The gap between pediatric emergency department procedural pain management treatments available and actual practice

An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond

BACKGROUND

Painful procedures are common in the ED setting and beyond. Although these procedures are often essential to patient management, they can also be distressing for children, parents, and health providers. As such, it is imperative that effective pain and anxiety-minimizing strategies be used consistently in all settings where painful procedures take place for children.

OBJECTIVES

This review article aims to provide a summary of several strategies, which are supported by definitive and systematically reviewed evidence, that can be implemented alone or in combination to reduce procedural pain and anxiety for children in the ED and beyond.

RESULTS

For neonates, breastfeeding, nonnutritive sucking, swaddling, and sucrose administration have all been shown to decrease pain during painful interventions. For neonates, venipuncture is much less painful than heel lance for blood draws. For infants, there is some support for sucrose use. For infants and older children, there is strong evidence for distraction techniques. In addition, the use of fast-acting topical anesthetic creams as an alternative or adjunct to infiltrating anesthetic before laceration repair or vascular access/venipuncture is recommended. Further, buffering of lidocaine can decrease pain during injection. Lastly, if a laceration is amenable to the use of tissue adhesive, this should be preferentially used.

CONCLUSIONS

In summary, there currently remains a knowledge-to-practice gap in the treatment of children's procedure-related pain. This article has identified multiple age-specific methods to improve the treatment of procedural pain. These simple interventions can improve the care provided to ill and injured children.

Care-related pain in hospitalized patients: severity and patient perception of management

BACKGROUND

Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP.

METHODS

All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included.

RESULTS

From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases.

CONCLUSIONS

Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.

A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children

STUDY OBJECTIVE

The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray.

METHODS

Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2).

RESULTS

Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups.

CONCLUSION

Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment.

Intraurethral Lidocaine for Urethral Catheterization in Children: A Randomized Controlled Trial

OBJECTIVES

To determine whether lidocaine is superior to nonanesthetic lubricant (NAL) for relieving pain in children undergoing urethral catheterization (UC).

METHODS

Children 0 to 24 months requiring UC were randomized to NAL or topical and intraurethral 2% lidocaine gel. Primary outcome was facial grimacing in the pre to during drug administration and catheterization phases. Secondary outcome was caregiver satisfaction by using a Visual Analog Scale.

RESULTS

There were 133 participants (n = 68 lidocaine, n = 65 NAL). There were no significant differences in mean (SD) scores during UC between lidocaine and NAL (86.4% [121.5%] vs 85.2% [126.6%]), respectively (Δ [confidence interval (CI)] = -1.2 [-21.0 to 49.0], P = .4). There was a significantly greater difference in mean (SD) scores during instillation of lidocaine versus NAL (61.8% [105.6%] vs 3.2% [84.9%]), respectively (Δ [CI] -58.6 [-95.0 to -32.0], P < .001). There were no significant differences in mean (SD) parental satisfaction scores between lidocaine and NAL (4.8 [3.2] vs 5.9 [2.9]), respectively (CI-0.1 to 2.2; P = .06). In the subgroup analysis, age, gender, and positive urine culture did not significantly influence between-group differences in facial grimacing.

CONCLUSIONS

Compared with NAL, topical and intraurethral lidocaine is not associated with significant pain reduction during UC, but significantly greater pain during instillation. Therefore, clinicians may consider using noninvasive pain-reducing strategies for young children who require UC.

Comforting strategies and perceived barriers to pediatric pain management during IV line insertion procedure in Uganda's national referral hospital: A descriptive study

BACKGROUND

Venipuncture and intravenous (IV) cannula insertions are the two common sources of pain in hospitalized children and health care today. The WHO asserts that, pain relief is a basic fundamental right and requires a multidisciplinary approach. Nonpharmacological comforting strategies when implemented are important to relive pain related distress in children during peripheral IV line insertion. However, evidence to date that suggests implementation of such strategies and their barriers in Uganda remains very limited. This study aimed at establishing the current practices in regard to the use of comforting strategies and the perceived barriers faced by health care providers to implement pediatric pain management during IV line insertion procedure in Uganda's national referral hospital, Mulago.

METHOD

A cross sectional and descriptive study was conducted between December 1, 2012 and February 28, 2013 involving doctors, nurses and interns in six pediatric wards of Mulago Hospital in Uganda. A pre-tested self- administered and semi- structured questionnaire was used to collect the data. Data was entered into SPSS and descriptive statistics run on all the variables.

