Introduction
Methods
Results
Assessment of pain-related distress
Pain
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment” (IASP 2014)
Acute pain “Acute pain should be viewed as the initiation phase of an extensive, persistent nociceptive and behavioural cascade triggered by tissue injury. This cascade has the potential to span orders of magnitude of space and time, but generally subsides within weeks” [89]
Postoperative pain Acute pain experienced post-surgery
Prolonged pain The terms prolonged and recurrent are used interchangeably in the literature. Prolonged or persistent pain is primarily caused by disease e.g. peritonitis. Prolonged pain differs from chronic pain in that there is a clear stimulus caused by disease (e.g. peritonitis) or therapy (e.g. mechanical ventilation, insertion of tubes or drains), with a clear definable beginning and an expected endpoint. But less than 3 months and full recovery of tissue damage can be expected, which is not the case in chronic pain [23] |
Non-pain-related distress
Distress is an organism’s response to aversive internal and external stimuli and may include discomfort, anxiety and fear [25]
Optimal sedation A state in which the patient is somnolent, responsive to the environment but untroubled by it, and with no excessive movements [13] |
Iatrogenic withdrawal syndrome
A clinical syndrome that manifests after stopping or reversing a drug after prolonged exposure to that drug [3, 4]
Tolerance A decrease in a drug’s effect or the need to increase the dose to achieve the same effect [3, 4]
Physiological dependence The requirement for continued administration of a sedative or analgesic to prevent signs of withdrawal syndrome |
Delirium
A neurocognitive disorder due to a somatic illness or its treatment [61] DSM-5 criteria: A. Disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment) B. The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day C. An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception) D. The disturbances in Criteria A and C are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma E. There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies |
Recommendation
-
Identify potential sources of pain and take appropriate actions (grade of recommendation = D).
COMFORT behavior scale | |
Categories | Score |
Alertness | 1–5 |
Calmness/agitation | 1–5 |
Respiratory response or cryinga
| 1–5 |
Physical movement | 1–5 |
Muscle tone | 1–5 |
Facial tension | 1–5 |
Total score 6–30 | |
Withdrawal Assessment Tool version 1 (WAT-1) | |
Information from patient record | |
Loose/watery stools | No = 0, yes = 1 |
Vomiting/retching/gagging | No = 0, yes = 1 |
Temperature > 37.8 °C | No = 0, yes = 1 |
2 min pre-stimulus observation | |
State | SBS ≤ 0 = 0, SBS ≥ 1 = 1 |
Tremor | No = 0, moderate/severe = 1 |
Any sweating | No = 0, yes = 1 |
Uncoordinated/repetitive movement | No = 0, moderate/severe = 1 |
Yawning of sneezing | No = 0, yes = 1 |
1 min stimulus observation | |
Startle to touch | No = 0, moderate/severe = 1 |
Muscle tone | Normal = 0, increased = 1 |
Post-stimulus recovery | |
Time to gain calm state (SBS ≤ 0) | 0–2 |
Total score 0–12 | |
Sophia Observation withdrawal Symptoms-scale (SOS) | |
Items | Score |
Autonomic dysfunction | |
Tachycardia | No = 0, yes = 1 (for all items) |
Tachypnoea | |
Fever (≥38.5 °C) | |
Sweating | |
CNS irritability | |
Agitation | |
Anxiety | |
Tremors | |
Increased muscle tension | |
Inconsolable crying | |
Grimacing | |
Sleeplessness | |
Motor disturbance | |
Hallucinations | |
Gastrointestinal dysfunction | |
Vomiting | |
Diarrhoea | |
Total score 0–15 |
Neonates | Infants and children | ||||||
---|---|---|---|---|---|---|---|
COMFORTneo [95] | |||||||
Age range | 28–40 weeks | 28–40 weeks | 23–40 weeks | 24–42 weeks | 0–3 years | 0–7 years | 0–31 months |
Type of pain | Procedural and postoperative pain | Procedural pain | Procedural and prolonged pain | Prolonged pain | Postoperative pain | Postoperative pain | Postoperative pain |
Variables assessed | Heart ratea
Oxygen saturationa
Brow bulgea
Eye squeezea
Nasolabial furrowa
Behavioural state | Heart ratea
Oxygen saturationa
Brow bulgeb
Eye squeezeb
Nasolabial furrowb
Behavioural state | Heart rate Respiratory rate Blood pressure Oxygen saturation crying, irritability Facial expressions Behavioural state Extremities/tone | Alertness Calmness/agitation Respiratory response or crying Body movement Muscle tone Facial tension | Alertness Calmness/agitation Respiratory response or crying Physical movement Muscle tone Facial tension | Facial expression, movement of limbs Cry, consolability | Vital signs HR and/ or BP Breathing pattern Facial expression Body movements State of arousal |
Score range (cut-off point) | 0–21 0–6 no to mild pain 7–12 moderate pain >12 severe pain | 0–21 0–6 no to mild pain 7–12 moderate pain >12 severe pain | Pain: 0–10 >3 | 6–30 6–13 no to mild discomfort 14–21 moderate discomfort >22 severe discomfort | 6–30 >17 pain | 0–10 1–3 mild discomfort 4–6 moderate discomfort 6–10 severe discomfort/pain | |
Adjustment for gestational age | Yes | Yesc
| Yes | No | NA | NA | NA |
Reliability data | + | – | + | + | + | + | + |
Forms of validity established | Construct and concurrent | Construct and concurrent | Construct and convergent | Concurrent | Construct and concurrent | Construct and concurrent | |
Clinical utility | + | – | + | + | + | ||
Grade | A | A | B | B | A | B | A |
Recommendation
-
Use an age-appropriate tool to assess acute and prolonged pain i.e. the PIPP(-revised) in neonates and the COMFORT behaviour scale, FLACC or MAPS in critically ill children (grade of recommendation = A).
