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Salimi-Jazi F, Sabapaty A, Santos Dalusag K, Abrajano C, Nguyen J, Robinson B, Caruso TJ, Rodriguez S, Hartman G, Chao SD. Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population. J Pediatr Surg 2024; 59:992-996. [PMID: 38307749 PMCID: PMC11031342 DOI: 10.1016/j.jpedsurg.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 12/18/2023] [Accepted: 01/03/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND In the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids. In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children. METHODS A retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia. RESULTS A total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58 % had private insurance. Most common diagnosis was precocious puberty (54 %) followed by gender dysphoria (46 %). Most common procedure was implant placement (72 %). 69 % of procedures were performed in the clinic and 31 % in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded. CONCLUSION VR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Fereshteh Salimi-Jazi
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Akanksha Sabapaty
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kyla Santos Dalusag
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Claire Abrajano
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jackie Nguyen
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Blaine Robinson
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas Jon Caruso
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Samuel Rodriguez
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Gary Hartman
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie D Chao
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Villegas Estévez FJ, López Alarcón MD, Beato C, Sanz-Yagüe A, Porta-Sales J, Morera López RM. Procedural pain in patients with cancer: a Delphi expert management consensus. BMJ Support Palliat Care 2023; 13:e428-e436. [PMID: 34210716 DOI: 10.1136/bmjspcare-2020-002668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/14/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Diagnosis, treatment and care of cancer often involve procedures that may be distressing and potentially painful for patients. The PROCEDIO Study aimed to generate expert-based recommendations on the management of moderate to severe procedural pain in inpatients and outpatients with cancer. METHODS Using a two-round Delphi method, experts from pain and palliative care units, medical and radiation oncology and haematology departments expressed their agreement on 24 statements using a 9-point Likert scale, which were classified as appropriate (median 7-9), uncertain (4-6) or inappropriate (1-3). Consensus was achieved if at least two-thirds of the panel scored within the range containing the median. RESULTS With an overall agreement on the current definition of procedural pain, participants suggested a wider description based on evidence and their clinical experience. A strong consensus was achieved regarding the need for a comprehensive pre-procedural pain assessment and experts emphasised that healthcare professionals involved in procedural pain management should be adequately trained. Most panellists (98.2%) agreed that pharmacological treatment should be chosen considering the duration of the procedure. Transmucosal fentanyl (96.5%) and morphine (71.7%) were recommended as the most appropriate drugs. Oral and nasal transmucosal fentanyl were agreed as the most suitable for both outpatients and inpatients, while consensus was reached for intravenous and subcutaneous morphine for inpatients. CONCLUSIONS These results provide updated expert-based recommendations on the definition, prevention and treatment of moderate to severe procedural pain, which could inform specialists involved in pain management of patients with cancer.
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Affiliation(s)
| | | | - Carmen Beato
- Departamento de Oncología Médica, Hospital Universitario de Jerez de la Frontera, Jerez de la Frontera, Spain
| | | | - Josep Porta-Sales
- Unidad de Cuidados Paliativos, Institut Catalá d'Oncologia, Girona, Spain
| | - Rosa M Morera López
- Servicio de Oncología Radioterápica, Hospital Universitario La Paz, Madrid, Spain
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Boisvert-Plante V, Poulin-Harnois C, Ingelmo P, Einhorn LM. What we know and what we don't know about the perioperative use of methadone in children and adolescents. Paediatr Anaesth 2023; 33:185-192. [PMID: 36281540 PMCID: PMC10416808 DOI: 10.1111/pan.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 02/05/2023]
Abstract
Postoperative pain control is essential to optimizing patient outcomes, improving satisfaction, and allowing patients to resume their baseline functional activities. Methadone, a synthetic mu-opioid agonist, has multiple pharmacologic properties that may be optimal for perioperative use. Compared to other opioids, methadone has a longer duration of action, rapid onset, extended dosing intervals, high oral bioavailability, low cost, lack of active metabolites, and action on multiple receptors. The current literature examining the use of methadone in the perioperative care of children and adolescents is limited and most often reported within the context of spine or cardiothoracic surgery. Overall, these studies support the hypothesis that perioperative methadone in pediatric patients may decrease postoperative pain, opioid consumption, length-of-stay, and the incidence of some opioid-related side effects, like constipation and urinary retention. A variety of protocols for the perioperative use of methadone have been described, including a single intraoperative dose as well as multiple small doses within multimodal pain protocols. The superiority of these protocols has not been established. Like all opioids, methadone has a side effect profile which includes nausea, vomiting, reduced GI motility, sedation, and respiratory depression at high doses. There is also a concern that it can cause QTc prolongation in patients. The primary aim of this educational review is to examine the pharmacologic data, published perioperative protocols, dosing considerations, and risks and benefits associated with inclusion of methadone in analgesic regimens for surgical patients. A secondary aim is to introduce opportunities for research around the perioperative use of methadone in children and adolescents. Based on our review, we would prioritize establishing optimal procedure-specific methadone protocols, determining generalizability for use in routine pediatric surgeries, and investigating methadone safety and efficacy prospectively as the primary opioid for pain management in the postanesthesia care unit or postsurgical floors.
