Dijk, M. van

The microcirculation is unchanged in neonates with severe respiratory failure after the initiation of ECMO treatment (Article)

2012-09-19T00:00:00Z

Purpose. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is known to improve cardiorespiratory function and outcome in neonates with severe respiratory failure. We tested the hypothesis that VA-ECMO therapy improves the microcirculation in neonates with severe respiratory failure. Methods. This single-center prospective observational pilot study took place in an intensive care unit of a level III university children's hospital. Twenty-one-term neonates, who received VA-ECMO treatment, were included. The microcirculation was assessed in the buccal mucosa, using Orthogonal Polarization Spectral imaging, within 24 hours before (T1) and within the first 24 hours after initiation of ECMO treatment (T2). Data were compared to data of a ventilated control group (N=7). Results. At baseline (T1), median functional capillary density (FCD), microvascular flow index (MFI), and heterogeneity index (HI) did not differ between the ECMO group and the control group. At T2 the median FCD was lower in the control group (median [range]: 2.4 [1.4-4.2] versus 4.3 [2.8-7.4] cm/cm2; P value <0.001). For MFI and HI there were no differences at T2 between the two groups. Conclusion. The perfusion of the microcirculation does not change after initiation of VA-ECMO treatment in neonates with severe respiratory failure.

The COMFORT behavior scale: Is a shorter observation period feasible? (Article)

2012-03-01T00:00:00Z

Objective: The COMFORT behavior scale has been validated for postoperative pain in 0- to 3-yr-old children. Scoring is preceded by a 2-min observation period, which nurses may consider too long. The objective of this study was to test the reliability of a 30-sec observation period. Design: Observational study. Setting: One Level III intensive care unit at a university children’s hospital. Participants: Designated pain specialist and all nursing staff. Interventions: None. Measurements: The pain specialist and caregiver nurse each conducted a bedside COMFORT behavior scale assessment and assigned an additional pain rating on the 11-point Numerical Rating Scale. Main Results: Total COMFORT behavior Scale score for the 2-min observation was 17 or higher in 19% of the patients and 11% for the 30-sec observation. The mean COMFORT behavior scale score for the 2-min observation was 13.5 (SD 3.8) and 12.7 (SD 3.7) for the 30-sec observation. The mean difference therefore was 0.8 (confidence interval 0.6–1.1, paired t test, p < .001). Sensitivity and positive predictive value for the 30-sec observa- tion were 0.44 and 0.80, respectively. Conclusions: A 30-sec COMFORT behavior scale observation increases the risk of underscoring pain. Therefore, the 2-min observation period should be adhered to in the interest of the patients.

The Microcirculation Is Unchanged in Neonates with Severe Respiratory Failure after the Initiation of ECMO Treatment (Article)

2012-01-01T00:00:00Z

Purpose. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is known to improve cardiorespiratory function and outcome in neonates with severe respiratory failure. We tested the hypothesis that VA-ECMO therapy improves the microcircu- lation in neonates with severe respiratory failure. Methods. This single-center prospective observational pilot study took place in an intensive care unit of a level III university children’s hospital. Twenty-one-term neonates, who received VA-ECMO treatment, were included. The microcirculation was assessed in the buccal mucosa, using Orthogonal Polarization Spectral imaging, within 24 hours before (T1) and within the first 24 hours after initiation of ECMO treatment (T2). Data were compared to data of a ventilated control group (N = 7). Results. At baseline (T1), median functional capillary density (FCD), microvascular flow index (MFI), and heterogeneity index (HI) did not differ between the ECMO group and the control group. At T2 the median FCD was lower in the control group (median [range]: 2.4 [1.4–4.2] versus 4.3 [2.8–7.4] cm/cm2 ; P value <0.001). For MFI and HI there were no differences at T2 between the two groups. Conclusion. The perfusion of the microcirculation does not change after initiation of VA-ECMO treatment in neonates with severe respiratory failure.

Screening pediatric delirium with an adapted version of the Sophia Observation withdrawal Symptoms scale (SOS) (Letter To Editor)

2011-12-08T00:00:00Z

Does postoperative 'M' technique® massage with or without mandarin oil reduce infants' distress after major craniofacial surgery? (Article)

2011-11-07T00:00:00Z

Aim. This article is a report of a randomized controlled trial of the effects of 'M' technique® massage with or without mandarin oil compared to standard postoperative care on infants' levels of pain and distress, heart rate and mean arterial pressure after major craniofacial surgery. Background. There is a growing interest in non-pharmacological interventions such as aromatherapy massage in hospitalized children to relieve pain and distress but well performed studies are lacking. Methods. This randomized controlled trial allocated 60 children aged 3-36months after craniofacial surgery from January 2008 to August 2009 to one of three conditions; 'M' technique® massage with carrier oil, 'M' technique® massage with mandarin oil or standard postoperative care. Primary outcome measures were changes in COMFORT behaviour scores, Numeric Rating Scale pain and Numeric Rating Scale distress scores assessed from videotape by an observer blinded for the condition. Results. In all three groups, the mean postintervention COMFORT behaviour scores were higher than the baseline scores, but differences were not statistically significant. Heart rate and mean arterial pressure showed a statistically significant change across the three assessment periods in all three groups. These changes were not related with the intervention. Conclusions. Results do not support a benefit of 'M' technique® massage with or without mandarin oil in these young postoperative patients. Several reasons may account for this: massage given too soon after general anaesthesia, young patients' fear of strangers touching them, patients not used to massage.

Patient safety culture in a Dutch pediatric surgical intensive care unit: An evaluation using the Safety Attitudes Questionnaire (Article)

2011-11-01T00:00:00Z

Objective: Nowadays, the belief is widespread that a safety culture is crucial to achieving patient safety, yet there has been virtually no analysis of the safety culture in pediatric hospital settings so far. Our aim was to measure the safety climate in our unit, compare it with benchmarking data, and identify potential deficiencies. Design: Prospective longitudinal survey study at two points in time. Setting: Pediatric surgical intensive care unit at a Dutch university hospital. Subjects: All unit personnel. Interventions: To measure the safety climate, the Safety Attitudes Questionnaire was administered to physicians, nurses, nursing assistants, pharmacists, technicians, and ward clerks in both May 2006 and May 2007. This questionnaire assesses caregiver attitudes through use of the six following scales: teamwork climate, job satisfaction, perceptions of management, safety climate, working conditions, and stress recognition. Earlier research showed that the Safety Attitudes Questionnaire has good psychometric properties and produced benchmarking data that can be used to evaluate strengths and weaknesses in a given clinical unit against peers. Measurements and Main Results: The response rates for the Safety Attitudes Questionnaire were 85% (May 2006) and 74% (May 2007). There were mixed findings regarding the difference between physicians and nurses: on three scales (i.e., teamwork climate, safety climate, and stress recognition), physicians scored better than nurses at both points in time. On another two scales (i.e., perceptions of management and working conditions), nurses consistently had higher mean scale scores. Probably due to the small number of physicians, only some of these differences between physicians and nurses reached the level of statistical significance. Compared to benchmarking data, scores on perceptions of management were higher than expected (p < .01), whereas scores on stress recognition were low (p < .001). The scores on the other scales were somewhat above (job satisfaction), close to (teamwork climate, safety climate), or somewhat below (working conditions) what was expected on the basis of benchmarking data, but no persistent significant differences were observed on these scales. Conclusions: Although on most domains the safety culture in our unit was good when compared to benchmark data, there is still room for improvement. This requires us to continue working on interventions intended to improve the safety culture, including crew resource management training, safety briefings, and senior executive walk rounds. More research is needed into the impact of creating a safety culture on patient outcomes.