Recommendation
-
Parent and family assessment of pain should be considered in pain assessment (grade of recommendation = D).
Recommendation
-
Pain assessment should take place routinely, depending on therapeutic goals, but at greater frequency (1–2 h) if the patient is receiving any analgesic infusion (grade of recommendation = D).
Recommendation
-
Pain assessment audits should take place regularly (grade of recommendation = C).
Non-pain-related distress
Sedation assessment
Recommendation
-
Search for potential causes of non-pain-related distress/discomfort to take appropriate actions (grade of recommendation = D).
State Behavioural Scale (SBS) [46] | |||
---|---|---|---|
Age range | 0–16 years | 0–16 years | 6 weeks–6 years |
Variables assessed | Distress Heart rate Mean arterial pressure Alertness Calmness Respiratory response Movement Muscle tone Facial expression | Distress Alertness Calmness/agitation Respiratory response or crying Physical movement Muscle tone Facial tension | Respiratory drive Coughing Best response to stimuli Attentiveness to care provider Tolerance to care Consolability Movement after consoled |
Score range (cut-off point) | 8–40 <17 oversedation 17–26 optimal sedation >26 undersedation | 6–30 <11 oversedation 11–22 adequate sedation >22 undersedation | 6-point scale; state behaviour on a scale of −3 to +2 0 = awake and calm |
Reliability data | + | + | + |
Forms of validity established | Face, construct and concurrent | Face, construct and concurrent, responsiveness | Face, construct |
Clinical utility | Feasibility and utility established at bedside | Feasibility and utility established at bedside | |
Grade | A | A | B |
Recommendation
-
Use standardized sedation assessment tools with proven validity, reliability and clinical utility; the COMFORT behaviour scale (grade of recommendation = A).
-
Together with the vital signs, the level of sedation must be assessed and documented every 4–8 h or as indicated by the sedation score or the child’s clinical condition (grade of recommendation = D).
Iatrogenic withdrawal syndrome assessment in infants and children
Recommendation
-
The potential risk of opioid and/or benzodiazepine iatrogenic withdrawal syndrome should be considered after 5 days of continuous administration of these drugs (grade of recommendation = C).
Paediatric Confusion Assessment Method-Intensive Care Unit (pCAM-ICU) [66] | |||||
---|---|---|---|---|---|
Age range | Children 0–16 years | Children 0–16 years | 5–16 years | 0–21 years | 0–16 years |
Variables assessed | Loose/watery stools Vomiting/retching/gagging Temperature > 37.8 °C State* Tremor Sweating Uncoordinated/repetitive movement Yawning of sneezing Startle to touch Muscle tone Time to gain calm state (SBS ≤ 0) | Tachycardia Tachypnoea Fever (≥38.5 °C) Sweating Agitation Anxiety Tremors Increased muscle tension Inconsolable crying Grimacing Sleeplessness Motor disturbance Hallucinations Vomiting Diarrhoea | Four features: 1. Acute change or fluctuation course of mental status 2. Inattention 3. Altered level of consciousness 4. Disorganized thinking | Eye contact with caregiver Purposeful actions Awareness of surrounding Communicate needs Restless Inconsolable Underactive Response to interaction | Agitation (restless), anxiety, eye contact, grimacing impaired attention Speech Tremors Muscle tone Purposeful actions Sleeplessness Hallucinations Disorientation Sweating Acute change/fluctuation Parents |
Score range (cut off point) | 0–12 points ≥3 | 0–15 points ≥4 | Features 1, 2 and 3 or 4a
| 0–40 (9) | 0–15 (4) |
Reliability data | + | + | + | + | ± |
Forms of validity established | Content, construct, responsiveness | Face, construct | Criterion | Criterion | Face (criterion pilot) |
Clinical utility | Feasibility and utility established at bedside | Feasibility and utility established at bedside | Feasibility | Utility established at bedside | Feasibility |
Grade | A | A | B | A | C |
Recommendation
-
Use standardized IWS assessment instruments with proven clinical utility, validity and reliability in infants and children; WAT-1 or the SOS (grade of recommendation = A).
Delirium
Recommendation
-
Search for potential sources of paediatric delirium and to take appropriate actions (grade of recommendation = D).
Delirium assessment
Recommendation
-
Use CAP-D as an instrument to assess paediatric delirium (grade of recommendation = A).
-
Together with the vital signs, delirium must be assessed and documented every 8–12 h (at least once per shift), 24–48 h after admission or as indicated by the delirium score of clinical condition of the child (grade of recommendation = D).
Pain and non-pain-related distress management protocols in relation to assessment
Recommendation
-
The effect (e.g. increasing or decreasing of a pump, bolus) of a drug should be re-evaluated depending on the drug’s half-life (grade of recommendation = D).
Recommendation
-
Reassess for symptoms of withdrawal after treatment interventions (grade of recommendation = D).
Recommendation
-
Validated assessment tools for pain, sedation, withdrawal syndrome and delirium should be integrated in pain and non-pain-related treatment protocols (grade of recommendation = C).