The Challenges of Providing Effective Pain Management for Children in the Pediatric Intensive Care Unit

Ahmad Ismail, RN, PhD(c)

Disclosures

Pain Manag Nurs. 2016;17(6):372-383. 

In This Article

Abstract and Introduction

Abstract

Providing effective pain management is necessary for all patients in the intensive care unit (ICU). Because of developmental considerations, caring for children may provide additional challenges. The purpose of this literature review is to describe key challenges in providing effective pain management in pediatric intensive care units (PICUs), with the aim of bringing about a better understanding by health care providers caring for children. Challenges of providing effective pain management in the PICU can be categorized into four levels. These levels are informed by the Nursing Pain Management Model and include challenges (1) to be considered before pain assessment, (2) related to pain assessment, (3) related to pain treatment, and (4) related to post-treatment. This review mainly discusses the challenges of the first three levels because the fourth (post-treatment) relates to reassessment of pain, which shares the same challenges of level two, pain assessment. Key challenges of level one are related to health care provider's characteristics, patients and their families' factors, and PICU setting. The main challenges of the assessment and reassessment levels are the child's age and developmental level, ability to self-report, relying on behavioral and physiological indicators of pain, selecting the appropriate pain assessment scale, assessing pain while the patient is being treated with sedative and paralytic agents, mechanical ventilation, and changes in patients' level of consciousness. In the treatment level (level three), nonpharmacological interventions factors; alterations in the pharmacokinetics and pharmacodynamics of medications to be used for pain management in critically ill children; and the complexity of the administration of sedatives, analgesics, and paralytic agents in critically ill children are the main challenges. Health care providers can bear in mind such important challenges in order to provide effective pain management. Health care providers can increase the use of available evidence for pain management.

Introduction

Pain management in children can be more challenging than in adults because of the complex nature of children's pain and their physical, psychosocial, and cognitive development (Srouji, Rantapalan & Schneeweiss, 2010). Pain management in the Pediatric Intensive Care Unit (PICU) can provide unique challenges. There are many reasons for this, such as the nature of the critical condition and the multidimensionality and complexity of illness in the critical care setting. Other potential challenges are the intensity of emotions in this environment due to the variety of pain syndromes that are apparent in the ICU and the fact that self-reported pain (widely considered the gold standard for pain assessment) (American Association of Critical-Care Nurses [AACCN], 2014) is compromised by administration of sedative agents, mechanical ventilation, and patients' changes in level of consciousness (Gélinas, Fortier, Viens, Fillion, & Puntillo, 2004; Oakes, 2011; Skrobik, 2008; Turner, 2005). The purpose of this review was to describe the challenges of providing effective pain management in the PICU, thus creating a better understanding of such challenges.

Children have the right to appropriate assessment and treatment of pain by educated health care providers (The International Association for Study of Pain [IASP], 2014). The Canadian Association of Critical Care Nurses (CACCN) addressed the key role that critical care nurses, such as PICU nurses, play in providing optimal pain assessment and management. The association's document titled Standards for Critical Care Nursing Practice states that a "critical care nurse discerns among pain, anxiety and delirium as the source of discomfort and implements individualized therapies (pharmacological and non-pharmacological) to prevent and/or alleviate suffering" (Canadian Association of Critical Care Nurses [CACCN], 2009, p. 4).

The most commonly used pain definitions were developed by the IASP (1986) and by Margo McCaffery (1977). The IASP defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (IASP, 1986, p. 217). McCaffery defined pain as "what the patient says it is, and exists whenever the patient says it does" (McCaffery, 1977, p. 11). McCaffery's definition of pain is advocated by many as the basis for effective pain assessment and treatment (Oakes, 2011) because a patient's self-report of pain (the gold standard for assessment) is considered the most important indicator for pain existence and pain relief (American Academy of Pediatrics, 2001; Von Baeyer et al., 2009). This basis is a challenge when providing pain management to preverbal children and infants who have not developed the language and cognitive capabilities to express their experience in detailed words. A definition that relies on one's self-report of pain is also a challenge when caring for unconscious and intubated patients, such as children and adolescents in PICUs who cannot self-report, and thus creates challenges for how health care providers evaluate the effectiveness of pain management interventions.

When a self-report of pain cannot be obtained, health care providers rely on observed physiological and behavioral measures (Van Hulle Vincent, Wilkie, & Wang, 2011). Although observed measures of pain can provide helpful information, they also can provide an inaccurate pain intensity score by possibly reflecting fear or distress (Ljungman, Kreuger, Gordh, & Sorensen, 2006; Oakes, 2011). In addition, children often participate in activities despite feeling pain (Ljungman et al., 2006; Oakes, 2011) and this could lead to under-rating pain intensity.

