The Prevalence and Management of Pain in Pediatric Intensive Care Units

Purpose: The purpose of this multi-site study is to describe the frequency and characteristics of pain experienced by critically ill children and the pain management practices provided to them during a 24-hour time period.

Though current research points to a problem of pain in PICUs, there is still much that is not well understood. Prior research has been limited in scope, evaluating pain in PICU sub-populations (Bai & Hsu, 2013; Grant, Scoppettuolo, Wypij, Curley, & Team, 2012) or a particular type of pain (e.g. pain from procedures or pain rated as moderate to severe) (Agarwal et al., 2010; Groenewald, Rabbitts, Schroeder, & Harrison, 2012; Larsen, Donaldson, Parker, & Grant, 2007; Stevens et al., 2011). Prevalence studies, which measure the proportion of the population with a condition such as pain, can provide insight into the problem. Yet, pediatric pain prevalence studies in North America have either excluded PICU patients (Ellis et al., 2002) or report few unit-specific results (Groenewald et al., 2012; Stevens et al., 2012; Taylor, Boyer, & Campbell, 2008). As a result of these gaps in the literature, it is not clear under which circumstances critically ill children are at greatest risk for pain. A more comprehensive evaluation of the pain critically ill children experience and the practices surrounding their pain, such as pain assessments and pharmacological and non-pharmacological interventions is needed.

Methods: For this point-prevalence study, the health records of children admitted to PICUs across four US children’s hospitals/units during a 24-hour time period were reviewed. Data were collected regarding pain assessments, pharmacological and non-pharmacological pain interventions, and painful procedures documented during the 24 hours.

Results: The records of 77 children were reviewed. Patients ranged in age from 1 month to 25 years old, and were more often male (N = 42, 54.5%), and Caucasian (N = 40, 53.3%). The majority of patients were admitted to the PICU for medical reasons (N = 61, 79.2%) versus surgical reasons (N = 11, 14.3%). PICU length of stay ranged from 1 to 752 days (median 7, mode 2); 39% of patients were mechanically ventilated at the time of the study. Pain assessments were conducted on average 10 times (SD 4.6) during the 24 hours (range 2 to 28), most often using a behavioral pain scale (N = 605, 79%). Pain was present in 14% of assessments (M = 0.6, SD 1.6). Pain quality was infrequently documented (N = 6, 6%). Pain location was recorded 25% (N = 25) and pain etiology 36% (N = 37) of the time. Pharmacological interventions were provided to 59 (77%) patients; most often (64%) opioid analgesics were provided. Non-pharmacological interventions were provided to 51% of patients. The most commonly documented non-pharmacological interventions included decreasing environmental stimuli, caregiver/parent presence, and repositioning. Nearly all (N = 65, 84%) patients received a potentially painful procedure (range 0 to 31); more than half of these procedures included suctioning of the airway.

Conclusion: This study begins to fill a gap in the literature regarding the prevalence of and practices surrounding pain for critically ill children in the United States. Results begin to inform future research and interventions to improve practice.