RESULTS

Of the 120 questionnaires distributed, 105 (RR = 87.5%) were returned and completed. The evidence based comforting strategies used for pain management during IV line insertion by the majority of health care professionals were; skin to skin (51%) and appropriate upright positioning of the child on mother's lap (69%). The least used comforting strategies were; allowing the child to suck his thumb or hand (70%), use of distraction (69%) and directing the child to suck one of his fingers into his mouth (90%). The identified barriers to implementing comforting strategies were; lack of time (42%), having emergency situations (18%), and not knowing the right method to use (11%). Of 105, 100 (95%) reported that there is need for continuous professional development on comforting strategies.

CONCLUSIONS

Findings demonstrated that fewer health care providers used some evidence based comforting strategies of pain relief during pediatric peripheral IV line insertion. Distraction and other evidence based strategies for pain and distress relieve are less often used by the majority of the health care providers. Incorporating pediatric pain management content in all health professionals training curricula could improve the current practices for better health outcomes.

Time to opioid administration after implementation of an intranasal fentanyl protocol

BACKGROUND

Prompt and effective analgesia is a mainstay of emergency department (ED) medicine; however, it is often delayed in times of overcrowding and by the need to establish intravenous (IV) access. Thus, noninvasive analgesic administration by means of the intranasal route could potentially reduce time to analgesic administration by eliminating IV line insertion.

METHODS

This retrospective study evaluated time from physician entry into patient's room to opioid administration after implementation of an intranasal fentanyl protocol. Data were collected on pediatric patients who received intranasal fentanyl in the ED 225 days after protocol implementation. Time to opioid administration was then evaluated against historical controls given IV opioids in the same ED 90 days before protocol implementation.

RESULTS

Seven patients were included in the intranasal fentanyl group and were evaluated against 47 patients given IV opioids. Time from physician entry into patient's room to opioid administration was significantly reduced for intranasal fentanyl (20.43 ± 11.54 minutes) vs IV opioids (42.04 ± 31.55 minutes; P = .002), and IV line insertion was avoided in all 7 intranasal fentanyl patients. No significant differences in adverse events were noted.

CONCLUSION

This study provides evidence that administration of fentanyl via the intranasal route in the ED decreases time to administration of opioids in pediatric patients.

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

OBJECTIVES

The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.

METHODS

Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression.

RESULTS

Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).

CONCLUSIONS

Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.

Canadian Emergency Medicine Residents’ Perspectives on Pediatric Pain Management

Background

Under-treatment of children’s pain in the emergency department (ED) can have many detrimental effects. Emergency medicine (EM) residents often manage pediatric pain, but their educational needs and perspectives have not been studied.

Methods

A novel online survey was administered from May to June 2013 to 122 EM residents at three Canadian universities using a modified Dillman methodology. The survey instrument captured information on training received in pediatric acute pain management, approach to common painful presentations, level of comfort, perceived facilitators, and barriers and attitudes towards pediatric pain.

Results

56 residents participated (46%), 25 of whom (45%) indicated they had not received any training in pediatric pain assessment. All levels of residents reported they were uncomfortable with pain assessment in 0-2 year olds (p=0.07); level of comfort with assessment increased with years of training for patients aged 2-12 years (p=0.02). When assessing children with disabilities, 83% of respondents (45/54) indicated they were ‘extremely’ or ‘somewhat’ uncomfortable. Sixty-nine percent (38/55) had received training on how to treat pediatric pain. All residents reported they were more comfortable using pain medication for a 9 year old, as compared to a 1 year old (oral oxycodone p<0.001, oral morphine p<0.001, IV morphine p=0.004). The preferred methods to learn about children’s pain management were role-modeling (61%) and lectures (57%). The top challenges in pain management were with non-verbal, younger, or developmentally delayed patients.

Conclusion

Canadian EM residents report receiving inadequate training in pediatric pain management, and are particularly uneasy with younger or developmentally disabled children. Post-graduate curricula should be adjusted to correct these self-identified weaknesses in children’s pain management.

Improving acute pain management in emergency medicine

Undertreatment of pain (oligoanalgesia) in the emergency department is common, and it negatively impacts patient care. Both failure of appropriate pain assessment and the potential for unsafe analgesic use contribute to the problem. As a result, achieving satisfactory analgesia while minimizing side effects remains particularly challenging for emergency physicians, both in the emergency department and after a patient is discharged. Improvements in rapid pain assessment and in evaluation of noncommunicative populations may result in a better estimation of which patients require analgesia and how much pain is present. New formulations of available treatments, such as rapidly absorbed, topical, or intranasal nonsteroidal anti-inflammatory drug formulations or intranasal opioids, may provide effective analgesia with an improved risk-benefit profile. Other pharmacological therapies have been shown to be effective for certain pain modalities, such as the use of antidepressants for musculoskeletal pain, γ-aminobutyric acid agonists for neuropathic and postsurgical pain, antipsychotics for headache, and topical capsaicin for neuropathic pain. Nonpharmacological methods of pain control include the use of electrical stimulation, relaxation therapies, psychosocial/manipulative therapies, and acupuncture. Tailoring of available treatment options to specific pain modalities, as well as improvements in pain assessment, treatment options, and formulations, may improve pain control in the emergency department setting and beyond.

Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial

BACKGROUND

Parents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training.

OBJECTIVE

The aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress.

METHODS

Children undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress.

RESULTS

A total of 574 children, ages 4-10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels.

DISCUSSION

Some parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.

Intranasal fentanyl for the management of acute pain in children

BACKGROUND

Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula.

OBJECTIVES

We identified and evaluated all randomized controlled trials (RCTs) and quasi-randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of "rescue analgesia," patient/parental satisfaction and patient mortality.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014).

SELECTION CRITERIA

We included RCTs comparing INF versus any other pharmacological/non-pharmacological intervention for the treatment of children in acute pain (aged < 18 years).

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a "bad taste" and vomiting with INF. Overall the risk of bias in all studies was considered low.

AUTHORS' CONCLUSIONS

INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non-inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a "medical" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a "medical" cause.

The impact of a locally applied vibrating device on outpatient venipuncture in children

OBJECTIVE

To assess the impact of a locally applied vibrating device on outpatient venipuncture in children.

METHOD

A retrospective review of survey data collected prospectively as part of a quality improvement project. Both patients and phlebotomists were surveyed. The sample consisted of 64 children aged 4 to 18 years (29 prior to the implementation of the vibrating device and 35 afterward) and 7 phlebotomists.

RESULTS

Prior to the use of the vibrating device, 17 children (59%) indicated that they wished something had been done to decrease venipuncture pain. Eighty percent of the cohort that used the vibrating device indicated that they would like it used for future procedures. Children with previous venipuncture experiences appeared to benefit most from use of the vibrating technique. The phlebotomists reported that vibration made the procedure easier in 81% of the cases; none reported that it complicated the procedure.

CONCLUSIONS

Locally applied vibration appears to be a well-accepted technique to minimize pediatric venipuncture discomfort that may facilitate completion of the procedure.

Effectiveness of external cold and vibration for procedural pain relief during peripheral intravenous cannulation in pediatric patients

The aim of this study was to investigate the effect of external cold and vibration stimulation via Buzzy on the pain and anxiety level of children during peripheral intravenous (IV) cannulation. This study was a prospective, randomized controlled trial. The sample consisted of 176 children ages 7 to 12 years who were randomly assigned to two groups: a control group that received no peripheral IV cannulation intervention and an experimental group that received external cold and vibration via Buzzy. The same nurse conducted the peripheral IV cannulation in all the children, and the same researcher applied the external cold and vibration to all the children. The external cold and the vibration were applied 1 minute before the peripheral IV cannulation procedure and continued until the end of the procedure. Preprocedural anxiety was assessed using the Children's Fear Scale, along with reports by the children, their parents, and an observer. Procedural anxiety was assessed with the Children's Fear Scale and the parents' and the observer's reports. Procedural pain was assessed using the Wong Baker Faces Scale and the visual analog scale self-reports of the children. Preprocedural anxiety did not differ significantly. Comparison of the two groups showed significantly lower pain and anxiety levels in the experimental group than in the control group during the peripheral IV cannulation. Buzzy can be considered to provide an effective combination of coldness and vibration. This method can be used during pediatric peripheral IV cannulation by pediatric nurses.

Paediatric pain management practice and policies across Alberta emergency departments

BACKGROUND

Many children requiring acute care receive suboptimal analgesia.

OBJECTIVES

To describe paediatric pain management practices and policies in emergency departments (EDs) in Alberta.

METHODS

A descriptive survey was distributed to each of the EDs in Alberta.

RESULTS

A response rate of 67% (72 of 108) was obtained. Seventy-one percent (42 of 59) of EDs reported the use of a pain tool, 29.3% (17 of 58) reported mandatory pain documentation and 16.7% (10 of 60) had nurse-initiated pain protocols. Topical anesthetics were reported to be used for intravenous line insertion by 70.4% of respondents (38 of 54) and for lumbar puncture (LP) by 30.8% (12 of 39). According to respondents, infiltrated anesthetic was used for LP by 69.2% (27 of 39) of respondents, and oral sucrose was used infrequently for urinary catheterization (one of 46 [2.2%]), intravenous line insertion (zero of 54 [0%]) and LP (one of 39 [2.6%]).

CONCLUSIONS

Few Alberta EDs use policies and protocols to manage paediatric pain. Noninvasive methods to limit procedural pain are underutilized. Canadian paediatricians must advocate for improved analgesia to narrow this knowledge-to-practice gap.