Protocolized post-operative pain management in infants; do we stick to it? (Article)

2011-10-28T00:00:00Z

Background: The American Academy of Pediatrics states that ongoing assessment of pain is essential for adequate pain treatment. Pain assessment by means of the COMFORT behaviour scale and the Numeric Rating Scale is therefore an important component of the post-operative pain treatment protocol for neonates and infants in our intensive care unit (ICU). Aim: The study aims to determine degrees of staff compliance with this protocol. Patients and methods: This retrospective chart review concerned post-surgical patients under the age of 3 years admitted to our level III ICU over a 1-year period. The degree of compliance to the post-operative pain protocol was measured by the frequency of deviations from protocol-dictated drug treatment and pain assessments. Results: Records of 200 children with a median age at surgery of 98 days (interquartile range 6–320) were analysed. A mean of 11 assessments in the first 72 h post-operatively per patient had been recorded. A total of 2103 pain assessments were retrieved, of which 1675 (79.7%) suggested comfort. Compliance to the protocol (reassessment and correct medication) was provided in 66 (15.4%) of the 428 assessments suggesting pain or distress. Conclusion: The post-operative pain protocol applied in our ICU appears to be effective; however, full compliance to the protocol was marginal, possibly leading to under-treatment of pain.

The COMFORT-Behavior scale is useful to assess pain and distress in 0- to 3-year-old children with Down syndrome (Article)

2011-06-02T00:00:00Z

Many pediatric intensive care units use the COMFORT-Behavior scale (COMFORT-B) to assess pain in 0- to 3-year-old children. The objective of this study was to determine whether this scale is also valid for the assessment of pain in 0- to 3-year-old children with Down syndrome. These children often undergo cardiac or intestinal surgery early in life and therefore admission to a pediatric intensive care unit. Seventy-six patients with Down syndrome were included and 466 without Down syndrome. Pain was regularly assessed with the COMFORT-B scale and the pain Numeric Rating Scale (NRS). For either group, confirmatory factor analyses revealed a 1-factor model. Internal consistency between COMFORT-B items was good (Cronbach's α = 0.84-0.87). Cutoff values for the COMFORT-B set at 17 or higher discriminated between pain (NRS pain of 4 or higher) and no pain (NRS pain below 4) in both groups. We concluded that the COMFORT-B scale is also valid for 0- to 3-year-old children with Down syndrome. This makes it even more useful in the pediatric intensive care unit setting, doing away with the need to apply another instrument for those children younger than 3.

Long-term effects of routine morphine infusion in mechanically ventilated neonates on children's functioning: Five-year follow-up of a randomized controlled trial (Article)

2011-06-01T00:00:00Z

Newborns on ventilatory support often receive morphine to induce analgesia. Animal experiments suggest that this may impair subsequent cognitive and behavioral development. There are sparse human data on long-term effects of neonatal morphine. We aimed to investigate the effects of continuous morphine administered in the neonatal period on the child's functioning. We conducted a follow-up study among 5-year-olds who, as mechanically ventilated neonates, had participated in a placebo-controlled trial on effects of morphine administration on pain and neurologic outcome. They were now tested on intelligence, visual motor integration, behavior, chronic pain, and health-related quality of life. Univariate analyses showed significantly lower overall intelligence quotient (IQ) scores for children who earlier had received morphine, that is, mean 94 (SD 14.5) versus 100 (SD 12.9) for those who received placebo (P = 0.049). Other between-group differences in outcomes were not found. The statistical difference disappeared after correction for treatment condition, open-label morphine consumption over the first 28 days, and a propensity score for clinically relevant co-variables in multiple regression analyses. However, scores on one IQ subtest, "visual analysis," were significantly negatively related to having received morphine and to open-label morphine consumption the first 28 days. The finding of a significant effect of morphine on the "visual analysis" IQ subtest calls for follow-up at a later age focusing on the higher-order neurocognitive functions. Morphine received in the neonatal period has negative effects on the child's cognitive functioning at the age of 5 years which warrants follow-up at a later age.

Persistent low microcirculatory vessel density in nonsurvivors of sepsis in pediatric intensive care (Article)

2011-01-01T00:00:00Z

Objective: To investigate the time course and predictive value of microvascular alterations in children with severe sepsis. Design: Single-center, prospective observational study. Setting: Intensive care unit of a level III university children's hospital. Patients: Patients with septic shock, requiring the administration of fluid and vasopressor agents and/or inotropes after the correction of hypovolemia, who were intubated and ventilated, were included. Interventions: None. Measurements and main results: The microcirculation was assessed in the buccal mucosa, using orthogonal polarization spectral imaging, within 24 hrs after admission. Subsequent measurements were performed every 24 hrs for 3 days. The measurements were discontinued when the patient was extubated. There were no significant differences in the functional capillary density or microvascular flow index for all vessel types between survivors and nonsurvivors on day 1. In the survival group, the functional capillary density increased significantly between day 1 and day 2 from 1.7 cm/cm2(0.8-3.4) to 4.3 cm/cm2(2.1-6.9) (p = .001). Functional capillary density values in nonsurvivors did not change (day 1: 3.2 cm/cm2[0.8-3.8]; day 2: 1.9 cm/cm2[1.0-2.1]). The median functional capillary density on days 2 and 3 were significantly lower in nonsurvivors (day 2: 1.9 cm/cm2[1.0 -2.1] vs. 4.3 cm/cm2[2.1-6.9], p = .009; day 3: 1.8 cm/cm2[1.0-2.0] vs. 4.7 cm/cm2[2.1-8.6], p = .01). The microvascular flow index for all vessel types improved in survivors and did not change in nonsurvivors. Differences in microvascular flow index values between survivors and nonsurvivors were not significant. Conclusion: Persistent microcirculatory alterations can be prognostic for survival in children with septic shock. Copyright

Early developmental assessment of children with major non-cardiac congenital anomalies predicts development at the age of 5 years (Article)

2010-12-01T00:00:00Z

Aim The aim of this study was to evaluate cognitive and motor development in children with major congenital anomalies and the predictability of development at age 5 years.Method A prospective, longitudinal follow-up study was undertaken. The Dutch version of the Bayley Scales of Infant Development Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) were administered at the ages of 6, 12, and 24 months. The Revised Amsterdam Children's Intelligence Test IQ and the Movement Assessment Battery for Children Total impairment score (TIS) were used at age 5 years. A total of 117 children participated in the study. After excluding 12 children who had a major chromosomal or syndromal abnormality, the analysis was limited to 105 children (50 females, 55 males). Seven groups of congenital anomalies were distinguished: (1) small intestinal anomalies; (2) abdominal wall defects, comprising gastroschisis and omphalocele; (3) oesophageal atresia; (4) congenital diaphragmatic hernia; (5) Hirschsprung disease; (6) anorectal malformations; and (7) miscellaneous diagnoses. Logistic regression analyses served to determine the ability of MDI and PDI to predict IQ and TIS at age 5 years.Results At age five, 83.7% of 104 children had an IQ of 85 or above and 16.3% an IQ of less than 85. TIS was normal in 71.3% of 87 children, while 17.2% demonstrated a borderline score and 11.5% a definite motor problem. MDI and PDI scores showed equal sensitivity to predict IQ (p=0.004 at 6 and 12mo, p=0.001 at 24mo) and TIS (p<0.001 at 6 and 12mo, p=0.002 at 24mo). MDI and PDI were positively correlated with IQ and TIS; TIS was positively correlated with IQ.Interpretation IQ scores at 5 years of age corresponded to Dutch population scores, but TIS scores differed significantly. Early development of children with major congenital anomalies is predictive of development at 5 years, which can guide individualized follow-up for this vulnerable group of children.

