title: An evaluation of instruments for scoring physiological and behavioral cues of pain, non-pain related distress, and adequacy of analgesia and sedation in pediatric mechanically ventilated patients: A systematic review.
abstract: OBJECTIVE
  Advancing technology allows for successful treatment of children with life-threatening illnesses. Effectively assessing and optimally treating a child's distress during their stay in the Pediatric Intensive Care Unit (PICU) is paramount. Objective measures of distress in mechanically ventilated pediatric patients are increasingly available but few have been evaluated. The objectives of this systematic review were to identify available instruments appropriate for measuring physiological and behavioral cues of pain, non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated pediatric patients, and evaluate these instruments in terms of their psychometric properties.
  
  
  METHODS
  A systematic review of original and validation reports of objective instruments to measure pain and non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated PICU patients was undertaken.
  
  
  METHODS
  A comprehensive search was conducted in 10 databases from January 1970 to June 2011. Reference lists of relevant articles were reviewed to identify additional articles.
  
  
  METHODS
  Studies were included in the review if they met pre-established eligibility criteria. Two independent reviewers reviewed studies for inclusion, assessed quality, and extracted data.
  
  
  RESULTS
  Twenty-five articles were included, identifying 15 instruments. The instruments had different foci including: assessing pain, non-pain related distress, and sedation (n=2); assessing pain exclusively (n=4); assessing sedation exclusively (n=7), assessing sedation in mechanically ventilated muscle relaxed PICU patients (n=1); and assessing delirium in mechanically ventilated PICU patients (n=1). The Comfort Scale demonstrated the greatest clinical utility in the assessment of pain, non-pain related distress, and sedation in mechanically ventilated pediatric patients. Modified FLACC and the MAPS are more appropriate, however, for the assessment of procedural pain and other brief painful events. More work is required on instruments for the assessment of distress in mechanically ventilated muscle relaxed PICU patients, and the assessment of delirium in PICU patients.
  
  
  CONCLUSIONS
  This review provides essential information to guide PICU clinicians in choosing instruments to assess pain, non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated pediatric patients. Effective knowledge translation is essential in the implementation, adoption, and successful use of these instruments.
authors.affiliation: University of Alberta, Edmonton, Canada. Electronic address: tdorfman@ualberta.ca.
authors.forename: Tamara L
authors.initials: TL
authors.lastname: Dorfman
authors.affiliation: University of Alberta, Edmonton, Canada. Electronic address: esumamo@gmail.com.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Sumamo Schellenberg
authors.affiliation: University of Alberta, Edmonton, Canada; Associate Professor, Faculty of Nursing, Canada; Alberta Heritage Foundation for Health Research (AHFMR), Canada. Electronic address: gwen.rempel@ualberta.ca.
authors.forename: Gwen R
authors.initials: GR
authors.lastname: Rempel
authors.affiliation: University of Alberta, Edmonton, Canada; Associate Professor, Faculty of Nursing, Canada; Alberta Heritage Foundation for Health Research (AHFMR), Canada; Canadian Institutes of Health Research, Canada. Electronic address: shannon.scott@ualberta.ca.
authors.forename: Shannon D
authors.initials: SD
authors.lastname: Scott
authors.affiliation: University of Alberta, Edmonton, Canada; Canadian Institutes of Health Research, Canada; ARCHE, Canada; University of Alberta Evidence-based Practice Center, Canada; Department of Pediatrics, Canada. Electronic address: hartling@ualberta.ca.
authors.forename: Lisa
authors.initials: L
authors.lastname: Hartling
mesh_terms: D000698:Analgesia; D002648:Child; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D010146:Pain / Q000503:physiopathology*; D012121:Respiration, Artificial; D013315:Stress, Psychological / Q000503:physiopathology*
chemical_list: D006993:Hypnotics and Sedatives
keywords: Assessment; Delirium; Distress; Pain; Pediatric Intensive Care; Sedation