EMLA® cream: A pain-relieving strategy for childhood vaccination

Objectives

To evaluate the effectiveness of topical eutectic mixture of local anaesthetics (EMLA®) cream in reducing the pain associated with vaccination injections.

Methods

This was a randomized, double-blind, placebo-controlled study that included children who presented for routine immunization. Eligible children were randomly assigned to receive either EMLA® or placebo cream. The Modified Behavioural Pain Scale (MBPS) was used to assess baseline and postvaccination pain scores, while a visual analogue scale (VAS) was used to assess pain at the time of the needle prick and at the end of the injection.

Results

A total of 107 children were enrolled in the EMLA® group and 109 children in the placebo group. The difference between the pre- and postvaccination MBPS scores was significantly lower in the EMLA group than in the placebo group (2.56 ± 1.96 versus 3.95 ± 2.20, respectively). The VAS scores at the time of the needle prick and after the injection were significantly lower in the EMLA® group compared with the placebo group (1.60 ± 1.67 versus 3.24 ± 2.01; 3.29 ± 2.27 versus 4.86 ± 2.20; respectively).

Conclusions

Application of EMLA® cream can be effectively incorporated as a routine pain-relieving intervention within routine vaccination appointments.

Pain management policies and practices in pediatric emergency care: a nationwide survey of Italian hospitals

BACKGROUND

Pain experienced by children in emergency departments (EDs) is often poorly assessed and treated. Although local protocols and strategies are important to ensure appropriate staff behaviours, few studies have focussed on pain management policies at hospital or department level. This study aimed at describing the policies and reported practices of pain assessment and treatment in a national sample of Italian pediatric EDs, and identifying the assocoated structural and organisational factors.

METHODS

A structured questionnaire was mailed to all the 14 Italian pediatric and maternal and child hospitals and to 5 general hospitals with separate pediatric emergency room. There were no refusals. Information collected included the frequency and mode of pain assessment, presence of written pain management protocols, use of local anaesthetic (EMLA cream) before venipuncture, and role of parents. General data on the hospital and ED were also recorded. Multiple Correspondence Analysis was used to explore the multivariable associations between the characteristics of hospitals and EDs and their pain management policies and practices.

RESULTS

Routine pain assessment both at triage and in the emergency room was carried out only by 26% of surveyed EDs. About one third did not use algometric scales, and almost half (47.4%) did not have local protocols for pain treatment. Only 3 routinely reassessed pain after treatment, and only 2 used EMLA. All EDs allowed parents' presence and most (17, 89.9%) allowed them to stay when painful procedures were carried out. Eleven hospitals (57.9%) allowed parents to hold their child during blood sampling. Pediatric and maternal and child hospitals, those located in the North of Italy, equipped with medico-surgical-traumatological ED and short stay observation, and providing full assessment triage over 24 hours were more likely to report appropriate policies for pain management both at triage and in ER. A nurses to admissions ratio ≥ median was associated with better pain management at triage.

CONCLUSIONS

Despite availability of national and international guidelines, pediatric pain management is still sub-optimal in Italian emergency departments. Multifaceted strategies including development of local policies, staff educational programs, and parental involvement in pain assessment should be carried out and periodically reinforced.

The use of the faces, legs, activity, cry and consolability scale to assess procedural pain and distress in young children

INTRODUCTION

Young children frequently undergo diagnostic and therapeutic procedures in the emergency department (ED). Although developed and validated for postoperative pain, Face, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scores have been recommended and used for the assessment of procedural pain as well. We set out to assess if FLACC scores can differentiate pain and distress and establish a hierarchy of FLACC scores experienced during common ED procedures.

METHODS

Prospective observational study at an urban tertiary children's hospital ED. We aimed to recruit 30 children each aged 6 to 42 months undergoing intravenous cannula (IV) insertion, nasogastric tube (NGT) insertion, metered dose inhaler (MDI) use and oxygen saturation (SpO(2)) measurement. Based on videotapes, 2 independent observers assessed pain and distress using FLACC scores during all procedural phases.

RESULTS

A total of 125 patients were recruited and filmed for IV (33), NGT (30), MDI (34), and SpO2 (28). Median FLACC scores were as follows: NGT, 10 (interquartile range [IQR] 8.75-10); IV, 6.5 (IQR, 4.5-9.75); MDI, 6.5 (IQR, 0-9); and SpO(2), 0 (IQR, 0-0.5). The FLACC scores increased during each of the 3 phases, before the procedure, during restraint, and during the procedure. Procedural distress decreased with age except for NGT insertions, which remained very high irrespective of age.