Pain management in intellectually disabled children: Assessment, treatment, and translational research (Article)

2010-12-01T00:00:00Z

The primary focus of pain research in intellectually disabled individuals is still on pain assessment. Several observational pain assessment scales are available, each with its own characteristics, its own target group and its own validated use. Observational studies report differences in the treatment of intra- and postoperative pain of intellectually disabled children and almost all children with intellectual disability have comorbidities that need to be addressed. The scope of research has started to broaden. In this review we aim to answer the question: Can we integrate validated ways of pain assessment and postoperative pain treatment in intellectually disabled children to develop specific analgesic algorithms? Regrettably there is little knowledge on possible interaction effects and other relevant pharmacological issues. Possible genotype-phenotype associations related to pain in children with Down syndrome have several promises as six possible candidate genes are located on chromosome 21. In conclusion, the pain assessment tools for intellectually disabled children are there. We should now focus on tailoring the pain treatment. To this aim we need to perform pharmacokinetic and pharmacodynamic studies of analgesics and obtain information about the genotype-phenotype relationships for pain. This can lead to the development of specific analgesic algorithms.

Functional capillary density decreases after the first week of life in term neonates (Article)

2010-12-01T00:00:00Z

Background: Changes in the microcirculation have been recognized to play a crucial role in many disease processes. In premature neonates, functional capillary density (FCD) decreases during the first months of life. Objectives: The aims of this study were to obtain microcirculatory parameters in term neonates and older children who did not present with compromised respiration or circulation and to determine developmental changes in the microcirculation in young children. Methods: This single-center prospective observational study was performed at a level III university children's hospital. Subjects eligible for inclusion were children up to the age of 3 years who did not have any respiratory compromise, circulatory compromise or signs of dehydration. The buccal mucosa of 45 children was assessed, using orthogonal polarization spectral imaging. Results: We found a significantly higher FCD in neonates younger than 1 week compared with older children. The median FCD was 8.1 cm/cm2(range 7.3-9.4) for 0- to 7-day-old neonates (n = 12), 6.9 cm/cm2(range 4.7-8.7) for 8- to 28-day-olds (n = 10), 7.3 cm/cm2(range 6.1-8.8) for 1- to 6-month-olds (n = 19) and 6.7 cm/cm2(range 6.5-9.2) for 3-year-olds (n = 4). After the first week, there was no significant correlation between age and FCD. Conclusion: FCD of the buccal mucosa decreases after the first week of life. Copyright

Is Pain Assessment Feasible as a Performance Indicator for Dutch Nursing Homes? A Cross-Sectional Approach (Article)

2010-07-26T00:00:00Z

Quality of care gains transparency with the help of performance indicators. For Dutch nursing homes, the current set of performance indicators does not include pain. To determine the feasibility of pain assessment as performance indicator, information about pain prevalence and analgesic prescription in one nursing home was collected. Within the time span of 3 days, pain intensity was measured in 91% of the residents (201 out of 221), either with a numeric rating scale, a verbal rating scale, or the Rotterdam Elderly Pain Observation Scale (REPOS). Numerical rating was used for 72%, verbal rating for 3%, and REPOS observation for 25% of the residents. Pain was substantial in 65 residents (32%), who received the following analgesic prescription: World Health Organization (WHO) step 1, 45%; WHO step 3, 12%; and neuroactive agents, 5%. Thirty-eight percent of these residents were in pain and received no analgesics. Residents with substantial pain significantly more often received analgesics (p = .007). Results suggest that pain assessment is feasible in a nursing home and would stimulate staff attention to pain. Further investigation is necessary to find out if a pain algorithm is feasible and will lead to improved pain treatment.

Parental satisfaction with follow-up services for children with major anatomical congenital anomalies (Article)

2010-01-18T00:00:00Z

Background: Since 1999 a multidisciplinary follow-up programme for parents and children with major anatomical congenital anomalies is in place in our hospital, run by a dedicated team. The aim of the present study was to evaluate the services of this team from a parental perspective. Methods: Parents completed a questionnaire including open and closed questions about satisfaction with the various professional disciplines involved in the follow-up, statements on usefulness of the follow-up services and suggestions for improvement. Results: Four hundred and sixty-nine surveys were sent out, of which 71% were returned. Non-responding parents included significantly more parents of non-Dutch origin (P = 0.038) and parents who never responded to invitations for follow-up examinations (P < 0.001). Parental satisfaction differed for the various disciplines. Eighty per cent of the parents were (very) satisfied with the social worker, compared with 92% with nurses. More than half of the parents agreed that the follow-up services give peace of mind. Almost a quarter of parents, however, considered the follow-up services as redundant. The children of these parents had significantly shorter intensive care unit stay (P = 0.02), were older at the time of the questionnaire (P = 0.04), of higher socio-economic status (P = 0.001) and less likely to be of non-Dutch origin (P = 0.008). Sixty-one per cent of the parents had contacted the 24-h helpline. Ninety per cent of the parents were satisfied with the intensive care unit, almost 80% with the general ward. Conclusion: Overall, parents were satisfied with the services of the follow-up team. Some parents, however, saw room for improvement related to better communication, recognizability of the team and better planning and organization. © 2009 The Authors. Journal compilation

Validation of the COMFORT Behavior Scale and the FLACC Scale for Pain Assessment in Chinese Children after Cardiac Surgery (Article)

2010-01-01T00:00:00Z

Appropriate pain assessment plays a key role in understanding the pain status of critically ill children. However, the utility of the face, legs, activity, cry, consolability (FLACC) scale and the COMFORT Behavior (COMFORT-B) scale have not been extensively explored for children after cardiac surgery in China. A repeated-observation study was conducted to evaluate the concurrent validity and the sensitivity and specificity of the COMFORT-B and FLACC scales for pain assessment after cardiac surgery in 0-7-year-old patients. Patients were assessed with the observational visual analog scale (VASobs), FLACC scale, and COMFORT-B scale simultaneously at 18 fixed time periods for 3 days. Correlations among pain assessments were computed to calculate concurrent validity. Receiver operating characteristic curve analyses identified the FLACC and COMFORT-B scores that could best discriminate pain and no pain based on the VASobs. Multiple regression analyses were performed with FLACC and COMFORT-B pain scores as dependent variables and disease-related treatment characteristics as predictor variables for conducting the analysis. A total of 170 children (98 boys and 72 girls) were included. Significantly positive correlations, ranging from 0.31 to 0.86, were found among the COMFORT-B, FLACC, and VASobs pain assessment instruments. The COMFORT-B and the FLACC scores for children assessed to be in pain (i.e., VASobs ≥4), were significantly higher than scores for children not in pain (VASobs <4). COMFORT-B showed good sensitivity (86%) and specificity (83%) with a cutoff point of 13. FLACC showed excellent sensitivity (98%) and good specificity (88%) for a cutoff point of 2. The COMFORT-B and FLACC scales seem to be useful tools in pain assessment for Chinese children at postcardiac surgery stages, but the study identified that this group of children demonstrated a lower cutoff point for pain than originally set for these two instruments.

