COMFORT Behaviour Scale Research Articles

Stress assessment instruments for hospitalized preterm newborns: scoping review

BackgroundThe highly technological environment existing in intensive care units, essential for the survival of the newborn, contributes with a potentially devastating and traumatic effect, especially in preterm newborns and in their future lives, due to the early and frequent exposure to multiple stressors. The preterm newborn must be observed in a systematic and structured way, before, during and after any intervention, aiming at the correct assessment and interpretation of his behaviour and signs of stress, and at the timely planning of interventions that minimize and prevent stress. The objective of this review is to identify and map the instruments for assessing stress in preterm newborns admitted to neonatal units in scientific evidence.MethodsA scoping review was carried out using the methodology presented by The Joanna Briggs Institute (JBI) and the PRISMA ScR model (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extended for Scoping Reviews) for structuring the collected information. The research was carried out in three distinct phases supported by the Medline, CINALH databases through the EBSCO, Scielo and PubMed platform. Two reviewers screened all citations, abstract data and full-text articles, independently.ResultsTen articles were selected, all primary studies. Seven different scales were identified in the studies.DiscussionThis review highlights the limited availability of instruments exclusively designed to assess neonatal stress in neonatology. While most tools, like the Newborn Comfort Behavior Scale and ALPS-Neo, focus on pain and stress together, the NISS and NSS provide valuable insights despite limitations in capturing individualized stress responses. Differentiating stress from pain is crucial for implementing targeted, neuroprotective interventions. Adapting neonatology environments and care practices to minimize stressors is essential for promoting newborns' well-being and long-term development.ConclusionThe findings underscore the critical need for stress-specific assessment tools in NICUs to differentiate between pain and stress. Existing instruments offer valuable insights but have notable limitations. Expanding validated tools and prioritizing individualized, neuroprotective care are essential for improving outcomes. Adapting neonatology practices to reduce stressors and implement family-centered care will support the holistic needs of newborns, fostering their development, physiological stability, and overall well-being.System review registrationOpen Science Framework (https://osf.io/nsu95/).

Translation and psychometric properties of the comfort behavioral scale-Persian version

BackgroundManaging pain and the level of sedation of critically ill children admitted to the intensive care unit is a complex process and one of the most basic problems of nurses, which requires the use of an available valid, and reliable scale. The present study aimed to translate the comfort behavioral scale into Persian and check its validity and reliability.MethodsThis methodological research was carried out in the children’s hospitals of Tehran Province (Iran) from Nov 2023 to Apr 2024. After forward and backward translation, face validity was performed qualitatively and quantitatively. Then, qualitative content validity was checked and the content validity ratio and content validity index were measured. The discriminant validity method was used to determine construct validity, and the nurse interpretation sedation scale and nurse report pain scale were used to check the criterion validity. The concordance correlation coefficient method was used to determine reliability.ResultsIn quantitative face validity, all 30 items received an impact score of more than 1.5. In qualitative content validity, some words were replaced with more concrete words. In the content validity ratio, considering the minimum value of 0.62 for 10 experts, none of the items were excluded. The content validity index for all items was higher than 0.8 and S-CVI/Ave for the whole scale was 0.96. There was a significant difference between the pain score in the painful state (24.87 ± 2.5) and the resting state (20.9714 ± 2.4) (P = 0.000). The correlation between Comfort and criterion instruments (NISS and NRS) in a resting state and during a painful procedure was positively significant (P < 0.05). The kappa agreement coefficient showed values higher than 0.4 and reliability was confirmed.ConclusionsThe Persian version of the COMFORT behavioral scale has good validity and reliability and can be used as a suitable tool for pain management of hospitalized children with a low level of consciousness and lack of verbal communication. The use of this tool not only helps the clinical, educational, and research process but also leads to an increase in the quality of care and satisfaction of the child and her parents in Iranian hospitals.

The Effect of Swaddling and Oropharyngeal Colostrum During Endotracheal Suctioning on Procedural Pain and Comfort in Premature Neonates: A Randomized Controlled Trial.

