Effectiveness of breastfeeding for pain relief in infants during vaccination at Bharatpur

Background: Vaccination is an integral part of childhood development since it protects children from a variety of diseases. It is, however, the most common cause of pain in children. Breastfeeding is effective tool for reducing pain in infants during vaccinations. The objective of the study was to determine the effectiveness of breastfeeding for pain relief in infants during vaccination.Methods: A true experimental pretest and posttest design was conducted at Maternal and Child Health Clinic at Bharatpur, Nepal among 140 infants receiving pentavalent vaccines (Diphtheria, Pertussis, Tetanus, Hepatitis B and Hemophilus influenzae B). A structured interview schedule was used to collect socio-demographic information of mothers and infants. Bio physiologic method was used to determine biological and physical status of the infants. Modified behavioral pain scale was used to measure the level of pain in infants in both the control and experimental groups.Results: The study revealed that the total modified behavioral pain scale (mean ±SD after vaccination was 8.74±0.53 in control and 8.23±1.07 in experimental respectively. The study showed that breastfeeding had significantly lowered pain level (p<0.001) and lessened duration of cry (p=0.002) in infants in experimental group than in control group after vaccination. However, related to injectable vaccination, the study showed that breastfeeding did not significantly stabilized heart rate in infants in both the groups (p=0.122).Conclusions: The study concluded that the infants who were breastfed experienced less pain than those who were not breastfed during vaccination.

Impact of Opioid-Minimizing Pain Protocols after Burn Injury

In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre (01/01/2018 to 07/31/2019) and Post (01/01/2020 to 06/30/2020) implementation of the protocols (08/01/2019 to 12/31/2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain-specific MME, and pain scores. Pain was estimated by creating a normalized pain score (range 0-1), which incorporated 3 different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effects were estimated using Bayesian generalized linear models.There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174). The Post group had significantly lower total MME (Post 110 MME [32, 325] versus Pre 230 [60, 840], p&lt;0.001), MME/day (Post 33 MME/day [15, 54] versus Pre 52 [27, 80], p&lt;0.001), and domain-specific total MME. No difference in average normalized pain scores was seen.Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.

Measurement of the nociceptive flexion reflex threshold in critically ill patients - a monocentric prospective observational study

Background Pain detection and treatment is a major challenge in the care of critically ill patients. However, in addition to the risk of analgesic undersupply, there is also the risk of overanalgesia. In the perioperative context, the measurement of the nociceptive flexion reflex threshold has become established for measuring the level of analgesia. To date, however, it is unclear whether measurement of NFRT can be usefully applied to noncommunicating, ventilated, and analgosedated ICU patients. Therefore, the aim of the present study was to investigate whether NFRT measurement correlates with the Behavioral Pain Scale (BPS) in critically ill, analgosedated, and mechanically ventilated patients and whether it can also detect possible overanalgesia.Methods In this prospective, observational, single-center study, 114 patients were included. All patients were admitted to the surgical Intensive Care Unit of the University hospital Ulm, Germany. First measurements of the NFRT and the Behavioral Pain Scale (BPS) were conducted within 12 hours after admission. In the further observation period, a structured pain assessment was performed at least twice daily until extubation (Group A: BPS + NFRT, Group B: BPS). Univariate analysis was performed to evaluate possible associations between NFRT measurement and baseline characteristics. Furthermore, mixed linear regression modeling was used to evaluate possible effects of administered analgesics or sedatives on NFRT. Results NFRT correlates negatively with the Behavioral Pain Scale. NFRT was almost twice as high in patients with a RASS of -5 compared with patients with a RASS ≥ -4 (RASS -5 - NFRT: 59.40 vs. RASS -4 - NFRT: 29.00, p < 0.001). By means of NFRT measurement, potential overanalgesia could not be detected.Conclusion The NFRT measurement reliably correlates negatively with the Behavioral Pain Scale in critically ill patients. In patients with RASS scores ≤ -4, in whom analgesia level is often difficult to assess, NFRT measurement provides guidance in the assessment of nociceptive processes. However, in order to detect possible overanalgesia and to derive therapeutic consequences, a defined stimulus threshold must be determined for the critically ill patient, above which the absence of pain can be safely assumed.Trial Registration Retrospectively registered at German Clinical Trials Register, registration number DRKS00021149, date of registration: March 26, 2020. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021149