The use of the behavioral pain scale to assess pain in conscious sedated patients (Article)

2010-01-01T00:00:00Z

Background: Assessing pain in mechanically ventilated critically ill patients is a great challenge. There is a need for an adequate pain measurement tool for use in conscious sedated patients because of their questionable communicative abilities. In this study, we evaluated the use of the Behavioral Pain Scale (BPS) in conscious sedated patients in comparison with its use in deeply sedated patients, for whom the BPS was developed. Additionally, in conscious sedated patients, the combination of the BPS and the patient-rated Verbal Rating Scale (VRS-4) was evaluated. Methods: We performed a prospective evaluation study in 80 nonparalyzed critically ill adult intensive care unit patients. Over 2 mo, nurses performed 175 observation series: 126 in deeply sedated patients and 49 in conscious sedated patients. Each observation series consisted of BPS ratings (range 3-12) at 4 points: at rest, during a nonpainful procedure, at retest rest, and during a routine painful procedure. Patients in the conscious sedated state also self-reported their pain using the 4-point VRS-4. Results: BPS scores during painful procedures were significantly higher than those at rest, both in deeply sedated patients (5.1 [4.8-5.5] vs 3.4 [3.3-3.5], respectively) and conscious sedated patients (5.4 [4.9-5.9] vs 3.8 [3.5-4.1], respectively) (mean [95% confidence interval]). For both groups, scores obtained during the nonpainful procedure and at rest did not significantly differ. There was a strong correlation between nurses' BPS ratings and conscious sedated patients' VRS-4 ratings during the painful procedure (rs = 0.67, P < 0.001). At rest and during nonpainful procedures, 98% of the observations were rated as acceptable pain (VRS 1 or 2) by both nurses and patients. During painful procedures, nurses rated the pain higher than patients did in 16% of the observations and lower in 12% of the observations. Conclusion: The BPS is a valid tool for measuring pain in conscious sedated patients during painful procedures. Thus, for noncommunicative and mechanically ventilated patients, it may be regarded as a bridge between the observational scale used by nurses and the VRS-4 used by patients who are able to self-report pain. Copyright

Weaning of opioids and benzodiazepines at home after critical illness in infants: A cost-effective approach (Article)

2010-01-01T00:00:00Z

Objective: To evaluate the feasibility of infants' weaning of opioids and sedatives at home. Design: Retrospective observational study. Setting: Level 3 pediatric intensive care unit. Patients: Neonates treated for congenital diaphragmatic hernia (CDH) with extra corporeal membrane oxygenation (ECMO). Intervention: Eligible infants were discharged early and further weaned of analgesics and/or sedatives at home. Results: Of the 30 neonates treated for CDH with ECMO from 2003 to 2005, 15 survived. Five of these were weaned at home, on the guidance of telephone contact once a week. The mean infusion rates of morphine and midazolam for these children were significantly higher than those for other infants. Weaning at home took 11, 42, 107, 173, and 180 days, respectively, in the resultant mean savings on hospitalization costs per patient amounted to €150,000. Conclusions: The results indicate that home weaning reduced the length of hospital stay by a median of 107 days for the five infants in this study, and thereby considerably reduced healthcare costs. Parents need to be informed clearly about possible withdrawal symptoms and should consent in this strategy. The strategy of final weaning with the aid of weekly telephone consultations with a consultant pediatric intensivist was feasible for these parents.

A prospective comparative evaluation of persistent respiratory morbidity in esophageal atresia and congenital diaphragmatic hernia survivors (Article)

2009-09-01T00:00:00Z

Purpose: The aim of the study was to compare long-term respiratory morbidity in children after repair of esophageal atresia (EA) or congenital diaphragmatic hernia (CDH). Patients and Methods: Children were seen at 6, 12, and 24 months and 5 years within a prospective longitudinal follow-up program in a tertiary children's hospital. Respiratory morbidity and physical condition were evaluated at all moments. At age 5 years, pulmonary function and maximal exercise performance were tested. Results: In 3 of 23 atresia patients and 10 of 20 hernia patients, bronchopulmonary dysplasia was developed. Seventeen atresia and 11 hernia patients had recurrent respiratory tract infections mainly in the first years of life. At age 5, 25% of EA and CDH patients measured showed reduced forced expiratory volume in 1 second (z-score < -2). Both atresia and hernia patients showed impaired growth, with catch-up growth at 5 years in patients with EA but not in those with hernia. Maximal exercise performance was significantly below normal for both groups. Conclusions: Esophageal atresia and CDH are associated with equal risk of long-term respiratory morbidity, growth impairment, and disturbed maximal exercise performance. Prospective follow-up of EA patients aimed at identifying respiratory problems other than tracheomalacia should be an integral part of interdisciplinary follow-up programs.

A prospective comparative evaluation of persistent respiratory morbidity in esophageal atresia and congenital diaphragmatic hernia survivors (Article)

2009-09-01T00:00:00Z

Assessment of pain: Can caregivers or relatives rate pain in nursing home residents? (Article)

2009-09-01T00:00:00Z

Aim. To compare pain reports of nursing home residents to ratings by proxies. Background. It is not easy to assess pain in cognitively impaired residents. For residents who are unable to report pain intensity themselves, proxies (i.e. relatives or caregivers) might serve as sources of information. The utility of these proxies in assessing residents' pain is not clear however. Design. A multicenter cross-sectional study. Methods. Pain intensity was rated on a Numeric Rating Scale; proxies were asked how certain they were about their observations. Agreements on ratings were computed by means of intra class correlation (ICC) coefficients for continuous variables and multiple linear regression analyses were performed with the level of pain intensity by proxies as the dependent variable. Results. The sample consisted of 174 residents (median age 82 years), of whom 124 were cognitively impaired and 50 intact, and 293 proxies: 171 caregivers and 122 relatives. All three parties reported median pain intensity during the preceding week as 6·0. Data were consistent with low-to-moderate correlation coefficients between residents and caregivers (ICC = -0·12 to 0·25), residents and relatives (ICC = -0·51 to 0·48) and caregivers and relatives (ICC = 0·03 to 0·31). Residents themselves judged pain intensity at rest significantly higher than did proxies (p = 0·05). Caregivers scored significantly higher ratings for residents on analgesics (p = 0·001) and significantly lower pain ratings if they were more satisfied with the prescribed analgesics (p = 0·01). Conclusions. Proxy report of relatives and caregivers on presence and intensity of pain is unreliable, especially for cognitively impaired persons. The use of a standardised pain observation scale could be helpful. Relevance to clinical practice. Pain management in nursing home residents could be improved by educating caregivers about assessment and treatment of chronic pain. Relatives should be informed about chronic pain and learn how to alleviate pain through non-pharmacological interventions.

Implementation of standard sedation management in paediatric intensive care: Effective and feasible? (Article)

2009-09-01T00:00:00Z

Objective. To study the effects of the introduction of a sedation treatment protocol for children in intensive care, including nurses' compliance. Background. While several sedation guidelines for adults and children have been developed and implemented, there is little evidence on use of sedation protocols in critically ill infants. Design. Pretest-posttest intervention study. Methods. Administered sedatives and analgesics over the first seven days of admission were documented for convenience samples, before (n = 27) and after (n = 29) implementation of standard sedation assessments and a sedation protocol. Sedation was assessed with the COMFORT behaviour scale, Nurse Interpretation of Sedation Score and the Visual Analogue Scale for three-month periods, both pretest and posttest. Starting 21 months after the posttest, nurses' compliance with the sedation protocol, as well as administered sedatives and analgesics were evaluated for 12 months. Results. Infants in the posttest period received significantly more midazolam and morphine. The proportion of patients adequately sedated on the grounds of COMFORT scores had increased from 63% pretest to 72% posttest and to 75% in the long run. Adequate sedation as judged from the sedation protocol cutoffs was found in 71% of the assessments. In 45% of assessments indicating undersedation, the infusion rate had been increased on the guidance of the protocol. A survey among staff revealed that most considered the sedation protocol comprehensible and useful. Conclusion. This study showed that regular sedation assessment in critically ill children was feasible and had become standard practice two years after the first posttest. There is insufficient evidence to conclude whether implementation of a sedation treatment protocol indeed improves sedation treatment. Relevance to clinical practice. This sedation protocol provides decision trees for increasing or weaning of sedatives in both haemodynamically stable and unstable patients. It standardises sedation management and allows nurses to adapt medication themselves.