Endotracheal suctioning (ES) is a painful procedure frequently performed in the neonatal intensive care unit. This procedure negatively affects the comfort level of premature neonates. To determine the effect of 2 nonpharmacologic methods, swaddling and the administration of oropharyngeal colostrum, on the pain and comfort levels of preterm neonates during ES. This randomized controlled experimental study comprised 48 intubated premature neonates (swaddling group n =16; oropharyngeal colostrum group n =16; and control group n =16) at 26 to 37weeks of gestation. The neonates were swaddled with a white soft cotton cloth or administered 0.4 mL of oropharyngeal colostrum 2minutes before ES, according to the group in which they were included. Two observers evaluated the pain levels (Premature Infant Pain Profile-Revize [PIPP-R]) and comfort (Newborn Comfort Behavior Scale [COMFORTneo]) of the infants by observing video recordings of before, during, and after the procedure. A significantly lower mean PIPP-R score was found in the swaddling group during ES compared with the control group ( P =.002). The mean COMFORTneo scores of the swaddling and oropharyngeal colostrum groups during ES ( P <.01, P =.002) and the mean PIPP-R and COMFORTneo scores immediately after ES and 5, 10, and 15minutes later were significantly lower than the control group ( P <.005). Swaddling was effective both during and after the procedure, while oropharyngeal colostrum was effective only after the procedure in reducing ES-related pain in premature neonates. Swaddling and oropharyngeal colostrum were effective in increasing comfort both during and after the procedure.

Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study)

BackgroundThe objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV).MethodsThirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients’ level of comfort. NIV failure was considered to be a requirement for endotracheal intubation.ResultsA total of 457 patients were included, with a median age of 3.3 months (IQR 1.3–16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230–1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009–1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS.ConclusionsSedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.

Pain Assessment in the Outpatient Pediatric Burn Patient: An Integrative Review.

There is no standardized practice in pediatric pain assessment with burn injuries in the outpatient clinic setting. This review aims to identify reliable, validated tools to measure pain in the pediatric burn clinic population. The literature search for this integrative review was conducted using the databases of PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane, and Embase from 2011 to 2023. Quality and relevance were appraised using the Johns Hopkins Nursing Evidence-Based Practice Model. Reporting was done according to a Preferred Reporting Items for Systemic Reviews and Meta-Analysis checklist. Fourteen articles and two clinical practice guidelines met inclusion criteria and were included in this review. The Pain Observation Scale for Young Children and the COMFORT Behavior Scale tools have shown good reliability and construct validity and can be safely used to measure background and procedural pain in daily burn practice. Further research on reliable, validated pain assessment techniques in the pediatric burn population is needed.

Evaluation of Comfort Behavior Levels of Newborn by Artificial Intelligence Techniques.

One of the scales most frequently used in the evaluation of newborn comfort levels is the Neonatal Comfort Behavior Scale (NCBS). It is important therefore that an increased use of the NCBS is encouraged through a more practical method of assessment. This study was carried out for the purpose of designing a means of assessing neonatal comfort levels by employing the techniques of artificial intelligence (AI). The AI-based study was conducted with 362 newborns under treatment in the neonatal intensive care unit of a hospital. A data collection form, the NCBS, and a camera system were used as data collection tools. The data were analyzed with the SPSS Statistics 21.0 program. Descriptive statistics and Cohen κ test were employed in the analysis. The 2 researchers named in the study first labeled the audiovisual recordings of the 362 newborns in the study. These labeled audiovisual recordings were used in training (80%) as well as testing (20%) the AI model. The AI model displayed a rate of success of 99.82%. It was ultimately seen that the AI model that had been developed was a successful tool that could be used to determine the comfort behavior levels of newborns in the neonatal intensive care unit.

Protocolized Sedation Utilizing COMFORT-B Scale versus Non-protocol-directed Sedation in Mechanically Ventilated Children - An Open-label, Randomized Controlled Trial.