Pain in intensive care: assessments and patients’ experience

The aim of the thesis was to translate, psychometrically test, and further develop the Behavioral Pain Scale for pain assessment in intensive care and to analyze if any other variables (besides the behavioral domains) could affect the pain assessments. Furthermore, the aim was to explore the patients’ experience of pain within the intensive care. The Behavioral Pain Scale (BPS), consisting of the domains “facial expression,” “upper limbs,” and “compliance with ventilator/vocalization,” was translated andculturally adapted into Swedish and psychometrically tested in a sample of 20 patients(study I). The instrument was then further developed within one of the domains and tested for inter-rater reliability, discriminant validity, and criterion validity (study II). The method for analysis in both study I and II was a method specifically developed for paired, ordered, and categorical data. To describe and analyze the process of pain assessment, a General Linear Mixed Model was used to investigate what variables, besides the behaviors, could be associated with the observers’ own assessment of the patients’ pain (study III). Further, the patients’ experiences of pain when being cared for in intensive care were explored (study IV) through interviews with 16 participants post intensive care. Qualitative thematic analysis with an inductive approach was used for the analysis. The first psychometric tests of the BPS (study I) showed inter-rater reliability with agreement of 85%. For the discriminant validity, all domains, except “compliance with ventilator,” indicated discriminant validity. Therefore, in study II, a developed domain of “breathing pattern” was tested alongside the original version. The BPS showed discriminant validity for both the original and the developed version and an inter-rater reliability with agreement of 76-80%. Wheninspecting the respective domains there was a difference in discriminant validity between the original domain of “compliance with ventilation” and the developed domain of “breathing pattern,” showing higher values on the scale for the developed domain during turning. For criterion validity, the BPS showed a higher sensitivity than the observers, who on the contrary had a higher specificity.The General Linear Mix Model (study III) showed that heart rate could be associated with the observers’ assessments of pain. For the behavioral signs, the result indicated that breathing pattern was most associated with the observers’ pain assessment, whilst facial expression did not show any impact on the observers’ assessments. The patients’ experiences of pain (study IV) in intensive care were described as generating a need for control; they experienced a lack of control when pain was present and continuously struggled to regain control. The experience of pain was not only related to the physical sensation but also to psychological and social aspects, along with the balance in the care given, which was important to the participants. In conclusion, the translated and developed version of the Swedish BPS showed promising psychometric results in assessing pain in the adult intensive care patients. Still, other signs, besides behavioral, is possibly used when pain assessing and therefore information about and training in pain assessment are needed to enhance the assessments that are made. Also, the patients’ own experiences highlight the importance of individualizing and adapting pain assessment and treatment to the needs of each patient. Making them a part of the team could enhance their feeling of control, thereby supporting them in facing the experience of pain.

The Effect of Positive Mental Imagery on Labor Pain Tolerance in Primiparous Women Referred to Atieh Hospital of Hamadan, Iran, 2018: A Randomized controlled clinical trial study

Background:: Childbirth is an important experience in the woman's life; and its quality has short- and long-term effects on them. Objective:: The present study aimed to determine the effect of positive mental imagery on the labor pain tolerance in primiparous women referred to Atieh teaching-medical center in Hamadan. Methods:: The present clinical trial study (IRCT20120215009014N242) was conducted on 90 primiparous mothers referred to Atieh Hospital of Hamadan in interventional (n= 45) and control (n= 45) groups. Data collection tools included demographic information forms, Behavioral pain scale, Visual analogue scale (VAS), and the birth registration checklist that were responded by both groups through interviews and observation during labor. The intervention group participated in 4 weekly counseling sessions in groups of 5 to 7 participants, but the control group received only routine care. Finally, the obtained data from above questionnaires was analyzed using SPSS 21 and analysis of covariance (ANCOVA), Independent t-test and chi-square test and the significance level of tests was considered to be at the level of 5%. Results:: The research results indicated that the mean age of control and intervention groups was 25.98±4.82 and 25.32± 4.85 respectively. The mean scores of Visual analogue scale (VAS) and the Behavioral Pain Scale significantly decreased compared to the control group (P <0.001). The mean scores of behavioral changes in the intervention group were 1.77 ± 0.68, 2.39± 0.54 and 3.09±0.60 in 4-5 cm, 6-7 cm and 8-10 cm dilatations respectively. That was statistically significant decrease compared to the control group (P=0.005). Conclusion:: Positive mental imagery counseling reduced the visual analogue intensity and behavioral pain intensity in primiparous women. It seems that continuing education and counseling during pregnancy and empowering mothers to control themselves and learn mental imagery techniques and practice during pregnancy and childbirth can help mothers to more relax and alleviate the labor painintensity.