Assessment of opioid and benzodiazepine withdrawal symptoms in critically ill children: current state of the art (Article)

2009-09-01T00:00:00Z

Prolonged administration of benzodiazepines and/or opioids to children in a paediatric intensive care unit (PICU) may in- duce physiological dependence and withdrawal symptoms. We reviewed the literature for relevant contributions on the nature of these withdrawal symptoms and on availability of valid scoring systems to assess the extent of symptoms in children. Symptoms of benzodi- azepine and opioid withdrawal can be classified into three groups: central nervous system (CNS) overstimulation, gastrointestinal dys- regulation and autonomic dysfunction. In children, symptoms associated with CNS overstimulation and autonomic dysfunction may overlap after long-term use of benzodiazepines or opioids. Symptoms of gastrointestinal dysfunction in the PICU population have only been described for opioid withdrawal. Four scoring systems for use in children have been described. Two of these provided good reli- ability and validity to determine withdrawal symptoms: the Withdrawal Assessment Tool version 1 (WAT-1) and the Sophia Observation withdrawal Symptoms-scale (SOS).

Taking up the challenge of measuring prolonged pain in (premature) neonates the COMFORTneo scale seems promising (Article)

2009-09-01T00:00:00Z

Objectives: Pain assessment is essential to tailor intensive care of neonates. The present focus is on acute procedural pain; assessment of pain of longer duration remains a challenge. We therefore tested a modified version of the COMFORT-behavior scale\-named COMFORTneo\-for its psychometric qualities in the Neonatal Intensive Care Unit setting. Methods: In a clinical observational study, nurses assessed patients with COMFORTneo and Numeric Rating Scales (NRS) for pain and distress, respectively. Interrater reliability, concurrent validity, and sensitivity to change were calculated as well as sensitivity and specificity for different cut-off scores for subsets of patients. Results: Interrater reliability was good: median linearly weighted Cohen κ 0.79. Almost 3600 triple ratings were obtained for 286 neonates. Internal consistency was good (Cronbach α 0.84 and 0.88). Concurrent validity was demonstrated by adequate and good correlations, respectively, with NRS-pain and NRS-distress: r=0.52 (95% confidence interval 0.44-0.59) and r=0.70 (95% confidence interval 0.64-0.75). COMFORTneo cut-off scores of 14 or higher (score range is 6 to 30) had good sensitivity and specificity (0.81 and 0.90, respectively) using NRS-pain or NRS-distress scores of 4 or higher as criterion. Discussion: The COMFORTneo showed preliminary reliability. No major differences were found in cut-off values for low birth weight, small for gestational age, neurologic impairment risk levels, or sex. Multicenter studies should focus on establishing concurrent validity with other instruments in a patient group with a high probability of ongoing pain.

Morphine glucuronidation in preterm neonates, infants and children younger than 3 years (Article)

2009-08-12T00:00:00Z

Background and objective: A considerable amount of drug use in children is still unlicensed or off-label. In order to derive rational dosing schemes, the influence of aging on glucuronidation capacity in newborns, including preterms, infants and children under the age of 3 years was studied using morphine and its major metabolites as a model drug. Methods: A population pharmacokinetic model was developed with the nonlinear mixed-effects modelling software NONMEM® V, on the basis of 2159 concentrations of morphine and its glucuronides from 248 infants receiving intravenous morphine ranging in bodyweight from 500 g to 18 kg (median 2.8 kg). The model was internally validated using normalized prediction distribution errors. Results: Formation clearances of morphine to its glucuronides and elimination clearances of the glucuronides were found to be primarily influenced by bodyweight, which was parameterized using an allometric equation with an estimated exponential scaling factor of 1.44. Additionally, a postnatal age of less than 10 days was identified as a covariate for formation clearance to the glucuronides, independent of birthweight or postmenstrual age. Distribution volumes scaled linearly with bodyweight. Conclusions: Model-based simulations show that in newborns, including preterms, infants and children under the age of 3 years, a loading dose in μg/kg and a maintenance dose expressed in μg/kg1.5/h, with a 50% reduction of the maintenance dose in newborns younger than 10 days, results in a narrow range of morphine and metabolite serum concentrations throughout the studied age range. Future pharmacodynamic investigations are needed to reveal target concentrations in this population, after which final dosing recommendations can be made.

Interdisciplinary structural follow-up of surgical newborns: a prospective evaluation (Article)

2009-07-01T00:00:00Z

Background: Information on physical and developmental outcomes of children with anatomical congenital anomalies (CAs) may indicate the need for early intervention and reduce impact on the child's life and parental burden. Methods: From 1999 to 2003, 101 children with CA (76.5% of initial survivors) were seen 6-monthly in a tertiary children's hospital. Growth, neurologic outcome, mental and psychomotor development as determined with the Bayley Scales of Infant Development, and categorization of predictive sociodemographic and medical variables of the children were evaluated prospectively and longitudinally. Results: Congenital diaphragmatic hernia (CDH) and esophageal atresia patients showed impaired growth, that is, both height for age (-1.5 standard deviation score [SDS]) and weight for height (-1.0 SDS). Overall neurologic outcome was normal, however, suspect or abnormal for 40% of CDH patients. Overall mental development was normal, but psychomotor scores were significantly lower than the norm (95% confidence interval, 83.8-92.2 at 6 months and 87.9-98.5 at 24 months). Sex, maternal age, socioeconomic status, CA, severity-of-disease covariables, and need of medical appliances at home could predict negative outcome significantly (P < .05). Conclusions: The CA survivors show impaired growth and psychomotor developmental delay up to age 2 years. This warrants specific follow-up programs and infrastructure for these patients.

Minor Painful Procedures in the NICU: Improved Care or Too Soon for Cheering? (Article)

2009-07-01T00:00:00Z

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

2009-06-01T00:00:00Z

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, anxiety, inconsolable crying, increased muscle tension, tremors, tachycardia and sweating were considered relevant by 85-95% of the experts. On the basis of the MDS results and the experts' opinions, 15 symptoms were included in the final instrument. Conclusions: We are the first to develop an assessment tool for withdrawal symptoms in pediatric ICU patients on the basis of the underlying empirical structure of co-occurrences of withdrawal symptoms that experts considered relevant. Future studies need to define cut-off points and clarify psychometric issues.

Pain Management in Dutch Nursing Homes Leaves Much to Be Desired (Article)

2009-03-01T00:00:00Z

This cross-sectional multicenter study describes several aspects of pain, pain intensity, and pain treatment in a Dutch nursing home population. A standardized pain questionnaire, including the Numeric Rating Scale (NRS), was used to measure aspects of pain and intensity of present pain, pain experienced in the previous week, and tolerable pain. The eligible sample comprised 320 residents (median age 79 years), of whom 233 residents completed the questionnaire. Sixty-six percent (n = 153) experienced (mostly chronic) pain, either in the previous week (median NRS 6) or at present (median NRS 5). Intolerable pain was recorded in 41% of 100 residents. The higher the pain scores, the more interference with activities of daily living was reported. Of the 153 residents with pain, about one-fourth did not receive any pain medication, and 65 (43%) received step 1, 13 (9%) step 2, and 16 (11%) step 3 analgesics. Most residents (60%) were satisfied with pain treatment, and 21% were not. Considering the high prevalences and intensities of pain, pain management in Dutch nursing homes leaves much to be desired. Apparently, residents do not seem to expect effective pain management. Awareness and knowledge about pain assessment and treatment, however, needs to be raised. Pain measurement tools and treatment protocols should be implemented in daily practice.

