A Multidimensional Approach to Pain Assessment in Critically Ill Infants During a Painful Procedure

Objectives: Inferring the pain level of a critically ill infant is complex. The ability to accurately extract the appropriate pain cues from observations is often jeopardized when heavy sedation and muscular blocking agents are administered. Near-infrared spectroscopy is a noninvasive method that may provide the bridge between behavioral observational indicators and cortical pain processing. We aimed to describe regional cerebral and systemic hemodynamic changes, as well as behavioral reactions in critically ill infants with congenital heart defects during chest-drain removal after cardiac surgery. Methods: Our sample included 20 critically ill infants with congenital heart defects, less than 12 months of age, admitted to the cardiac intensive care unit after surgery. Results: Cerebral deoxygenated hemoglobin concentrations significantly differed across the epochs (ie, baseline, tactile stimulus, noxious stimulus) (P=0.01). Physiological systemic responses and Face Leg Activity Cry Consolability (FLACC) pain scores differed significantly across the events (P<0.01). The 3 outcome measures were not found to be associated with each other. Mean FLACC pain scores during the painful procedure was 7/10 despite administration of morphine. Midazolam administration accounted for 36% of the variance in pain scores. Discussion: We demonstrated with a multidimensional pain assessment approach that significant cerebral, physiological, and behavioral activity was present in response to a noxious procedure in critically ill infants despite the administration of analgesic treatment. Considering that the sedating agent significantly dampened pain behaviors, assessment of cerebral hemodynamic in the context of pain seems to be an important addition.National Institutes of Health (U.S.) (Grant R01EB001659)National Institutes of Health (U.S.) (Grant K24NS057568)National Institutes of Health (U.S.) (Grant R21HD056009)National Institute for Biomedical Imaging and Bioengineering (U.S.)National Institute of Neurological Disorders and Stroke (U.S.)Eunice Kennedy Shriver National Institute of Child Health and Human Development (U.S.

Conceptualizing post intensive care syndrome in children: the PICS-p Framework*

Context: Over the past several decades, advances in pediatric critical care have saved many lives. As such, contemporary care has broadened its focus to also include minimizing morbidity. Post Intensive Care Syndrome, also known as “PICS,” is a group of cognitive, physical, and mental health impairments that commonly occur in patients after ICU discharge. Post Intensive Care Syndrome has been well-conceptualized in the adult population but not in children. Objective: To develop a conceptual framework describing Post Intensive Care Syndrome in pediatrics that includes aspects of the experience that are unique to children and their families. Data Synthesis: The Post Intensive Care Syndrome in pediatrics (PICS-p) framework highlights the importance of baseline status, organ system maturation, psychosocial development, the interdependence of family, and trajectories of health recovery that can potentially impact a child’s life for decades. Conclusion: Post Intensive Care Syndrome in pediatrics will help illuminate the phenomena of surviving childhood critical illness and guide outcomes measurement in the field. Empirical studies are now required to validate and refine this framework, and to subsequently develop a set of core outcomes for this population. With explication of Post Intensive Care Syndrome in pediatrics, the discipline of pediatric critical care will then be in a stronger position to map out recovery after pediatric critical illness and to evaluate interventions designed to mitigate risk for poor outcomes with the goal of optimizing child and family health

Mothers' experiences of a touch and talk nursing intervention to optimise pain management in the PICU: a qualitative descriptive study

Background: Parents consistently express a desire to support their child and retain a care-giving role in the paediatric intensive care unit (PICU). Qualitative data gathered as part of a PICU intervention study were analysed to explore mothers’ experiences using a Touch and Talk intervention to comfort their children during invasive procedures. Objectives: To describe how mothers experienced involvement in their children's care through a Touch and Talk intervention and whether they would participate in a similar intervention again. Research methodology and setting: A qualitative descriptive design was used and semi-structured interviews conducted with 65 mothers in three Canadian PICUs. Data were subjected to thematic analysis. Results: The overarching theme centred on the importance of comforting the critically ill child. This included being there for the child (the importance of parental presence); making a difference in the child's pain experience; and feeling comfortable and confident about participating in care. All but two mothers would participate in the intervention again and all would recommend it to others. Conclusions: Giving parents the choice of being involved in their child's care using touch and distraction techniques during painful procedures can provide an invaluable opportunity to foster parenting and support the child during a difficult PICU experience

Cerebral Near-Infrared Spectroscopy as a Measure of Nociceptive Evoked Activity in Critically III Infants

Due to the subtlety or absence of predictable, objective signs of pain in critically ill infants, health care professionals must often rely on observations of behavioural or nonspecific physiological signals. Although parameters such as heart rate or blood pressure could be regarded as relatively more objective or quantifiable measures than behavioural signals, they are often unstable and generally nonspecific. However, reducing inaccuracies in pain assessment and misinterpretation of pain intensity may be facilitated by new techniques that shed light on the cerebral responses to pain that could be measured directly. Near-infrared spectroscopy is one such technique that has been used to detect subtle changes in the concentrations of oxygenated and deoxygenated hemoglobin in the brains of preterm and term infants in response to stressful and/or painful stimuli. Following a review of cortical pain responses, this article provides an overview of near-infrared spectroscopy technology and its use in functional activation studies in critically ill infants, and its potential applications in clinical settings and pain research

Children’s psychological and behavioral responses following pediatric intensive care unit hospitalization: the caring intensively study