Comparison between Dexmedetomidine and Midazolam for Sedation in Patients with Intubation after Oral and Maxillofacial Surgery

The aim of the investigation is to clarify the beneficial sedative effects for patients with postoperative intubation in the intensive care unit (ICU) after oral and maxillofacial surgery. Forty patients with postoperative intubation were divided into two groups in method of random number table: midazolam group and dexmedetomidine group. The Ramsay score, the behavioral pain scale (BPS) score, SpO2, HR, MAP, and RR were recorded before sedation (T0), 30 minutes (T1), 1 hour (T2), 2 hours (T3), 6 hours (T4), and 12 hours (T5) after dexmedetomidine or midazolam initiation in intensive care unit, and 10 minutes after extubation (T6). The rate of incidences of side effects was calculated. Sedation with midazolam was as good as standard sedation with dexmedetomidine in maintaining target sedation level. The BPS score in the midazolam group was higher than that in the dexmedetomidine group. The time of tracheal catheter extraction in the dexmedetomidine group was shorter than that in the midazolam group (p≤0.001). The incidence of bradycardia in the dexmedetomidine group was higher than that in the midazolam group (p=0.028). There was no statistically significant difference in the incidence of hypotension between the two groups (p=0.732). The incidence of respiratory depression of group midazolam was higher than that of group dexmedetomidine (p=0.018). The incidence of delirium in the dexmedetomidine group was significantly lower than that in the midazolam group, and the difference was statistically significant (p=0.003). Dexmedetomidine and midazolam can meet the needs for sedation in ICU patients. And dexmedetomidine can improve patients’ ability to communicate pain compared with midazolam.

A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults

This is an updated, comprehensive review of the psychometric properties of behavioral pain assessment tools for use with noncommunicative, critically ill adults. Articles were searched in 5 health databases. A total of 106 articles were analyzed, including 54 recently published papers. Nine behavioral pain assessment tools developed for noncommunicative critically ill adults and 4 tools developed for other non-communicative populations were included. The scale development process, reliability, validity, feasibility, and clinical utility were analyzed using a 0 to 20 scoring system, and quality of evidence was also evaluated. The Behavioral Pain Scale, the Behavioral Pain Scale-Nonintubated, and the Critical-Care Pain Observation Tool remain the tools with the strongest psychometric properties, with validation testing having been conducted in multiple countries and various languages. Other tools may be good alternatives, but additional research on them is necessary.

Studi Kualitatif Pemahaman Perawat Intensive Care Unit tentang Pengkajian Nyeri Behaviour Pain Scale

Assessment is the initial nursing process. In the nursing assessment obtained information about patient data used as a baseline and determine the next stage. Patients in intensive rooms with ventilators often received nursing actions that cause pain. Pain assessment in patients using ventilators must use special assessment techniques. Patients with ventilators require standardized assessment methods because they cannot communicate the pain they feel verbally. Payen in 2001 developed the Behavioral Pain Scale (BPS). Critical patients who are fitted with ventilators need a systematic and consistent assessment of pain. Understanding is the ability to explain correctly and in detail about something. Before performing an action properly one needs to understand the action. This study aimed to determine the experience and understanding of ICU nurses about pain assessment using BPS at M Yunus Bengkulu General Hospital. This study used the qualitative study that focus on disclosing nurses' understanding of pain assessment using BPS. Themes that emerged in this study were 1. use BPS, 2. Three items in the BPS assessment, 3. Indicators assessing pain, 4. Maximum minimum scoring, 5. Range of pain values. Nurse’s understanding about BPS was very necessary.