The American Pain Society considers pain as the fifth vital sign along with temperature, heart rate, blood pressure, and respiratory rate (American Pain Society, 2012). If pain is assessed with the same ardor as the other vital signs, it would have a better chance of being treated appropriately (American Pain Society, 2012; Geriatrics and Extended Care Strategic Healthcare Group, 2000). In the PICU, vital signs are continuously monitored and recorded hourly. It is challenging for health care providers in the PICU to assess and manage pain with every check of vital signs of sedated and paralyzed patients, patients who are affected by inotropic agents, patients who cannot report their pain, and ventilated patients.

Unrelieved pain in children can result in negative consequences. Depending on the severity of tissue injury, reactions to pain may include systemic responses encompassing alteration in cardiovascular, pulmonary, and other physiological functions (Anand et al., 2006; Oakes, 2011). For example, pain can cause an elevation of the heart rate, blood pressure, and oxygen consumption by the heart; however, such responses could be poorly tolerated by medically fragile children (Oakes, 2011) such as critically ill children. Pain can result in an ineffective cough or an impaired ability to take deep breaths, which may lead to an increased risk of pulmonary infections, atelectasis, and subsequent reduced gas exchange (Dowden, 2009; Oakes, 2011). Pain can negatively affect sleep (Eccleston, Jordan, & Crombez, 2006). Disrupted sleep patterns characterized by shortened and fragmented sleep commonly are reported by people suffering from pain (Roehrs & Roth, 2005). In addition, untreated or poorly managed pain can lead to psychological consequences including anxiety, fear, anger, guilt, frustration, and depression (Linton & Shaw, 2011). Critically ill children and adolescents in the PICU are at risk for these negative effects because they are exposed to multiple painful procedures and may not be able to engage in self-reporting.

Untreated or poorly managed pain can negatively affect critically ill children, both physiologically and psychologically (Rennick et al., 2004; Rush & Harr, 2001). For example, pain can lead to increased sympathetic responses, resulting in increased cardiac effort and oxygen consumption, elevated stress hormones, immunosuppression, and delays in wound healing (Thorp & James, 2010). Pain caused by chest wounds and abdominal incisions reduces chest and abdominal movement that can lead to an increased chance of infection and delays in weaning from a mechanical ventilator (Oakes, 2011; Thorp & James, 2010). Pain can result in negative psychological outcomes after discharge from the PICU. Rennick et al. (2004) indicated that exposure to invasive procedures was the most important predictor of negative psychological outcomes following discharge from a PICU. Untreated or poorly treated pain in children, including children in PICUS, may lead to chronic pain that may continue in adulthood (Mathews, 2011; Zeltzer, Anderson, & Schechter, 1990). Children in the PICU are exposed to recurrent and intense pain from different sources every day (Oakes, 2011; Stevens et al., 2011). For example, Stevens et al. (2011) found that the highest number of painful procedures in children in Canadian hospitals was in the PICU (mean per day 13.1, SD 8.8). They also reported examples of painful procedures that cause moderate-to-severe pain, such as insertion of an endotracheal tube, removal of a chest tube, and insertion of a central venous line. These procedures commonly are performed in the PICU. Persistent and intense pain can cause allodynia (pain caused by a stimulus that does not usually induce pain), hyperalgesia (increased pain sensitivity from a stimulus that usually induces pain), and hyperpathia (abnormal reaction and increased threshold to painful stimuli) (Voscopoulos & Lema, 2010). This could transform acute pain to chronic pain by diminishing the normal response functioning to painful stimuli (Voscopoulos & Lema, 2010).

The effect of pain extends beyond physiological responses. It can affect the patient's family, who often are overwhelmed by the high technology environment of the PICU. They may feel helpless and distressed when they see their child's pain and discomfort (Turner, 2005). In addition, those involved in caring for a child with inadequate pain management may feel frustration, anger, and lack of control (Cooper & Mitchell, 1990; Turner, 2005). Health care providers could develop stress because of child's pain and discomfort (Turner, 2005).

Many sources of pain in the ICU and PICU can make pain management more complex than in other settings (Oakes, 2011; Thorp & James, 2010; Turner, 2005). Pain can be caused by the underlying illness or injury, e.g., cardiac surgery, burns, fractures, wounds, and trauma. Pain can be a complication of the primary illness, e.g., pancreatitis, peritonitis, and ischemic bowel disease. Frequent medical procedures result in pain, e.g., insertion of intravenous needles, chest tubes, arterial catheters, and heel lances. Also, supporting and monitoring systems can contribute to pain, e.g., nasogastric tube insertion, endotracheal tube insertion and suctioning, and mechanical ventilation. Tissue hypoxia that develops because of low oxygen saturation, low cardiac output, or anemia can result in pain (Thorp & James, 2010). In addition, many other causes of pain are present in the PICU, such as painful joints, pressure point pain, and pain resulting from changing positions (Oakes, 2011; Stevens et al., 2009; Thorp & James, 2010). Pain management in the PICU shares both the challenges of providing pain management for children and for critically ill patients.

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