CONCLUSIONS

FLACC scores can be high during nonpainful procedures and the during restraint phase of painful procedures. This indicates that FLACC measures a composite of pain and distress in young children. This study identified substantial levels of pain and distress in young children by FLACC during commonly performed ED procedures, with nasogastric tube insertion having very high and intravenous cannulation/venepuncture and MDI having high FLACC scores.

Distraction techniques for children undergoing procedures: a critical review of pediatric research

Pediatric patients are often subjected to procedures that can cause pain and anxiety. Although pharmacologic interventions can be used, distraction is a simple and effective technique that directs children's attention away from noxious stimuli. However, there is a multitude of techniques and technologies associated with distraction. Given the range of distraction techniques, the purpose of this article was to provide a critical assessment of the evidence-based literature that can inform clinical practice and future research. Recommendations include greater attention to child preferences and temperament as a means of optimizing outcomes and heightening awareness around child participation in health care decision making.

An integration of vibration and cold relieves venipuncture pain in a pediatric emergency department

OBJECTIVE

A randomized controlled trial compared a reusable device combining cold and vibration to standard care for pediatric venous access pain relief.

METHODS

Pediatric emergency department patients received either the cold vibration device placed 5 to 10 cm proximally throughout venipuncture or standard care control (primarily vapocoolant spray). Block randomization of patients with or without lidocaine cream already in place ensured equal allocation in both intervention groups. Pain was measured via self- and parent-report using the 0- to 10-point Faces Pain Scale-Revised and with coded videotaped observed behaviors. Venipuncture success, use of distraction, and access times were also assessed.

RESULTS

Eighty-one 4- to 18-year-olds were randomized to the device (n = 41) or standard care (n = 40) (median age, 10.09 years; 95% confidence interval [95% CI], 8.91-10.89). Median patient-reported pain scores with the device were lower than with standard care (-2; 95% CI, -4 to 0), as were parent-assessed pain scores (-2; 95% CI, -4 to -2). Observed distress behaviors were more common with standard care (2; 95% CI, 1-3) than with the device (1; 95% CI, 0-2). Venipuncture success was more likely with the device (odds ratio, 3.05; 95% CI, 1.03-9.02). There were no device refusals.

CONCLUSIONS

The combination of cold and vibration decreased venipuncture pain significantly more than standard care without compromising procedural success. A device incorporating these elements could overcome the common barriers to needle procedure pain control.

Comprehensive pain management protocol reduces children's memory of pain at discharge from the pediatric ED

BACKGROUND

Historically, pain has been poorly managed in the pediatric emergency department (ED) (PED), resulting in measurable psychosocial issues both acute and delayed.

OBJECTIVE

The aim of the study was to measure the impact of protocolized pain management on patients with painful conditions or undergoing painful procedures in the PED.

METHODS

We performed an analysis before and after the implementation of the protocol, dubbed the "Comfort Zone." Validated, age-appropriate pain scales were performed. Validation (using Cronbach α, confirmatory factor analysis) was followed by comparison of responses between the pre- and posttests collected (χ(2) and Wilcoxon rank sum tests). Pain scores were collected at triage and at discharge. At triage, patients were asked to report pain levels. At discharge, they were asked to report their current pain and recall the level of pain during their stay. At triage, parents were asked to report about their perception of the child's pain. At discharge, they were asked to report about their perception of the child's current pain and recall the level of pain during the stay and during procedures, if done.

RESULTS

Five hundred thirty-one patients were enrolled in the preprotocol group; 47% were women with a median age of 5 years (range, 30 days-18 years). Two hundred sixty-three patients were enrolled in the protocol group; 39% were women with a median age of 6 years (range, 30 days-18 years). Patient-recalled pain scores of the ED visit in the protocol group were significantly lower than those of the preprotocol group (Wong-Baker Faces Pain Scale, 5.07-4.01; P < .001); yet parent estimates of pain did not show a significant change at any point. Patient assessment of pain at ED discharge did not show a significant change either (Wong-Baker Faces Pain Scale, 1.99-1.56; P = .09). The Faces scale is not well validated for patients younger than 4, so that group had only parental assessment of pain and, consistent with the larger data set, showed no significant pain scale reduction at any point.

CONCLUSION

Protocolized pain management reduces patients' memory of pain during PED visits but may not affect parental memory of perceived pain or parent- and patient-reported pain at discharge.

A comparison of traditional incision and drainage versus catheter drainage of soft tissue abscesses in children

BACKGROUND/PURPOSE

Soft tissue infections are increasingly being seen for surgical management, which is associated with painful dressing changes, lost days at school, time away from family, and scarring, which can have a great impact on both child and caretaker. We postulated that a drainage technique using a modified Pezzar catheter would be associated with shorter hospital stays and less wound care.