This study aimed to determine the effect of protocolized sedation using the COMFORT-B scale on the duration of mechanical ventilation (DMV). Eighty children with anticipated Duration of mechanical ventilation (DMV) >24h admitted to the Pediatric intensive care unit (PICU) were randomized into one group that received protocolized sedation (PS) using the COMFORT behavioural (COMFORT-B) scale, and another group that received non-protocolized sedation (NPS). The primary outcome was the impact on the DMV. The DMV was significantly lower in PS (PS: 3.5 [3-7] vs. NPS group: 8.5 [4.25-13.75] d; p = 0.008). The cumulative dose and duration of fentanyl in the PS group was significantly lower (median [IQR]; 120 [62.88-279.12] vs. 320.4 [110.88-851.52] μg/kg; p = 0.007 and 4 [2.25-7.75] vs. 8 [4-17.5] d; p = 0.009, respectively). The authors found a decrease in DMV and sedation related adverse events (SRAE) like ventilator associated pneumonia (VAP), accidental extubation, post-extubation stridor and dose and duration of sedative agents with PS.

The Effect of Lullabies and Classical Music on Preterm Neonates' Cerebral Oxygenation, Vital Signs, and Comfort During Orogastric Tube Feeding: A Randomized Controlled Trial.

This study investigated the effect of lullabies and classical music on preterm neonates' cerebral oxygenation, vital signs, and comfort during orogastric (OG) tube feeding. This was a parallel-group pretest-posttest randomized controlled study. The research was conducted between December 2020 and May 2022. The sample consisted of 51 preterm neonates hospitalized in the neonatal intensive care unit (NICU) of Selçuk University Faculty of Medicine Hospital in Konya, Türkiye. Participants were randomized into three groups (17 preterm infants in each group). The first group listened to lullabies sung by their mothers and the second group listened to classical music during OG tube feeding. The control group received routine care with no music. Data were collected using a Neonatal Identification Information Form, Physiological Parameters and rSO2 Monitoring Form, and the Newborn Comfort Behavior Scale (Comfort-Neo). The study was registered on the ClinicalTrials database (NCT05333575). The lullaby group had stable peak heart rates and oxygen saturation levels (p = .002). Both lullaby and classical music groups had significantly higher cerebral oxygenation levels than the control group. The classical music group had the highest cerebral oxygenation level (p = .001). Both lullaby and classical music groups had significantly higher mean Comfort-Neo scores than the control group. The classical music group had the highest mean Comfort-Neo score (p = .040). Preterm neonates who listen to lullabies and classical music are likely to have higher cerebral oxygen and comfort levels. Listening to lullabies helps stabilize vital signs. These results suggest that healthcare professionals should encourage parents to get their preterm neonates to listen to lullabies and classical music.

Parental presence and intranasal dexmedetomidine for the prevention of anxiety during anesthesia induction in children undergoing tonsillectomy and/or adenoidectomy surgery: A randomized controlled trial.

Background: During the perioperative period of pediatric surgery, it is extremely stressful for children and parents to enter the operating room and receive the anesthesia induction. This study was designed to evaluate the perioperative outcomes with parental presence at induction of anesthesia (PPIA), intranasal dexmedetomidine, and combined use of PPIA and intranasal dexmedetomidine. Methods: In this prospective study, 124 children were randomly divided into four groups: control (no parental presence or intranasal dexmedetomidine), PPIA (parental presence), DEX (intranasal dexmedetomidine (1.0μg/kg)), and PPIA + DEX (parental presence and intranasal dexmedetomidine (1.0μg/kg)). The anxiety of children was mainly evaluated by the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Secondary evaluation methods were, for example, the Induction Compliance Checklist (ICC), the Pediatric Anesthesia Emergence Delirium Scale (PAED), the COMFORT Behavior Scale (COMFORT-B Scale), the State-Trait Anxiety Inventory (STAI), and the Visual Analog Scale (VAS). Results: Children in the PPIA + DEX group exhibited significantly lower mYPAS-SF and ICC scores compared with all three other groups (p < 0.001), and children in that group exhibited significantly lower mYPAS-SF and ICC scores compared with the PPIA and DEX groups (p < 0.05). The children's PAED scores in the PPIA, DEX, and PPIA + DEX groups were significantly lower than the control group (p < 0.001).The STAI-S scores of the PPIA, DEX, and PPIA + DEX groups were significantly lower than the score of the control group (p < 0.001). The VAS scores of the PPIA, DEX, and PPIA + DEX groups were significantly higher than that of the control group (p < 0.001), while the score of the PPIA + DEX group was significantly higher than those of the PPIA and DEX groups (p < 0.05). Conclusion: The combined use of PPIA and intranasal dexmedetomidine is more effective than PPIA or intranasal dexmedetomidine for alleviating the preoperative anxiety of children, improving children's induction compliance and parental satisfaction.

