers, educators, and researchers. In round 1, the qualitative responses were analyzed by content analysis and a list of research statements and domains was generated. In rounds 2 and 3, the statements were ranked on a scale of one to six (not important to most important). Mean scores and SDs were calculated for rounds 2 and 3. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Round 1 started with 90 participants, with round 3 completed by 64 (71%). The seven highest ranking statements ( 5.0 mean score) were related to end-of-life care, decision making around forgoing and sustaining treatment, prevention of pain, education and competencies for pediatric intensive care nurses, reducing healthcare-associated infections, identifying appropriate nurse staffing levels, and implementing evidence into nursing practice. Nine research domains were prioritized, and these were as follows: 1) clinical nursing care practices, 2) pain and sedation, 3) quality and safety, 4) respiratory and mechanical ventilation, 5) child- and family-centered care, 6) ethics, 7) professional issues in nursing, 8) hemodynamcis and resuscitation, and 9) trauma and neurocritical care. CONCLUSIONS:: The results of this study inform the European Society of Pediatric and Neonatal Intensive Care's nursing research agenda in the future. The results allow nurse researchers within Europe to encourage collaborative initiatives for nursing research