METHODS

A consecutive series of 400 children with soft tissue abscesses was evaluated from April 2007 to October 2008. Children were managed according to the operating surgeon's preference. Children remained in the hospital until they were afebrile and the wounds could be adequately managed at home. Drains were removed 1 week after surgery in clinic.

RESULTS

There were no treatment failures. Three hundred twenty-two children were managed with standard incision and drainage (I&D) and 78 patients with catheter drainage. Twenty-two children in the catheter drainage group (28%) required hospitalization of greater than 1 day compared with 151 children (47%) in the I&D group (P = .001, Fisher exact test). Thirty-four percent of the children managed with I&D required packing at home, which was required in none of the patients managed with catheter drainage. Patient age, catheter drainage, and site of the lesion were associated independently with shorter hospital stays.

CONCLUSION

We conclude that catheter drainage of soft tissue abscesses in children is safe and effective. Catheter drainage is associated with a decreased hospital stay. Other factors related to shorter hospital stays include age of the patient and the site of soft tissue abscess.

Intranasal fentanyl for pain management in children: a systematic review of the literature

Intranasally administered fentanyl (INF) has been studied as an alternate route of delivery for pain relief in children. The purpose of this systematic review is to evaluate the available research evidence on the use of INF in the pediatric population. A search was conducted of PubMed, ISI, Scopus, Popline, CINAHL, and Embase for research studies evaluating INF in this population (0-18 years of age). The studies were graded on the strength of the evidence and the results reviewed. All of the reviewed studies showed similar or improved pain scores when compared with other opioids and administration methods. No severe adverse outcomes were reported. Current evidence suggests that INF is a safe and effective method of pain management for children in a variety of clinical settings.

Procedural pain management: a position statement with clinical practice recommendations

The American Society for Pain Management Nursing (ASPMN) has developed a position statement and clinical practice recommendations related to procedural preparation and comfort management. Procedures potentially produce pain and anxiety, both of which should be assessed and addressed before the procedure begins. This position statement refers to "comfort management" as incorporating the management of pain, anxiety, and any other discomforts that may occur with procedures. It is the position of ASPMN that nurses and other health care professionals advocate and intervene based on the needs of the patient, setting, and situation, to provide optimal comfort management before, during, and after procedures. Furthermore, ASPMN does not condone procedures being performed without the implementation of planned comfort assessment and management. In addition to outlining this position with supporting evidence, this paper reviews the ethical considerations regarding procedural comfort management and provides recommendations for nonpharmacologic and pharmacologic management during all phases of the procedure. An appendix provides a summary of this position statement and clinical practice recommendations.

Pain management of musculoskeletal injuries in children: current state and future directions

BACKGROUND

Pain is the most common reason for seeking health care in the Western world and is a contributing factor in up to 80% of all emergency department (ED) visits. In the pediatric emergency setting, musculoskeletal injuries are one of the most common painful presentations. Inadequate pain management during medical care, especially among very young children, can have numerous detrimental effects. No standard of care exists for the management of acute musculoskeletal injury-related pain in children. Within the ED setting, pain from such injuries has been repeatedly shown to be undertreated.

OBJECTIVES

Upon completion of this CME article, the reader should be better able to (1) distinguish multiple nonpharmacological techniques for minimizing and treating pain and anxiety in children with musculoskeletal injuries, (2) apply recent medical literature in deciding pharmacological strategies for the treatment of children with musculoskeletal injuries, and (3) interpret the basic principles of pharmacogenomics and how they relate to analgesic efficacy.

RESULTS

Pediatric musculoskeletal injuries are both common and painful. There is growing evidence that, in addition to pharmacological therapy, nonpharmacological methods can be introduced to improve analgesia in the ED and after discharge. Traditionally, acetaminophen with codeine has been used to treat moderate orthopedic injury-related pain in children. Other oral opioids (hydrocodone, oxycodone) are gaining popularity, as well. Current data suggest that ibuprofen is at least as effective as acetaminophen-codeine and codeine alone. Medication compliance might be improved if adverse effects were minimized, and ibuprofen has been shown to have a similar or better adverse effect profile than the oral opioids to which it has been compared. Pharmacogenomic data show that nearly 50% of individuals have at least 1 reduced functioning allele resulting in suboptimal conversion of codeine to active analgesic, so it is not surprising that codeine analgesic efficacy is not optimal. At the same time, nonpharmacological therapies are emerging as commonly used treatment options by parents and adjuncts to analgesic medication. The efficacy and role of techniques (massage, music therapy, transcutaneous electrical nerve stimulation), although promising, require further clarification in the treatment of orthopedic injury pain.