Effects of the facilitated tucking position in early period on physiological parameters, comfort and breastfeeding performance in late preterm infants: A randomized controlled trial

ObjectiveThis study's aim to determine the effect of facilitated tucking position applied to late preterm infants on physiological parameters, comfort, and breastfeeding performance. DesignThe study was conducted in a randomized controlled experimental design (Clinical Trial number: NCT04704180). MethodsThe study was conducted in the neonatal intensive care unit of a state hospital in eastern Turkey between November 2018 and July 2019. The sample consisted of 89 neonates meeting the inclusion criteria. Data were collected using the Neonatal Introductory Information Form, Physiological Parameter Follow-Up Chart, Neonatal Comfort Behavior Scale (NCBS), and Latch Breastfeeding Diagnosis Measurement Form. Facilitated tucking position was applied to the neonates in the experimental group (n = 44) in the early postnatal period. The routine application of the unit was performed on neonates (n = 45) in the control group. Ethical principles were followed at every stage of the study. FindingsIt was determined that the physiological parameters (heart rate, oxygen saturation, body temperature, respiratory rate) in the experimental group positioned with facilitated tucking showed a significant improvement compared to the control group (p<0.001). When the mean comfort (Experiment: 9.79±3.63, Control: 15.73±5.13) and LATCH (Experiment: 8.00±1.76, Control: 5.82±2.18) scores of neonates in the experimental group were compared with the control group, a significant difference was found in favor of the experimental group (p<0.001). Implications for practiceIt was determined that the physiological parameters, comfort level and sucking success of late preterm infants who were positioned with facilitated tucking in the early postnatal period were positively affected.

Caudal epidural morphine versus intravenous morphine for postoperative analgesia in pediatric cardiac surgery

Background &amp; objective: Traditionally, analgesia after heart surgery is obtained with the use of intravenous opioids (particularly morphine). Continuous infusion of narcotic analgesics results in a more constant level of analgesia, but slow accumulation may cause excessive sedation. The caudal epidural narcotics, alone or with local anesthetics have been advocated following lower abdominal and thoracic surgery in children. We compared the analgesic effect and safety of caudal epidural morphine (CEM) after heart surgery with intravenous morphine infusion.&#x0D; Methodology: Sixty children, aged 6 months to 5 y, undergoing elective cardiac surgery under general anesthesia were enrolled in the study. The patients were randomly allocated to one of the two groups to receive either 0.06 mg/kg CEM at induction of anesthesia (study group or CEM group) or postoperative morphine infusion at a rate of 0.025 mg/kg/h intravenously (control group or PIVM group). Postoperative pain scores were assessed according to the COMFORT behavior scale. Two patients were excluded from the study after randomization and 58 patients completed the study.&#x0D; Results: Time from pediatric intensive care unit (PICU) admission to the need of intravenous morphine boluses was significantly longer in the CEM group compared with the control group (16-20 h vs 38 min; P &lt; 0.0001). In CEM group, 68.97% of patients did not require additional morphine and the total intravenous morphine consumption over the 48 h postoperatively was lower (P &lt; 0.0001). Moreover, the use of CEM resulted in earlier extubation and earlier discharge from the PICU (P = 0.011). Over-sedation was recorded in the control group on the first postoperative day. The incidence of adverse events was low in both groups. Respiratory depression was not seen in CEM group patients.&#x0D; Conclusion: A single dose of morphine 0.06 mg/kg in caudal epidural, preoperatively in pediatric cardiac surgery, had a significant intravenous morphine sparing effect as compared to a postoperative morphine infusion at a rate of 0.025 mg/kg/h, and was associated with a low incidence of adverse events after pediatric cardiac surgery. Effective analgesia was achieved for 16-20 h after surgery.&#x0D; Key words: Caudal epidural morphine; COMFORT behavior scale; Opioid–related adverse events; Pediatric cardiac surgery; Analgesia, Postoperative&#x0D; Citation: Nguyen TD, Ngo D, Pham NH, Jantzen T. Caudal epidural morphine versus intravenous morphine for postoperative analgesia in pediatric cardiac surgery. Anaesth. pain intensive care 2022;26(4):514-522.&#x0D; DOI: 10.35975/apic.v26i4.1959&#x0D; Received: August 15, 2022; Reviewed: January 02, 2022; Accepted: July 07, 2022

