Research paperNurse titrated analgesia and sedation in intensive care increases the frequency of comfort assessment and reduces midazolam use in paediatric patients following cardiac surgery
Introduction
Providing optimal analgesia and sedation for children in intensive care is a challenge for clinicians.1 Children who are not provided with sufficient analgesics are at risk of experiencing pain due to invasive treatments; if children are also not adequately sedated, they may be at risk of discomfort.2 Alternatively, children treated with excessive analgesics or sedatives are at risk of developing withdrawal or tolerance.3, 4 Potential long-term consequences of administering sedatives include apoptosis of brain cells5 and learning difficulties.6 However, obtaining an accurate assessment of the child’s level of pain and discomfort, in order to provide an appropriate level of treatment, is challenging in paediatric intensive care (PICU).7, 8 Developmental age, administration of sedatives and intubation all impair the child’s ability to adequately communicate their needs.9, 10
Self-report remains the gold standard of pain assessment,11 though children are not always able to self-report their pain or discomfort due to different developmental stages.12 Pain assessment tools utilise behavioural and physiological parameters in order to overcome developmental communication barriers with children.12 Specific pain tools for children within intensive care have been developed and validated in order to assess children who may be unable to communicate due to developmental age and intensive treatments such as intubation and sedation.13, 14, 15, 16 Utilising a pain and sedation protocol that incorporates a validated assessment tool may aid clinicians to provide evidence- based treatment to children, and avoid incidences of under or over treatment of pain and discomfort.17
Introducing a protocol to manage pain and sedation may influence other outcomes than performing pain assessments, such as analgesic and sedative administration.18, 19 Evaluation of PICU pain and sedation protocols in current literature reveals that there are differences in primary outcome measures. Some studies have reported an increase in administration of sedatives and analgesics following the introduction of a pain and sedation protocol into PICUs18, 20 whilst others report a decrease.19, 21 At the time that this study was conducted, a consensus on how pain and sedation protocols influence ICU length of stay and duration of ventilation was unclear.22
Section snippets
Background
In 2010 the COMFORT B tool was introduced into the PICU for the assessment of both pain and sedation. The COMFORT B tool has demonstrated internal consistency (Cronbach’s alpha 0.78), concurrent validity (Kruskal–Wallis chi squared = 237, df = 2, p = <0.001) and interrater reliability (Kappa 0.71) within the paediatric intensive care for patients aged 0–18 years.14, 15 Using one tool to assess for both pain and sedation is controversial, however the COMFORT B tool has been used for this purpose
Aim
To assess the influence of using a pain and sedation protocol on management of children admitted to PICU following cardiac surgery. Key outcomes included frequency of pain and sedation assessments, dosage/administration of analgesics or sedatives and length of ventilation.
Methods
The setting was a 21 bed PICU that cares for children within the Victorian state of Australia. The unit provides cardiac surgery to approximately 900 children per year.
A retrospective audit of medical records before and after the pain and sedation protocol was performed. Hospital ethics approval was obtained prior to commencing the study. The medical records of 100 patients were audited, as this was deemed achievable within the timeframe required to perform the study. The patients included 50
Inclusion criteria
Intubated and ventilated patients less than 18 years of age admitted into the PICU after cardiac surgery.
Exclusion criteria
Patients were excluded if they received more than two doses of neuromuscular blocking agents once they arrived in PICU.
Collected data included basic demographic information such as age, weight and diagnosis according to the Risk Adjusted Congenital Heart Surgery (RACHS-1) fields.28 Duration of mechanical ventilation and PICU length of stay was also collected. The type of pain and sedation assessment performed was collected, along with the overall score.
Data collection also included amount of
Results
A total of 100 patients admitted to PICU following cardiac surgery were included in the study (Fig. 1). Double data entry revealed 80 out of 7500 data points (1.07%) required review to address errors or to correct missing fields. As detailed in Table 1, there were significantly younger patients in the post protocol group, mostly in the 5 weeks to 12 month group (22% pre protocol vs 50% post protocol, p = 0.004) and the 13 months to 4 years (32% pre protocol vs 2% post protocol, p = 0.001). There
Pain and sedation assessments
The majority of patients received a pain and sedation assessment using the Comfort B score whilst receiving mechanical ventilation (41 pre protocol and 47 post protocol). COMFORT B assessments were performed more frequently in the post protocol group (pre protocol 3/24 h, post protocol 5/24 h, p = 0.006), see Table 2.
Discussion
This study demonstrated that following the introduction of a pain and sedation protocol, the frequency of documented validated pain scores increased. Secondly, there was no change to the COMFORT B score level despite a reduction in the amount of midazolam administered to patients post protocol introduction. However, there was a an increase in the duration of ventilation.
Limitations
In interpreting the study results several limitations are considered; this includes the small number of patients in each group and that the study was performed as a single centre retrospective chart audit. This increases the risk to internal validity through uncontrolled confounding variables.40 However, due to the resources available, this design was the most feasible and thus a sample size calculation would have been inappropriate. The authors considered it important to evaluate the impact of
Implications for practice
Implementing a nurse titrated pain and sedation protocol has contributed to increased frequency of pain and sedation assessment scores and administration of morphine boluses performed by nurses. This is an important outcome of the treatment protocol as it enables nurses to provide timely pain relief in response to the patient’s needs and has the potential to improve patient outcomes in PICU through increased recognition of children’s pain or distress.
Less midazolam was delivered to patients,
Conclusion
Introducing a pain and sedation protocol into the PICU at RCH was associated with important changes in pain and sedation management. Notably an increase in COMFORT B documentation and moderation of sedative administration. Protocolisation enabled nursing staff to provide pain and sedation management in a consistent and timely manner. However, a trend towards increased duration of ventilation is of concern, although may be due to propensity matching not being performed between the patient groups
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