CONCLUSIONS

There is a need to optimize the measurement, documentation, and treatment of pain in children. There is growing evidence that nonpharmacological methods can be introduced to improve analgesia in the ED, and efforts to help parents implement these methods at home might be advantageous to optimize outpatient treatment plans. In pharmacotherapy, ibuprofen has emerged as an appropriate first-line choice for mild-moderate orthopedic pain. Other oral opioids (hydrocodone, oxycodone) are gaining popularity over codeine, because of the current understanding of the pharmacogenomics of such medications.

Pattern of pain management during lumbar puncture in children

BACKGROUND

Although studies have shown that children have similar physiological pain responses as adults, children often receive less pain medication compared with adults with similar painful conditions. The lumbar puncture is a painful procedure that historically has been commonly performed without local anesthesia, especially in young infants.

OBJECTIVE

The aim of the study was to determine what type of pain management, if any, pediatric patients received during lumbar puncture and whether its use varied by patient age.

METHODS

We performed a retrospective review of patients who had cerebrospinal fluid cultures obtained via lumbar puncture during 2003 at a large urban children's hospital. Eligible cases were reviewed for demographic data, hospital patient care area, and type of pain management used for the procedure.

RESULTS

Of the 353 children who had lumbar punctures performed, 84 (23.8%) received some form of pain management before their lumbar puncture. Sixty (17.0%) received local anesthesia, 43 (12.2%) received sedation, and 19 (5.4%) of these received both local anesthesia and sedation. Younger patients received pain management less frequently (P < 0.001): 16 (6.5%) of 246 neonates (0-2 months), 4 (14.3%) of 28 infants (3-18 months), 9 (60%) of 15 preschoolers (19-59 months), and 55 (85.9%) of 64 older children (60 months to 21 years). Among infants, patients treated in the emergency department received pain management more often than those treated in the nursery (13/103 [12.6%] vs 1/117 [0.9%]; P = 0.001).

CONCLUSIONS

Despite advances in the awareness and attentiveness given to pain and pain management in the pediatric population, children are still not receiving satisfactory pain management for lumbar punctures.

Development of a Pain Management Protocol for a Paediatric Ward in the Gambia, West Africa

Despite recent advances in our understanding of paediatric pain and its management, pain continues to be undertreated globally, particularly in children and in low income countries. This article describes the development of a paediatric analgesia and sedation protocol, tailored to the specific setting of the Medical Research Council (MRC) paediatric ward in the Gambia, West Africa. An iterative process was used throughout development, with inputs from the medical literature, local providers, and pain experts, incorporated to ensure a safe, effective, and locally appropriate protocol. We demonstrate that evidence-based published guidelines, can and should be adapted to allow for optimal pain management given the resources and capabilities of specific health care settings. It is hoped that the process and protocol described here, will not only help to improve care on the MRC ward, but serve as an example to others working toward improving pain management in similar health care settings.

Pain management practices in paediatric emergency departments in Australia and New Zealand: a clinical and organizational audit by National Health and Medical Research Council's National Institute of Clinical Studies and Paediatric Research in Emergency Departments International Collaborative

OBJECTIVE

To audit pain management practices and organization in paediatric ED across Australia and New Zealand.

METHODS

Retrospective audit of pain management practices in Paediatric Research in Emergency Departments International Collaborative ED in 20 cases each of migraine, abdominal pain and femoral shaft fracture. Review of organizational status of pain management at Paediatric Research in Emergency Departments International Collaborative sites.

RESULTS

Of 14 ED, 10 participated in the clinical audit. A total of 196 migraine, 197 abdominal pain and 177 femur fracture cases were reviewed. Less than half had degree of pain measured or had pain score documented on triage. Migraine received analgesia in 62% of cases (opioids in 11%). Abdominal pain received analgesia in 62% of cases (opioids in 14%). Fractured femurs received analgesia in 78% of cases (opioids 49%, femoral nerve blocks 40%). Median minutes to enteral medication were 100, 85 and 75, and for parenteral medication (mainly opiates) 103, 137 and 26, for migraine, abdominal pain and femur fracture, respectively. Thirteen hospitals participated in the organizational audit. Of all ED, 92% had pain management policies or guidelines, 92% taught pain management topics in education programmes and 62% used mandatory pain competencies. Only 15% had quality improvement programmes for pain reduction.

CONCLUSION

We found a notable lack of pain assessment documentation and delays to analgesia. There is a need to improve pain assessment and management, although a majority of paediatric ED surveyed had important organizational and educational structures in place. Issues to explore include use of opioids in migraine and the underuse of femoral nerve blocks.

Knowledge, attitude and practices among health care professionals regarding pain

OBJECTIVE

To assess the knowledge, attitude and practices among health care professionals regarding pain in children.