Specificity and sensibility of the Spanish version of the COMFORT Behaviour Scale for assessing pain, grade of sedation and withdrawal syndrome in the critically ill paediatric patient. Multicentre COSAIP study (Phase 1)

AimThe main aim of this investigation was to analyse the specificity and sensibility of the COMFORT Behaviour Scale (CBS-S) in assessing grade of pain, sedation, and withdrawal syndrome in paediatric critical care patients. MethodAn observational, analytical, cross-sectional and multicentre study conducted in Level III Intensive Care Areas of 5 children's university hospitals. Grade of sedation was assessed using the Spanish version of the CBS-S and the Bispectral Index on sedation, once per shift over one day. Grade of withdrawal was determined using the CBS-S and the Withdrawal Assessment Tool-1, once per shift over three days. ResultsA total of 261 critically ill paediatric patients with a median age of 5.07 years (P25:0.9-P75:11.7) were included in this study. In terms of the predictive capacity of the CBS-S, it obtained a Receiver Operation Curve of .84 (sensitivity of 81% and specificity of 76%) in relation to pain; .62 (sensitivity of 21% and specificity of 78%) in relation to sedation grade, and .73% (sensitivity of 40% and specificity of 74%) in determining withdrawal syndrome. ConclusionsThe Spanish version of the COMFORT Behaviour Scale could be a useful, sensible and easy scale to assess the degree of pain, sedation and pharmacological withdrawal of critically ill paediatric patients.

Pain and sedation management and monitoring in pediatric intensive care units across Europe: an ESPNIC survey

BackgroundManagement and monitoring of pain and sedation to reduce discomfort as well as side effects, such as over- and under-sedation, withdrawal syndrome and delirium, is an integral part of pediatric intensive care practice. However, the current state of management and monitoring of analgosedation across European pediatric intensive care units (PICUs) remains unknown. The aim of this survey was to describe current practices across European PICUs regarding the management and monitoring of pain and sedation.MethodsAn online survey was distributed among 357 European PICUs assessing demographic features, drug choices and dosing, as well as usage of instruments for monitoring pain and sedation. We also compared low- and high-volume PICUs practices. Responses were collected from January to April 2021.ResultsA total of 215 (60% response rate) PICUs from 27 European countries responded. Seventy-one percent of PICUs stated to use protocols for analgosedation management, more frequently in low-volume PICUs (77% vs 63%, p = 0.028). First-choice drug combination was an opioid with a benzodiazepine, namely fentanyl (51%) and midazolam (71%) being the preferred drugs. The starting doses differed between PICUs from 0.1 to 5 mcg/kg/h for fentanyl, and 0.01 to 0.5 mg/kg/h for midazolam. Daily assessment and documentation for pain (81%) and sedation (87%) was reported by most of the PICUs, using the preferred validated FLACC scale (54%) and the COMFORT Behavioural scale (48%), respectively. Both analgesia and sedation were mainly monitored by nurses (92% and 84%, respectively). Eighty-six percent of the responding PICUs stated to use neuromuscular blocking agents in some scenarios. Monitoring of paralysed patients was preferably done by observation of vital signs with electronic devices support.ConclusionsThis survey provides an overview of current analgosedation practices among European PICUs. Drugs of choice, dosing and assessment strategies were shown to differ widely. Further research and development of evidence-based guidelines for optimal drug dosing and analgosedation assessment are needed.

Use of Musical Intervention in the Pediatric Intensive Care Unit of a Developing Country: A Pilot Pre-Post Study.

