Research article
The impact of introducing nurse-led analgesia and sedation guidelines in ventilated infants following cardiac surgery

https://doi.org/10.1016/j.iccn.2020.102879Get rights and content

Abstract

Introduction

Enhanced clinical outcomes in the Paediatric Intensive Care Unit following standardisation of analgesia and sedation practice are reported. Little is known about the impact of standardisation of analgesia and sedation practice including incorporation of a validated distress assessment instrument on infants post cardiac surgery, a subset of whom have Trisomy 21. This study investigated whether the parallel introduction of nurse-led analgesia and sedation guidelines including regular distress assessment would impact on morphine administered to infants post cardiac surgery, and whether any differences observed would be amplified within the Trisomy 21 population.

Methodology

A retrospective single centre before/after study design was used. Patients aged between 44 weeks postconceptual age and one year old who had open cardiothoracic surgery were included.

Results

61 patients before and 64 patients after the intervention were included. After the intervention, a reduction in the amount of morphine administered was not evident, while greater use of adjuvant sedatives and analgesics was observed. Patients with Trisomy 21 had a shorter duration of mechanical ventilation after the change in practice.

Conclusion

The findings from this study affirm the importance of the nurses’ role in managing prescribed analgesia and sedation supported by best available evidence. A continued education and awareness focus on analgesia and sedation management in the pursuit of best patient care is imperative.

Introduction

Critically ill children in paediatric intensive care units (PICU) routinely receive analgesics and sedatives to prevent pain and anxiety, ensuring the security of invasive lines, endotracheal tube and monitoring equipment. While analgesia and sedation administration may be considered a fundamental role of the PICU nurse, there is wide variability in the clinical management of analgesia and sedation therapy across individual PICUs. This is often due to individual or institutional preferences, or custom and practice (Deeter et al., 2011, Harris and Tume, 2011). Achieving optimal sedation targets in PICU patients can be challenging, which can result in under-sedation or more commonly, over-sedation. The risks associated with over-sedation include prolonged PICU stay, tolerance and iatrogenic withdrawal syndrome (Vet et al., 2013).

Consensus recommendations from the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) advocate a standardised approach in analgesic and sedative management in the PICU, with comprehensive patient assessment using a validated tool (Harris et al., 2016). A current evidence base for a standardised approach is lacking. A systematic review by Poh et al. (2014) determined an association between use of PICU sedation guidelines, protocols or algorithms (sGPA) and decreased sedation dose and PICU length of stay. In contrast, a multicentre study showed no difference in duration of mechanical ventilation in critically ill children managed with a sedation protocol versus usual care (Curley et al., 2015).

Many post-operative congenital cardiac surgery patients share important characteristics, including age and type of surgery (i.e. many undergo sternotomy and cardio-pulmonary bypass). Within the Irish population Trisomy 21 is strongly represented, with an incidence of 1 in 546 live births (Ni She and Filan, 2014), compared with 1 in 691 live births in the United States (Parker et al., 2010). There is a prevalence of 51% for congenital heart disease in this population (Ni She and Filan, 2014) and patients with Trisomy 21 have been reported as having a greater post-operative need for analgesia and sedation (Gakhal et al., 1998, Mitchell et al., 1995). This previously held view was not substantiated in subsequent clinical studies (Valkenburg et al., 2012, Van Driest et al., 2013, Valkenburg et al., 2012, Terada et al., 2016, Valkenburg et al., 2016). However the impact of analgesia and sedation guidelines on the Trisomy 21 cohort compared with a non-Trisomy 21 post-op cardiac cohort has not been investigated.

The primary objective of this study was to determine if the introduction of a standardised nurse-led analgesia and sedation practice which incorporates a validated pain and distress instrument, would impact on the amount of morphine administered in the first 72 hours in a population of post cardiac PICU patients. A secondary objective was to ascertain whether there would be a difference in the amount of morphine administered to patients with Trisomy 21 after cardiac surgery.

The setting for this study was a 23-bed PICU, of a university affiliated teaching hospital. This study concerns the management of analgesia and sedation in the immediate post-operative period; from the point of handover from the operating theatre nurse to 72 hours post-operatively. Widespread variability in analgesia and sedation management practices prompted guideline development by the multidisciplinary PICU Pain and Sedation Group. A six month education campaign with mandatory staff training was undertaken on the new guideline (see Table 1). The guidelines required using the COMFORT Behaviour (COMFORT-B) scale which incorporates a Numerical Rating Scale (NRS) (Dorfman et al., 2014, Harris et al., 2016). All staff received a two hour training session in guideline use and distress assessment using COMFORT-B by using both videotaped instruction and by performing 10 bedside assessments with an “expert”. Scores were recorded and Cohen’s kappa calculated. A linearly weighted Cohen’s Kappa of >0.65 indicated competency in using COMFORT-B. Training sessions were delivered during the day shift and offered at night shift to accommodate all staff and ensure all nurses and doctors were signed off as competent.