METHODS

This was a prospective descriptive survey conducted at a tertiary care hospital in north India. A semi structured questionnaire regarding pain in children was administered to pediatric residents and nurses in a teaching hospital. The questionnaire consisted of 24 items, of which 18 items were rated on a 5-point scale ('strongly agree' to 'strongly disagree') and 6 items were open-ended questions.

RESULTS

The response rate was 89.5%. Of 77 participants, 47 (61.1%) were nurses and 30 (38.9%) were pediatric residents. The knowledge about pain scales among the studied healthcare professionals was not widespread. Majority of respondents believed that the best judge of intensity of pain is the child. Nearly two-thirds of the respondents felt that non-pharmacological measures were better to control pain and also their practices showed that most were willing to allow the parental presence during minor invasive procedures.

CONCLUSION

There is need to improve the knowledge of health care personnel regarding pain assessment and management in children.

A randomized clinical trial of lidocaine gel for reducing infant distress during urethral catheterization

OBJECTIVES

The purpose of this study was to determine whether a lidocaine-enhanced lubricant that was used topically and instilled into the urethra decreased infants' distress that was associated with catheterization.

METHODS

Eligible study participants were febrile 2- to 24-month-old pediatric emergency department patients in need of a catheter-obtained urinalysis. Patients were randomly assigned to 1 of 3 groups. Patients had catheterization performed after a 4-minute protocol that included a topical lubricant control, topical and intraurethral lubricants, or topical and intraurethral lidocaines. All patients were filmed during the procedure and evaluated at 3 phases: the start of the study, time of instillation, and at the time of maximal catheter insertion. The 3 phases were analyzed by blinded coders using the Modified Behavioral Pain Scale.

RESULTS

A total of 45 patients were enrolled in 1 of the 3 study groups. Patients who received lidocaine had a lower overall distress at a level approaching significance at the time of catheterization (phase 3; P = 0.065) and a significantly lower distress as measured by crying during the catheterization (phase 3; P = 0.036) than infants who did not have a lubricant instilled into the urethra.

CONCLUSIONS

The use of topical and intraurethral lidocaine resulted in a lower distress when compared with a topical lubricant, at a level approaching significance for global distress. When a subsection of the total distress score that measured infant cry was evaluated, the difference between the intraurethral lidocaine group and the group without intraurethral instillation was statistically significant. Although the results are promising, intraurethral lidocaine did not fully alleviate discomfort associated with urethral catherization. The use of lidocaine is suggested for pediatric patients undergoing urethral catherization; however, evaluation of additional agents and techniques for further decreasing pain is also warranted.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children

STUDY OBJECTIVE

Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

METHODS

We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

RESULTS

In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route.

CONCLUSION

Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Pharmacologic approaches for reducing venous access pain in children

A variety of pharmacologic options are available to clinicians who want to provide effective and safe topical local anesthesia to children undergoing venous access procedures. These options can be distinguished on the basis of how they deliver active drug through the impermeable outer layer of skin, the stratum corneum, to pain receptors located in the dermis and epidermis. Three general methodologies are typically used to bypass the stratum corneum: direct injection of local anesthetics, usually via a small-gauge hypodermic syringe; passive diffusion from topical creams or gels; and active needle-free drug strategies that enhance the rate of drug passage into the dermis and epidermis. Examples of the latter mechanisms include heat-enhanced diffusion, iontophoresis, sonophoresis, laser-assisted transdermal passage, and pressurized gas delivery of powdered drug particles. Pharmacologic options in this setting can also be distinguished on the basis of the time to onset of full anesthetic effect. Several available agents induce significant local anesthesia within 1 to 3 minutes of administration, or faster, allowing easy integration into the skin preparation and subsequent venous access procedure. In combination with nonpharmacologic approaches, these agents can be used to dramatically lessen this significant source of pediatric pain.

Clinical implications of unmanaged needle-insertion pain and distress in children

Increasing evidence has demonstrated that pain from venipuncture and intravenous cannulation is an important source of pediatric pain and has a lasting impact. Ascending sensory neural pain pathways are functioning in preterm and term infants, yet descending inhibitory pathways seem to mature postnatally. Consequently, infants may experience pain from the same stimulus more intensely than older children. In addition, painful perinatal procedures such as heel lancing or circumcision have been found to correlate with stronger negative responses to venipuncture and intramuscular vaccinations weeks to months later. Similarly, older children have reported greater pain during follow-up cancer-related procedures if the pain of the initial procedure was poorly controlled, despite improved analgesia during the subsequent procedures. Fortunately, both pharmacologic and nonpharmacologic techniques have been found to reduce children's acute pain and distress and subsequent negative behaviors during venipuncture and intravenous catheter insertion. This review summarizes the evidence for the importance of managing pediatric procedural pain and methods for reducing venous access pain.