Music is frequently used in different clinical settings, and it is implemented as a complementary, low-cost and useful intervention to reduce pain, anxiety and to improve relaxation. This pilot pre–post study aimed to examine the feasibility and preliminary effectiveness of a specific musical intervention in patients ≤16 years admitted to the Pediatric Intensive Care Unit (PICU) of an Iraqi hospital. The COMFORT Behavior Scale (CBS) was used by nurses to assess the level of sedation. Fifty-nine children were enrolled during the study period (March 2020–August 2021). CBS was lowered by 2.2 (95% CI: 1.9 to 2.6) points after 30 min, and by 3.3 (95% CI: 2.9 to 3.6) points after 60 min from music initiation. Thirty minutes after music initiation, heart rate decreased by 6.3 (95% CI: 4.5 to 8.1) beats per minute, whereas at 60 min, heart rate decreased by 9.1 (95% CI: 7.2 to 10.9) beats per minute. No clinically significant variations were detected in the other vital signs (blood pressure, respiratory rate and oxygen saturation). These findings support the feasibility of musical intervention in a developing country. CBS and heart rate variation may be worth following up in larger and conclusive studies.

Validity and Reliability of the Richmond Agitation-Sedation Scale in Pediatric Intensive Care Patients: A Multicenter Study.

Background: There is limited data about the psychometric properties of the Richmond Agitation-Sedation Scale (RASS) in children. This study aims to analyze the validity and reliability of the RASS in assessing sedation and agitation in critically ill children.Methods: A multicenter prospective study in children admitted to pediatric intensive care, aged between 1 month and 18 years. Twenty-eight observers from 14 PICUs (pediatric intensive care units) participated. Every observation was assessed by 4 observers: 2 nurses and 2 pediatric intensivists. We analyzed RASS inter-rater reliability, construct validity by comparing RASS to the COMFORT behavior (COMFORT-B) scale and the numeric rating scale (NRS), and by its ability to distinguish between levels of sedation, and responsiveness to changes in sedative dose levels.Results: 139 episodes in 55 patients were analyzed, with a median age 3.6 years (interquartile range 0.7–7.8). Inter-rater reliability was excellent, weighted kappa (κw) 0.946 (95% CI, 0.93–0.96; p < 0.001). RASS correlation with COMFORT-B scale, rho = 0.935 (p < 0.001) and NRS, rho = 0.958 (p < 0.001) was excellent. The RASS scores were significantly different (p < 0.001) for the 3 sedation categories (over-sedation, optimum and under-sedation) of the COMFORT-B scale, with a good agreement between both scales, κw 0.827 (95% CI, 0.789–0.865; p < 0.001), κ 0.762 (95% CI, 0.713–0.811, p < 0.001). A significant change in RASS scores (p < 0.001) was recorded with the variance of sedative doses.Conclusions: The RASS showed good measurement properties in PICU, in terms of inter-rater reliability, construct validity, and responsiveness. These properties, including its ability to categorize the patients into deep sedation, moderate-light sedation, and agitation, makes the RASS a useful instrument for monitoring sedation in PICU.

Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit

BackgroundProper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We...

The effect of foot reflexology applied to neonates before oro/nasopharyngeal suctioning on procedural pain and comfort in the neonatal intensive care unit

Introduction and aim. This study was performed to examine the effect of foot reflexology applied to the neonates on the level of pain and discomfort developed due to suctioning procedure. Material and methods. The study was conducted experimentally by taking pretest and repeated measurements on reflexology and control groups determined by simple randomization. The study was carried out with 66 neonates (reflexology applied: 33 and control group: 33). Neonatal Information Form, Neonatal Infant Pain Scale (NIPS) and Newborn Comfort Behavior Scale (NCBS) were used as the data collection tools. Results. The during (p&lt;0.001) and after suctioning (p&lt;0.001), the NIPS scores of the neonates in the intervention group was statistically lower than the control group. The NCBS scores of the neonates in the intervention group during (p&lt;0.001), and after suctioning (p&lt;0.001), were statistically significantly lower than the control group. Conclusion. It was concluded that foot reflexology applied to neonates was effective both in reducing pain during and after the suctioning and in increasing comfort during and after the suctioning.