The analgesia and sedation guidelines required an initial post-operative distress assessment using COMFORT-B, subsequent 2-hourly assessment in the initial 8 hours post-operative period and 2–4 hourly assessments thereafter. Morphine doses were specified according to patient weight (see Analgesia and Sedation Guideline, Fig. 1). A morphine loading dose at commencement of infusion therapy was indicated to achieve therapeutic concentrations, morphine infusion rates were capped according to patient weight, and as-required, or pre-emptive morphine bolus dosing amounts specified. Administration of intravenous acetaminophen was indicated 6-hourly post-operatively, followed by regular oral dosing on availability of the enteral route. If not contra-indicated a non-steroidal anti-inflammatory agent (NSAID) was recommended. IV midazolam or enteral chloral hydrate was prescribed if sedation was required. Weaning of intravenous morphine was specified after the immediate post-operative period, whereby transition to oral morphine then occurred. Clonidine was indicated as a weaning adjunct. Nurses in the PICU used both the COMFORT-B scale which incorporates a Visual Analogue Scale (VAS) to determine the numeric rating of pain, to assess pain and distress (see Fig. 2). A COMFORT-B score of ≥17 with an NRS value of ≥4 indicated the presence of pain, while a COMFORT-B score of ≥17 with an NRS < 4 suggested under-sedation. After the immediate 6–8 hours post-operative period, COMFORT-B score of ≤10, suggesting over-sedation prompted a controlled wean of analgesia and/or sedation according to the duration of therapy. The PICU Research Nurse and Pharmacist were responsible for guideline adherence surveillance by reviewing patient charts daily. Compliance with maximum guideline morphine infusion rates, frequency of distress assessment and prescription of adjunct and co-analgesia as well as morphine boluses were closely monitored.

Section snippets

Methods

A retrospective before/after study design was used. Ethical approval for conducting the study was obtained (GEN/12809). All patients admitted to the PICU within the defined time periods meeting the inclusion criteria were included in the study. Patients aged between 44 weeks post-conceptual age and one-year post-partum who had open cardiothoracic surgery were included. Children previously ventilated, previously exposed to opiates, possessing a documented opioid sensitivity, requiring Extra

Results

150 eligible patients were identified for inclusion, of which 125 provided sufficient data for analysis: 61 pre-intervention and 64 post-intervention (Fig. 3). The demographic and clinical characteristics of both groups are listed in Table 2. Patients in the before group had a lower gestational age than those in the after group (38.3 weeks vs 40 weeks (p = 0.02)). There was a higher proportion of patients with Trisomy 21 in the before group (54% vs 35.9% p = 0.049). The groups were otherwise

Discussion

This study showed morphine infusion rates were significantly lower after the change in practice, demonstrating good adherence to maximum guideline infusion rates. While morphine remains the primary analgesic after cardiac surgery due to its efficacy, the pharmacokinetic and pharmacodynamic susceptibility of the neonate to opioids is well acknowledged (Wolf and Jackman, 2011). A departure from practice from morphine delivery by high rate infusion is welcome, given awareness of the neurotoxic

Limitations

This study was a retrospective single centre study, limiting its generalisability. A further limitation was the use of before/after methodology, as in the majority of precedent studies. Although there were no significant staff or practice changes during the study period, temporal trends may have influenced our results. While an RCT approach was considered, the change intervention involved required large scale and resource intensive education and awareness initiatives for all PICU staff,

Conclusion

Findings from this study support responsibility for PICU nurses for autonomously administering analgesia and sedation based on validated assessment, supported by clinical guidelines. While a demonstrable impact on the primary outcome was not evident in this study, an altered pattern of morphine administration emerged; characterised by lower infusion rates and greater use of boluses based on patient assessment. The pattern of specific co analgesic and sedation administration was also

Funding statement

Funding was provided by the National Children's Research Centre, Dublin.https://www.nationalchildrensresearchcentre.ie/.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (33)

  • S. Gopisetti et al.

    Sedation and analgesia for critically ill children

    Paediatrics Child Health

    (2015)
  • Harris, J., Tume, L., 2011. UK and Ireland Audit in analgesia and sedation practices in PICU. Paediatric Intensive Care...
  • J. Harris et al.

    Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals

    Intensive Care Med.

    (2016)
  • E. Ista et al.

    Assessment of sedation levels in pediatric intensive care patients can be improved by using the COMFORT “behaviour” scale

    Pediatric Crit. Care Med.

    (2005)
  • E. Ista et al.

    Implementation of standard sedation management in paediatric intensive care: effective and feasible?

    J. Clin. Nurs.

    (2009)
  • H.S. Jin et al.

    The efficacy of the COMFORT scale in assessing optimal sedation in critically ill children requiring mechanical ventilation

    J. Korean Med. Sci.

    (2007)
  • Cited by (3)

    View full text