Comfortably Calm: Soothing Sedation of Critically Ill Children without Withdrawal Symptoms

Critically ill children admitted to an intensive care unit (ICU) are bound to experience some degree of discomfort, distress and pain, more than in other settings in a children’s hospital. Inserting intravenous lines, catheters and tubes is a major source of these adverse effects. In order to achieve that children will experience ICU stay less consciously they will regularly receive sedatives, such as midazolam, and analgesics, such as morphine, fentanyl). One of the nurse’s responsibilities is observing the degree of discomfort and the effect of the sedatives and analgesics used. Adequate sedation is very important. Scoring tools may help to objectivize evaluation. This thesis explores how to best determine depth of sedation in children in an ICU. We concluded that on the basis of the behavioral items, which form the COMFORT behavior scale, nurses are capable of assessing level of sedation in critically ill children in a reliable and valid manner. As a next step we defined new cutoff points for the COMFORT behavior scale. Score ranges 6 to 10 and 23 to 30 are associated with a high degree of certainty that a child is ‘oversedated’ or ‘undersedated’, respectively. The intervening score range 11 to 22 forms a grey area that requires the nurse’s clinical expertise expressed in the Nurse’s Interpretation of Sedation Score (NISS). Long-term administration of sedatives and analgesics in critically ill children may lead to various complications. For example, too rapid tapering or abrupt discontinuation of this medication may result in withdrawal symptoms. We therefore studied frequencies of occurrence of withdrawal symptoms in critically ill children. On the basis of the findings we then constructed a tool, the Sophia Observation withdrawal Symptoms-scale (SOS), with which nurses can assess withdrawal symptoms

Construction of the Sophia Observation withdrawal Symptoms-scale (SOS) for critically ill children

Objective: To construct a reliable and clinically practical instrument for monitoring opioids and benzodiazepine withdrawal symptoms in pediatric ICU patients. Design: Instrument development. Setting: Intensive care unit in an academic children's hospital. Patients and participants: 79 patients up to age 16 years on intravenous midazolam and/or opioids for ≥5 days. An expert panel of 85 physicians and nurses rated clinical relevance of withdrawal symptoms. Intervention: During drug weaning repeated observations were performed with a checklist of 24 withdrawal symptoms described in the literature. Measurements and results: For 76 children, 932 observations were obtained within 24 h after decrease and/or discontinuation of midazolam or opioids. Most frequent symptoms were tachypnea, agitation, motor disturbance, diarrhea, fever, anxiety, sleep disturbance and hypertension (14.6-29.6%). Multidimensional scaling (MDS) was performed to detect the underlying empirical structure of co-occurrences of symptoms. An expert panel judged clinical relevance of each withdrawal symptom on a four-point scale ranging from 'definitively so' to 'definitively not'. Agitation, an

A roadmap for paediatric and neonatal critical care nursing science in Europe: Engage, action and impact

Guest editoria

Using an intervention mapping approach to develop a discharge protocol for intensive care patients

Background: Admission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need. Methods: Intervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-

Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals

Background: This position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain related distress (adequacy of sedation, iatrogenic withdrawal syndrome, and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient. Methods: A multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain related distress in critically ill and non-verbal children, and searched the PubMed/Medline, Cinahl, and Embase databases for studies describing the psychometric properties of assessment instruments. Further, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added based on the level of evidence. Results: An ESPNIC Position Statement was drafted which provides clinical recommendations on assessment of pain (n=5), distress and/or level of sedation (n=4), iatrogenic withdrawal syndrome (n=3), and delirium (n=3). These recommendations were based on the available evidence and consensus amongst the experts and other members of the ESPNIC society. Conclusions: This multidisciplinary ESPNIC Position Statement guides professionals in the assessment and re-assessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium

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

Evaluating outpatient transition clinics: a mixed methods study protocol

__Introduction:__ To support young people in their transition to adulthood and transfer to adult care, a number of interventions have been developed. One particularly important intervention is the transition clinic (TC), where paediatric and adult providers collaborate. TCs are often advocated as best practices in transition care for young people with chronic conditions, but little is known about TC models and effects. The proposed study aims to gain insight into the added value of a TC compared with usual care (without a TC). __Methods and analysis:__ We propose a mixedmethods study with a retrospective controlled design consisting of semistructured interviews among healthcare professionals, observations of consultations with young people, chart reviews of young people transferred 2–4 years prior to data collection and questionnaires among the young people included in the chart reviews. Qualitative data will be analysed through thematic analysis and results will provide insights into structures and daily routines of TCs, and experienced barriers and facilitators in transitional care. Quantitatively, within-group differences on clinical outcomes and healthcare use will be studied over the four measurement moments. Subsequently, comparisons will be made between intervention and control groups on all outcomes at all measurement moments. Primary outcomes are ‘no-show after transfer’ ( process outcome) and ‘experiences and satisfaction with the transfer’ (patient-reported outcome). Secondary outcomes consider clinical outcomes, healthcare usage, self-management outcomes and perceived quality of care. __Ethics:__ The Medical Ethical Committee of the Erasmus Medical Centre approved the study protocol (MEC-2014-246). __Dissemination:__ Study results will be disseminated through peer-reviewed journals and conferences. The study started in September 2014 and will continue until December 2016. The same study design will be used in a national study in 20 diabetes settings (2016–2018)