Quantifying the Pharmacodynamics of Morphine in the Treatment of Postoperative Pain in Preverbal Children.

While the pharmacokinetics of morphine in children have been studied extensively, little is known about the pharmacodynamics of morphine in this population. Here, we quantified the concentration‐effect relationship of morphine for postoperative pain in preverbal children between 0 and 3 years of age. For this, we applied item response theory modeling in the pharmacokinetic/pharmacodynamic analysis of COMFORT‐Behavior (COMFORT‐B) scale data from 2 previous clinical studies. In the model, we identified a sigmoid maximal efficacy model for the effect of morphine and found that in 26% of children, increasing morphine concentrations were not associated with lower pain scores (nonresponders to morphine up‐titration). In responders to morphine up‐titration, the COMFORT‐B score slowly decreases with increasing morphine concentrations at morphine concentrations >20 ng/mL. In nonresponding children, no decrease in COMFORT‐B score is expected. In general, lower baseline COMFORT‐B scores (2.1 points on average) in younger children (postnatal age <10.3 days) were found. Based on the model, we conclude that the percentage of children at a desirable COMFORT‐B score is maximized at a morphine concentration between 5 and 30 ng/mL for children aged <10 days, and between 5 and 40 ng/mL for children >10 days. These findings support a dosing regimen previously suggested by Krekels et al, which would put >95% of patients within this morphine target concentration range at steady state. Our modeling approach provides a promising platform for pharmacodynamic research of analgesics and sedatives in children.

Perioperative sedation requirements of infants aged 0 to 3 months subjected to lower-body surgery under caudal blockade: a randomized controlled trial.

It remains unclear how much sedation is required for subumbilical surgery under caudal blockade, and sedatives may carry a poorly understood risk of late sequelae in infants. We designed a randomized controlled study to evaluate total propofol consumption and perioperative sedation quality with the avoidance of continuous perioperative sedation in infants undergoing surgery under caudal anesthesia. Thirty-two infants (age: 0-3 months) were randomized to one of two groups in which perioperative administration of propofol was provided either "as needed" or by continuous infusion (5 mg kg-1 h-1). After induction of anesthesia via a facemask with sevoflurane, a venous access was established and 1 mL kg-1 of ropivacaine 0.35% was injected for caudal anesthesia. Intraoperative stress was assessed by repeated recording comfort behavioral scale scores and heart rates. Significantly (P=0.0001) less propofol was administered in the as-needed group (0.7±1.4 mg/kg) than in the continuous-infusion group (3.0±1.6 mg/kg). This difference was not reflected in different requirements of additional intraoperative sedation (0.5±0.8 mg/kg in 5 versus 0.6±1.0 mg/kg in four cases; P=0.76). As needed propofol administration offers no disadvantage in terms of intraoperative sedation, but significant dose reductions can be achieved by avoiding continuous propofol infusion.

Impact of Propofol Bolus Administration on the Nociceptive Flexion Reflex Threshold and Bispectral Index in Children—A Case Series

We analyzed the impact of propofol administration during continuous sedation and analgesia on the nociceptive flexion reflex threshold (NFRT) and Bispectral Index (BIS) in ventilated children. We examined patients who received propofol before planned endotracheal suctioning. Patients were clinically assessed using the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale and COMFORT-B (Comfort Behavior) scale. We continuously recorded the NFRT and BIS. We recorded 23 propofol administrations in eight patients with an average age of 8.6 ± 3.5 years. The median (minimum-maximum) scores for the mFLACC scale and COMFORT-B scale were 0 (0–5) and 6 (6–17), respectively, before the bolus. The administration of a weight-adjusted propofol bolus of 1.03 ± 0.31 mg/kg resulted in an increase in NFRT and burst-suppression ratio; BIS and electromyogram values decreased. Changes from baseline (95% CI) after propofol bolus administration were BIS −23.9 (−30.8 to −17.1), EMG -10.5 dB (−13.3 to −7.7), SR 14.8 % (5.6 to 24.0) and NFRT 13.6 mA (5.5 to 21.7). Further studies are needed to determine whether sedated children may benefit from objective pain and sedation monitoring with BIS and NFRT.