Changes in buccal microcirculation following extracorporeal membrane oxygenation in term neonates with severe respiratory failure (Article)

2009-03-01T00:00:00Z

OBJECTIVES:: Extracorporeal membrane oxygenation (ECMO) is known to improve cardiorespiratory function and outcome in neonates with severe respiratory failure. In this study, we tested two hypotheses: 1) neonates with severe respiratory failure exhibit alterations of the microcirculation and 2) after ECMO therapy these microcirculatory alterations are improved. DESIGN:: Single-center prospective observational study. SETTING:: Intensive care unit of a level III university children's hospital. PATIENTS:: Term neonates receiving venoarterial ECMO. Control patients with and without respiratory failure. MEASUREMENTS AND MAIN RESULTS:: The microcirculation was assessed in the buccal mucosa, using orthogonal polarization spectral imaging, before and after ECMO. Functional capillary density was lower in patients with severe respiratory failure before ECMO (n = 14) compared with control patients (n = 10; p < 0.01). Functional capillary density had increased significantly after ECMO (p < 0.01). CONCLUSION:: Microcirculatory parameters are depressed in neonates with severe respiratory failure and improve significantly following ECMO treatment.

The Rotterdam Elderly Pain Observation Scale (REPOS): A New Behavioral Pain Scale for Non-Communicative Adults and Cognitively Impaired Elderly Persons (Article)

2009-01-01T00:00:00Z

Abstract: Several observation scales have been developed to measure pain in elderly persons with cognitive impairments. Most scales, however, do not provide cut-off scores for pain, and previous studies do not include data on non-verbal patients with diagnoses other than dementia. Objective: The development of an easy-to-use, reliable and valid pain observation scale, the Rotterdam Elderly Pain Observation Scale (REPOS), for use in nursing home residents incapable of reporting pain themselves. Methods: In this multicenter case-control study 174 residents of various cognitive levels were videotaped at rest and during a potentially painful activity. Prevalences and co- occurrences of behaviors were examined, and interrelationships were identified. To reduce number of items, multiple linear regression analysis was used. Interrater-, and intrarater agreements and internal consistency were investigated. To estimate validity, REPOS was related to Numeric Rating Scale (NRS) and Pain Assessment in Advanced Dementia-Scale (PAINAD), and activity and rest situations were compared. Results: A one- dimensional model with a good fit was found. After redundancy analysis, ten items remained. Interrater- and intrarater agreements of two observers were good. Internal consistency was moderate. Correlations between REPOS and NRS were small to medium, and between REPOS and PAINAD large. REPOS-scores for the two situations differed significantly. A total score of 3 and higher indicates pain. Conclusions: REPOS appears to be promising for identifying pain in residents of various cognitive levels. To improve pain management, a cut-off score for pain was determined, together with a treatment protocol. Its conciseness suggests good usefulness in daily practice.

Evaluation of a Pilot Project for Implementation of REPOS in Daily Practice (Article)

2009-01-01T00:00:00Z

Abstract: Pain assessment in elderly people with a communication disability is a well-known problem. Objective: To explore the feasibility of a new pain observation scale. Study group: Fifteen nurses employed at eight wards in one nursing home. Methods: We developed the Rotterdam Elderly Pain Observation Scale (REPOS), which includes 10 behavioral items scored as present (1) or absent (0) after a 2-minutes observation. In addition, pain level is rated on the Numeric Rating Scale (NRS). A REPOS score of ≥3 in combination with a NRS of ≥4 indicates pain. Fifteen nurses received a 2-hours theoretical training, and performed paired bedside observations with the trainer. After obtaining a sufficient interrater agreement, nurses were asked to continue REPOS observations. These data were examined after six months. Results: All nurses reached sufficient interrater agreement (kappa ≥ 0.61) within a median of 8 weeks (range 4 to 10), after a median of 12 observations. The next 6 months, in total 52 observations were completed by seven nurses at five different wards. Combined REPOS and NRS scores indicated pain in 22 (42%) of 52 observations. In most of these cases (77%) nurses took action as indicated in the decision tree that comes with the REPOS. Conclusions: The REPOS is feasible in daily nursing practice provided training is given. The decision tree was a useful guide for nurses to reflect on residents’ pain and take appropriate action.

Intraoperative awareness during paediatric anaesthesia (Article)

2009-01-01T00:00:00Z

Background. Previous studies indicate a higher incidence of awareness during anaesthesia in children than in adults, that is, around 1% vs 0.2%. In this prospective cohort study, we determined the incidence of intraoperative awareness in children undergoing elective or emergency surgery at a university children's hospital. Methods. Data from 928 consecutive paediatric patients, aged 5-18 yr, were collected prospectively over a 12 month period. Interviews using a structured questionnaire were scheduled at three time points: within 24 h after the operation, and 3-7 and 30 days after operation. Reports of suspected awareness were sent to four independent adjudicators. If they all agreed, the case was classified as a true awareness case. Results. The interviews generated 26 cases of suspected awareness. Six cases were judged to be true awareness, equalling a 0.6% incidence (95% confidence interval 0.03-1.40%). Auditory and sensory perceptions were the sensations most reported by these six children. Pain, anxiety, and paralysis were less often mentioned. The children in general did not report awareness as stressful. Conclusions. The incidence of awareness in this study, in children undergoing general anaesthesia, is comparable with recent reports from other countries, and appears to be higher than that reported in adults.

Telephone helpline for parents of children with congenital anomalies (Article)

2008-12-01T00:00:00Z

Aim. This paper is a report of a study to evaluate how often and for what reason parents of children born with severe anatomical congenital anomalies use a 24-hour telephone helpline, and to identify differences between callers and non-callers. Background. Children born with severe congenital anomalies often remain dependent on medical care and technology after discharge. Adequate medical consultation in the home situation may lower parental burden. Method. Observational study of telephone contacts from 2000 to 2006 with parents of congenital anomaly patients discharged home after neonatal intensive care admission. Frequency of telephone calls was categorized per type of anomaly. Resulting interventions in terms of consultation and hospital admission were recorded. Finally, costs of personnel needed to provide 24-hour telephone helpline availability were calculated. Findings. A total of 670 calls occurred outside office hours, from 34.4% of all parents; 23.7% of these calls concerned feeding problems. Parents of children with oesophageal atresia, urogenital malformation and congenital diaphragmatic hernia called most frequently (44.3-50.6%). Non-callers were more often first-time parents, divorced/separated or immigrants. Nurses handled 24.5% of calls by themselves and 20.2% of calls led to emergency room consultations resulting in 4.9% admissions. First contact took place at median age 3 months, last contact at median age 8 months. Total personnel costs amounted to €27,191 per year. Conclusion. A 24-hour telephone helpline provides easy access to medical and supportive care for parents of children with congenital anomalies at relatively low cost. Nurses can effectively run this telephone helpline with paediatrician back-up.

Impact of a child with congenital anomalies on parents (ICCAP) questionnaire; a psychometric analysis (Article)

2008-11-23T00:00:00Z

Background: The objective of this study was to validate the Impact of a Child with Congenital Anomalies on Parents (ICCAP) questionnaire. ICCAP was newly designed to assess the impact of giving birth to a child with severe anatomical congenital anomalies (CA) on parental quality of life as a result of early stress. Methods: At 6 weeks and 6 months after birth, mothers and fathers of 100 children with severe CA were asked to complete the ICCAP questionnaire and the SF36. The ICCAP questionnaire measures six domains: contact with caregivers, social network, partner relationship, state of mind, child acceptance, and fears and anxiety. Reliability (i.e. internal consistency and test-retest) and validity were tested and the ICCAP was compared to the SF-36. Results: Confirmatory factor analysis resulted in 6 six a priori constructed subscales covering different psychological and social domains of parental quality of life as a result of early stress. Reliability estimates (congeneric approach) ranged from .49 to .92. Positive correlations with SF-36 scales ranging from .34 to .77 confirmed congruent validity. Correlations between ICCAP subscales and children's biographic characteristics, primary CA, and medical care as well as parental biographic and demographic variables ranged from -.23 to .58 and thus indicated known-group validity of the instrument. Over time both mothers and fathers showed changes on subscales (Cohen's d varied from .07 to .49), while the test-retest reliability estimates varied from .42 to .91. Conclusion: The ICCAP is a reliable and valid instrument for clinical practice. It enables early signaling of parental quality of life as a result of early stress, and thus early intervention.