Abstract Background Pediatric intensive care unit (PICU) hospitalization places children at increased risk of persistent psychological and behavioral difficulties following discharge. Despite tremendous advances in medical technology and treatment regimes, approximately 25% of children demonstrate negative psychological and behavioral outcomes within the first year post-discharge. It is imperative that a broader array of risk factors and outcome indicators be explored in examining long-term psychological morbidity to identify areas for future health promotion and clinical intervention. This study aims to examine psychological and behavioral responses in children aged 3 to 12 years over a three year period following PICU hospitalization, and compare them to children who have undergone ear, nose and/or throat (ENT) day surgery. Methods/Design This mixed-methods prospective cohort study will enrol 220 children aged 3 to 12 years during PICU hospitalization (study group, n = 110) and ENT day surgery hospitalization (comparison group, n = 110). Participants will be recruited from 3 Canadian pediatric hospitals, and followed for 3 years with data collection points at 6 weeks, 6 months, 1 year, 2 years and 3 years post-discharge. Psychological and behavioral characteristics of the child, and parent anxiety and parenting stress, will be assessed prior to hospital discharge, and again at each of the 5 subsequent time points, using standardized measures. Psychological and behavioral response scores for both groups will be compared at each follow-up time point. Multivariate regression analysis will be used to adjust for demographic and clinical variables at baseline. To explore baseline factors predictive of poor psychological and behavioral scores at 3 years among PICU patients, correlation analysis and multivariate linear regression will be used. A subgroup of 40 parents of study group children will be interviewed at years 1 and 3 post-discharge to explore their perceptions of the impact of PICU hospitalization on their children and enhance our understanding of findings generated from standardized measures in the larger cohort study. An interpretive descriptive approach will guide qualitative data collection and analysis. Discussion This study aims to generate new information regarding the magnitude and duration of psychological and behavioral disturbances among children admitted to PICUs, potentially leading to remedial or preventive interventions

Canadian Developmental Follow-up Practices in Children With Congenital Heart Defects: A National Environmental Scan

Background: Developmental follow-up is central to the timely identification of delays in at-risk children. Throughout Canada, data are currently lacking on the follow-up of children with congenital heart disease (CHD) after open-heart surgery. The objective of this study was to describe current Canadian developmental follow-up practices and to explore barriers to optimal follow-up. Methods: A cross-sectional study was implemented with health professionals involved with the developmental follow-up of children with CHD in the 8 specialized hospitals that perform pediatric open-heart surgery in Canada. A questionnaire collected descriptive information about the setting and current follow-up practices. In addition, an interview was conducted to explore what would be considered optimal developmental follow-up in Canada and identify potential barriers. Results: Four of the 8 tertiary care centres had a systematic developmental follow-up program that included screening and formal evaluation. These programs were only accessible to a subset of children with CHD identified to be at higher risk. Participants described current practices as suboptimal and aimed to develop a more systematic developmental follow-up program or expand an existing one. Participants emphasized the lack of human resources, financial supports, and limited dedicated time as major barriers to offering optimal follow-up care. Conclusions: Current follow-up practices in Canada are considered suboptimal by health care specialists involved in treating children with CHD. These practices may fail to promptly identify children and adolescents with CHD who have developmental challenges. It is essential that we develop national recommendations to optimize the developmental follow-up practices in Canada for this high-risk population. Résumé: Contexte: Le suivi développemental est essentiel afin d’identifier rapidement les retards chez les enfants à risque. Il n’existe actuellement pas de données sur le suivi des enfants atteints d’une cardiopathie congénitale ayant nécessité une intervention chirurgicale à cœur ouvert. L’objectif de cette étude consistait à décrire les pratiques actuelles de suivi développemental et à explorer les obstacles à un suivi optimal au Canada. Méthodologie: Une étude transversale a été menée auprès de professionnels de la santé assurant le suivi du développement d’enfants atteints de cardiopathie congénitale dans huit hôpitaux spécialisés qui pratiquent des chirurgies à cœur ouvert au Canada. Un questionnaire a permis de recueillir des renseignements descriptifs sur les établissements et les pratiques actuelles de suivi. De plus, une entrevue a été menée pour explorer ce qui pourrait être considéré comme un suivi optimal du développement au Canada et cerner les obstacles actuels. Résultats: Quatre des huit centres de soins tertiaires disposaient d’un programme de suivi systématique du développement qui comprenait un dépistage et une évaluation formelle. Ces programmes n’étaient accessibles qu’à un sous-groupe d’enfants atteints d’une cardiopathie congénitale, identifiés comme étant à risque élevé de retard de développement. Les participants ont décrit les pratiques actuelles comme sous-optimales et souhaitaient mettre en place un programme de suivi développemental plus systématique ou à élargir un programme existant. Les participants ont souligné le manque de ressources humaines et financières ainsi que le peu de temps qui peut être consacré au suivi comme étant les principaux obstacles pour offrir un suivi optimal. Conclusions: Les professionnels de la santé œuvrant dans le traitement des enfants atteints de cardiopathie congénitale considèrent que les pratiques actuelles de suivi au Canada sont sous-optimales. Ces pratiques peuvent ne pas permettre d’identifier rapidement les enfants et les adolescents atteints de cardiopathie congénitale qui présentent des retards de développement. Il est essentiel que nous élaborions des recommandations nationales pour optimiser les pratiques de suivi développemental au Canada pour cette population à risque élevé