Pain management and weaning from narcotics and sedatives

Pediatric immunohematopoietic stem cell transplantation at a tertiary care center in Cape Town

INTRODUCTION AND STUDY DESIGN: We conducted a retrospective analysis of consecutive referrals of patients under 18 years of age undergoing immunohematopoietic stem cell transplantation to assess the influence of age, diagnosis, graft type and gender on survival. We also contrasted program activity and outcome to that reported from a state hospital in the same geographical area over a comparable period.

METHODS

Conditioning employed either a sequential combination of fractionated 12Gy whole body and 6Gy total nodal irradiation separated by 120mg/kg of cyclophosphamide in patients over 15 years of age. Alternatively, the latter agent was combined initially with oral busulphan and later the intravenous equivalent. Neuroblastoma cases were prepared using a different regimen. In allografts the harvested product underwent ex vivo T-cell depletion with the humanized version of anti-CD 52 monoclonal antibody designated Campath 1H. No additional immunosuppression was given except where matched unrelated volunteer donors were employed.

RESULTS

Sixty-eight procedures were carried out in 61 patients over a 6-year period. Of 11 with acute myeloid leukemia, 8 are alive and well whereas 8 of the 14 with the lymphoblastic variant have died. Of the remaining 12 with hematologic malignancy, all but 2 are alive. Ten of the 17 with aplasia are alive as are all with thalassemia or sickle cell disease. None of the four variables tested affected survival.

CONCLUSION

Our analysis indicates that the standardized preparative regimen, coupled with a now well-established immunosuppressive regimen, is as effective in patients under 18 years of age as in adults. Our analysis also indicates that in a resource-scarce or developing country, it is mandatory to limit high-risk and relatively expensive procedures to active teams that enjoy international accreditation, whether these be in the state or private sector.

The social ecology of changing pain management: do I have to cry?

OBJECTIVE

To improve acute pain management for children with systematic assessment and appropriate analgesia.

DESIGN

An action research design was used; pre-post data were collected during a four-phase intervention. The intervention was a social ecological approach to changing pain assessment and prescription practices.

SETTING

A university-affiliated public hospital in the greater Los Angeles area.

PARTICIPANTS

An interdisciplinary team of clinicians and hospital administrators were engaged in implementing new pain management procedures for children with postoperative and procedural pain.

INTERVENTIONS

We implemented the Poker Chip Tool as a standard pain assessment tool, changed policy to make morphine drug of choice for acute postoperative pain, provided extensive educational activities, and conducted weekly rounds with anesthesiologist/intensivist, nurses, pharmacist, and child life specialist. Role modeling by leaders was used to build skill in interdisciplinary collaboration for staff. We promoted the initiative as an activity of the medical center strategic plan. Efforts were linked to national shifts in pain management through guideline review and use of a visiting expert.

OUTCOME MEASURES

Charts were audited for assessment of pain intensity. Doses dispensed by pharmacy were used as a proxy measure of analgesia administered to children to establish change in pattern of analgesic use.

RESULTS

In Phase I: 54% of charts audited had documentation of pain intensity. This rate climbed to Phase II, 93% of the audited charts at full implementation and stabilized at 84% at the project conclusion. Record of doses of analgesia dispensed demonstrated a shift from reliance on meperidine to morphine and acetaminophen with codeine. The relative rates demonstrated a 100% increase in acetaminophen with codeine distributed from the beginning of the study to full implementation of the project (chi(2) = 9.01, df = 1, p < 0.002). The relative rate for meperidine demonstrated a 250% decrease (chi(2) = 12.26, df = 1, p < 0.0004), and the relative rate for morphine exhibited a 455% increase (chi(2) = 209.20, df = 1, p < 0.0001). By the final phase (IV: Evaluation), meperidine was only 1% of the analgesia dispensed. Morphine doses that were initially 35% climbed to 62% at the close of the study. Acetaminophen with codeine shifted correspondingly from 24% to 36%. Anecdotal reports suggested that skills in assessment and building collaboration generalized to other patient care situations.

CONCLUSIONS

Using a social ecology approach that focused simultaneously on the environment (ward, medical center, and national scene) and relationships among the clinical team improved pain management practices. These changes took place over 2 years and were sustained 2 years after the intense intervention.