Pain prevalence and characteristics in three Dutch residential homes (Article)

2008-10-01T00:00:00Z

Background: In Anglo-Saxon countries, high prevalence rates of pain have been reported for elderly living in nursing homes, residential homes and for community-dwelling elderly. No information on pain prevalence is available for elderly living in Dutch residential homes. Methods: We performed an explorative study on pain prevalence, characteristics and treatment in three residential homes in Rotterdam, the Netherlands. Residents were interviewed using a standardized pain questionnaire. Results: The overall prevalence of pain was 69%. In case of pain, it was chronic in 93% of residents. Present pain and mean pain during the preceding week were substantial (numeric rating scale ≥4) in 68% and 85% of residents, respectively. Of the residents with pain, 22% did not receive any analgesics and only 3% was prescribed a strong opioid. When analgesics were prescribed, they were given only 'as needed' in 31% of residents. In a majority of residents, pain interfered with daily living and mood. Almost 60% of the elderly was convinced that pain is a part of ageing, 70% indicated that they did not always report their pain to the caregivers. Thirty-seven percent was satisfied with the caregivers' and 39% with the doctors' attention towards pain. Conclusions: The pain prevalence rate in Dutch residential homes is similar to rates found in other Anglo-Saxon countries. Furthermore, they are also comparable to rates reported from European nursing homes. Pain treatment is insufficient and although pain interferes with daily activities and mood, elderly tend to accept pain as an unavoidable part of aging.

Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: A first evaluation (Article)

2008-08-01T00:00:00Z

OBJECTIVE: To establish frequencies of benzodiazepine and opioid withdrawal symptoms, and correlations with total doses and duration of administration. DESIGN: A prospective, repeated-measures design. SETTING: Two pediatric intensive care units in a university children's hospital. PATIENTS: Seventy-nine children, aged 0 days to 16 yrs, who received intravenous midazolam and/or opioids for >5 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pediatric intensive care unit nurses assessed withdrawal symptoms using the Sophia Benzodiazepine and Opioid Withdrawal Checklist, which includes all withdrawal symptoms (n ≤ 24) described in the pediatric literature. Over 6 months, 2188 observations in 79 children were recorded. Forty-two percent of observations were performed within 24 hrs after tapering off or discontinuation of medication. Symptoms representing overstimulation of the central nervous system, such as anxiety, agitation, grimacing, sleep disturbance, increased muscle tension, and movement disorder, were observed in >10% of observations. Of symptoms reflecting gastrointestinal dysfunction, diarrhea and gastric retention were most frequently observed. Tachypnea, fever, sweating, and hypertension as manifestations of autonomic dysfunction were observed in >13% of observations. The Spearman's rank-correlation coefficient between total doses of midazolam and maximum sum score (of the Sophia Benzodiazepine and Opioid Withdrawal Checklist) was .51 (p < 0.001). The correlation between total doses of opioids and the maximum sum score was .39 (p < 0.01). A significant correlation (.52; p < 0.001) was also found between duration of use and maximum sum score. CONCLUSIONS: This is the first study to report frequencies of all 24 withdrawal symptoms observed in children after decrease or discontinuation of benzodiazepines and/or opioids. Agitation, anxiety, muscle tension, sleeping <1 hr, diarrhea, fever, sweating, and tachypnea were observed most frequently. Longer duration of use and high dosing are risk factors for development of withdrawal symptoms in children.

Pharmacokinetics and analgesic effects of intravenous propacetamol vs rectal paracetamol in children after major craniofacial surgery (Article)

2008-07-01T00:00:00Z

Background: The pharmacokinetics and analgesic effects of intravenous and rectal paracetamol were compared in nonventilated infants after craniofacial surgery in a double-blind placebo controlled study. Methods: During surgery all infants (6 months-2 years) received a rectal loading dose of 40 mg·kg-1paracetamol 2 h before anticipated extubation. On admittance to the pediatric surgical ICU, the children were randomized to receive either a 15 min intravenous infusion of 40 mg·kg-1propacetamol, a prodrug of paracetamol, or 20 mg·kg-1paracetamol rectally every 6 h. A population pharmacokinetic analysis of the paracetamol plasma concentration time-profiles was undertaken using nonlinear mixed effects models. The visual analogue scale (VAS) (score 0-10 cm) and COMFORT Behavior scale (score 6-30) were used to monitor analgesia in the 24-h period following surgery. Results: Twelve infants received intravenous propacetamol and 14 paracetamol suppositories. Paracetamol pharmacokinetics were described according to a two-compartmental model with linear disposition. Pharmacokinetic parameters were standardized to a 70 kg person using allometric '1/4 power' models. Parameter estimates were: absorption half-life from the rectum 4.6 h, propacetamol hydrolysis half-life 0.028 h, clearance 12 l·h-1·70 kg-1, intercompartmental clearance 116 l·h-1·70 kg-1, central and peripheral volume of distribution 7.9 and 44 l·70 kg-1, respectively. During the 24-h study period 22 infants exhibited VAS scores <4 cm, which was considered a cutoff point. On single occasions four patients, two in each group, exhibited a VAS score ≥4 cm. Nine patients in the rectal treatment group and three patients in the intravenous treatment group received midazolam for COMFORT-B scores exceeding 17 (P < 0.05). Conclusions: Intravenous propacetamol proved to be more effective than rectal paracetamol in infants after craniofacial surgery. Midazolam was more frequently administered to patients receiving paracetamol suppositories, indicating that these children experienced more distress, possibly caused by pain.

Is topical local anaesthesia necessary when performing paediatric flexible nasendoscopy? A double-blind randomized controlled trial (Article)

2007-11-01T00:00:00Z

Objective: To evaluate the effectiveness of lignocain 2% and oxymetazoline 0.025% compared to oxymetazoline 0.025% alone when administered prior to fibreoptic nasendoscopy in paediatric patients. Study design: Prospective, randomized controlled, double-blind study. A group of 56 children, undergoing nasendoscopy to determine adenoidal size, were randomized into two groups and received either lignocain 2% and oxymetazoline 0.025% or oxymetazoline 0.025% alone prior to fibreoptic nasendoscopy. Setting: A tertiary care Paediatric Hospital. Method: The endoscopist recorded the ease of performance of the procedure, cooperation of patient and quality of the view achieved using a visual analogue scale (VAS). The pain and anxiety levels of the child were recorded before, during and immediately after the procedure, using a VAS. The duration of performing the procedure was recorded from insertion of the endoscope into the nostril until removal. Results: All 56 children were able to undergo the endoscopy and the full anxiety and pain assessment was done. Three children were excluded because they have undergone nasendoscopies before. Of the 53 patients included, 27 children received solution A (oxymetazoline 0.025%) and 26 children received solution B (oxymetazoline 0.025% and lignocain 2%). There was no statistical difference between the two groups regarding the duration of the endoscopy, quality of view, ease of performance and cooperation of the patients. The median pain and anxiety scores were not significantly different between the two groups. Conclusions: This study concludes that the use of a decongestant (oxymetazoline) for paediatric nasendoscopy is just as effective as the use of oxymetazoline with lignocain. Pain and anxiety is not increased in the absence of lignocain.

Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: A literature review. "Assessment remains troublesome" (Article)

2007-08-01T00:00:00Z

Background: Prolonged administration of benzodiazepines and/or opioids to children in a pediatric intensive care unit (PICU) may induce physiological dependence and withdrawal symptoms. Objective: We reviewed the literature for relevant contributions on the nature of these withdrawal symptoms and on availability of valid scoring systems to assess the extent of symptoms. Methods: The databases PubMed, CINAHL, and Psychinfo (1980-June 2006) were searched using relevant key terms. Results: Symptoms of benzodiazepine and opioid withdrawal can be classified in two groups: central nervous system effects and autonomic dysfunction. However, symptoms of the two types show a large overlap for benzodiazepine and opioid withdrawal. Symptoms of gastrointestinal dysfunction in the PICU population have been described for opioid withdrawal only. Six assessment tools for withdrawal symptoms are used in children. Four of these have been validated for neonates only. Two instruments are available to specifically determine withdrawal symptoms in the PICU: the Sedation Withdrawal Score (SWS) and the Opioid Benzodiazepine Withdrawal Scale (OBWS). The OBWS is the only available assessment tool with prospective validation; however, the sensitivity is low. Conclusions: Withdrawal symptoms for benzodiazepines and opioids largely overlap. A sufficiently sensitive instrument for assessing withdrawal symptoms in PICU patients needs to be developed.

Effects of low-dose naloxone on opioid therapy in pediatric patients: A retrospective case-control study (Article)

2007-01-01T00:00:00Z

Objective: To develop novel therapies that prevent opioid tolerance in critically ill children we examined the effects of low-dose naloxone infusions on patients' needs for analgesia or sedation. Design and setting: Matched case-control study in a pediatric intensive care unit at a university children's hospital. Patients: We compared 14 pediatric ICU patients receiving low-dose naloxone and opioid infusions with 12 matched controls receiving opioid infusions. Measurements and main results: Opioid analgesia and sedative requirements were assessed as morphine- and midazolam-equivalent doses, respectively. No differences were observed between groups in opioid doses at baseline or during naloxone, but in the postnaloxone period opioid doses tended to be lower in the naloxone group. Compared to baseline the naloxone group required more opioids during naloxone but fewer opioids after naloxone. Total sedative doses were comparable at baseline in both groups, with no differences in the postnaloxone period. The naloxone group required less sedation after naloxone but sedation doses were unchanged in controls. The two groups did not differ in pain scores, sedation scores, or opioid side effects. Conclusions: Naloxone did not reduce the need for opioid during the infusion period but tended to reduce opioid requirements in the postnaloxone period without additional need for sedation. Randomized clinical trials may examine the effects of low-dose naloxone on opioid tolerance and side effects in pediatric ICU patients requiring prolonged opioid analgesia.

Pijnregistratie en pijnbehandeling in verpleeghuizen kunnen nog beter. (Article)

2007-01-01T00:00:00Z

AIM. To assess the effect of implementation of pain registration in nursing homes on the residents’ pain (treatment); a secondary aim was measuring nursing compliance. METHODS. Prior to implementation of pain registration, all relevant aspects of pain (treatment) were recorded through interviews with the residents (pretest). Interviews were repeated after at least three months following implementation of pain registration (posttest). RESULTS. Three fourths of all residents were able to give information about their pain and two thirds could provide a numerical rating. On average, 69% of all residents with recorded pain history experienced pain in the pretest. Pain registration resulted in a significant decrease in the proportion of residents suffering from substantial pain during the previous week. CONCLUSION. Pain registration is feasible in the majority of elderly living in nursing homes and may improve pain treatment and satisfaction with caretakers.

Observation scales for pain assessment in older adults with cognitive impairments or communication difficulties (Article)

2007-01-01T00:00:00Z

BACKGROUND: Several pain observation scales have been developed to accurately assess and manage pain in older adults with severe cognitive impairments, communication difficulties, or both. OBJECTIVE: To review relevant pain observation scales and the psychometric qualities of these scales. METHODS: The literature was searched for articles reporting the use of a pain observation scale in an empirical study and describing psychometric properties in older adults with cognitive impairments, communication difficulties, or both. RESULTS: Thirteen pain observation scales were included. Scales differed in numbers of items, types of categories, and psychometric properties. Facial expression, vocalization, motor behavior, and social behavior or mood are categories present in most of the scales. In terms of reliability and validity, however, most studies are too limited or incomplete to allow definite conclusions to be drawn about usefulness in daily practice. DISCUSSION: As different methods of evaluating reliability and validity were used, and different aims (e.g., type of pain) were pursued, the available scales cannot be compared easily. Nevertheless, a few are promising, given preliminary results. These should be examined further on psychometric properties and usefulness in different populations because optimal pain assessment is necessary for efficient and effective pain treatment.

Assessment of sedation levels in pediatric intensive care patients can be improved by using the COMFORT "behavior" scale (Article)

2005-01-01T00:00:00Z

Objectives: The original COMFORT scale, including both observational and physiologic items, has been validated for measuring distress in children admitted to a pediatric intensive care unit. However, physiologic variables are influenced by drugs given in the pediatric intensive care unit setting. The objectives of this study were to assess the usefulness of physiologic variables in judgment of sedation and to determine new cutoff points for the COMFORT "behavioral" scale (COMFORT-B), using only observational items. Design: Prospective observational study. Setting: Pediatric intensive care unit in a university hospital Patients: Seventy-eight patients admitted to the pediatric intensive care unit. Interventions: None. Measurements and Results: COMFORT scores were obtained in this patient group. Similar to the original COMFORT scale validation, the expert opinion of nurses (Nurse Interpretation Score of Sedation) served to determine optimal cutoff scores for the COMFORT-B scale. A total of 843 combined COMFORT and Nurse Interpretation Score of Sedation scores were obtained in 78 patients. Cronbach's alpha for the COMFORT scale was .78, increasing to .84 when the physiologic items, blood pressure and heart rate, were excluded. COMFORT scores were significantly different for the three Nurse Interpretation Score of Sedation categories (Kruskal-Wallis, p < .001). According to the pediatric intensive care unit nurses, undersedation was present in 11% and oversedation in 3% of all observations. Cutoff points for the COMFORT-B scale were ≤10 for oversedation and ≥=23 for undersedation. The area in the COMFORT-B score between 11 and 22 does not adequately predict under- or oversedation, pointing to a need for supplemental observation. Conclusions: The COMFORT-B scale is a reliable alternative to the original COMFORT scale. The cutoff points of the COMFORT-B scale in conjunction with the Nurse Interpretation Score of Sedation facilitate the use of sedation algorithms on the pediatric intensive care unit. Copyright

Pain Unheard? Postoperative Pain Assessment in Neonates and Infants (Doctoral Thesis)

2001-01-24T00:00:00Z

Study aim: The study aimed at answering two questions: • How reliable. valid, and feasible is the multidimensional COMFORT scale to assess postoperative pain in infants and toddlers 0-3 years of age? • What is the difference between intermittent morphine administration and continuous intravenous morphine in terms of quality and effectiveness of analgesia for postoperative pain in infants and toddlers 0-3 years of age? The studies described in this thesis deal primarily with the first question. The differences between the two morphine conditions in relation to hormonal and metabolic plasma levels and morphine plasma levels will be reported elsewhere. During data collection a third research question came up, inspired by the eventful hospital history of some children combined with the individual differences in pain response and morphine requirement after surgery in our sample. This question was also justified by publications on subsequent and long-tenn consequences of neonatal pain. The third, additional question is: • Are the present postoperative pain and stress response related to past experiences with pain?