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Affiliation(s)
| | - Christelle Poulin-Harnois
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
| | - Pablo Ingelmo
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
- Alan Edwards Centre for Pain Research, McGill University, Montreal, Quebec, Canada
- Edwards Family Interdisciplinary Complex Pain Centre, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Lisa M. Einhorn
- Department of Anesthesiology, Pediatric Division, Duke University School of Medicine, Durham, North Carolina, United States
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An observational cohort study comparing ibuprofen and oxycodone in children with fractures. PLoS One 2021; 16:e0257021. [PMID: 34499688 PMCID: PMC8428788 DOI: 10.1371/journal.pone.0257021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 08/22/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the effectiveness and safety of prescribing ibuprofen and oxycodone for at-home management of children's fracture pain. METHODS A prospective observational cohort was conducted at the Stollery Children's Hospital pediatric emergency department (June 2010-July 2014). Children aged 4-16 years with an isolated fracture discharged home with advice to use either ibuprofen or oxycodone were recruited. RESULTS A cohort of 329 children (n = 217 ibuprofen, n = 112 oxycodone) were included. Mean age was 11.1 years (SD 3.5); 68% (223/329) were male. Fracture distribution included 80.5% (264/329) upper limb with 34.3% (113/329) requiring fracture reduction. The mean reduction in Faces Pain Score-Revised score (maximum pain-post-treatment pain) for Day 1 was 3.6 (SD 1.9) (ibuprofen) and 3.8 (SD 2.1) (oxycodone) (p = 0.50); Day 2 was 3.6 (SD 1.8) (ibuprofen) and 3.7 (SD 1.6) (oxycodone) (p = 0.56); Day 3 was 3.7 (SD 1.7) (ibuprofen) and 3.3 (SD 1.7) (oxycodone) (p = 0.24). Children prescribed ibuprofen (51.2%, 109/213) experienced less adverse events compared to those prescribed oxycodone (70.5% 79/112) on Day 1 (p = 0.001). Children prescribed ibuprofen (71.8%, 150/209) had their function (eat, play, school, sleep) affected less than those prescribed oxycodone (83.0%, 93/112) (p = 0.03) on Day 1. CONCLUSION Children prescribed ibuprofen or oxycodone experienced similar analgesic effectiveness for at-home fracture pain. Oxycodone prescribing was associated with more adverse events and negatively impacted function. Oxycodone use does not appear to confer any benefit over ibuprofen for pain relief and has a negative adverse effect profile. Ibuprofen appears to be a safe option for fracture-related pain.
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Ali S, Sivakumar M, Beran T, Scott SD, Vandermeer B, Curtis S, Jou H, Hartling L. Study protocol for a randomised controlled trial of humanoid robot-based distraction for venipuncture pain in children. BMJ Open 2018; 8:e023366. [PMID: 30552264 PMCID: PMC6303653 DOI: 10.1136/bmjopen-2018-023366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/15/2018] [Accepted: 10/26/2018] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Intravenous insertion (IVI) is a very common procedure in the emergency department (ED). IVI is often painful and stressful for both children and their families. Currently, distraction therapy is not used as a standard of care for IVI in North America. We propose that interaction with a humanoid robot may effectively distract children during IVI thereby reducing their pain and distress. METHODS AND ANALYSIS This randomised controlled superiority trial will be conducted in a Canadian paediatric ED. We plan to recruit 80 patients. Children will be eligible if they (1) are 6 to 11 years of age, (2) need an IVI, (3) are fully conscious and alert, (4) have sufficient knowledge of the English language to understand and complete the study assessments and (5) are accompanied by a legal guardian. Our primary objective is to compare patient-reported pain and distress with the use of distraction (via a humanoid robot) versus standard care in children. The primary outcomes will be (1) self-reported pain, as measured by the Faces Pain Scale-Revised and (2) observed distress, as measured by the Observational Scale of Behavioural Distress-Revised. Secondary outcomes will include (1) measuring parental anxiety, (2) examining the association between parental anxiety and child outcomes and (3) children's degree of engagement with the humanoid robot via the Intrinsic Motivation Inventory tool. First enrolment occurred in April 2017 and is ongoing. ETHICS AND DISSEMINATION This study has been approved by the Health Research Ethics Board (University of Alberta). Informed consent to participate will be obtained from all participants' parents/guardian, in conjunction with assent from the participant themselves. This study data will be submitted for publication regardless of results. Purchase of the robot was facilitated through a Stollery Children's Hospital Foundation donation. Recruitment costs are supported by the Women and Children's Health Research Institute. TRIAL REGISTRATION NUMBER NCT02997631; Pre-results.
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Affiliation(s)
- Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women & Children’s Health Research Institute, Edmonton, Alberta, Canada
| | - Mithra Sivakumar
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Tanya Beran
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Sarah Curtis
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women & Children’s Health Research Institute, Edmonton, Alberta, Canada
| | - Hsing Jou
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
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Veziari Y, Kumar S, Leach M. The development of a survey instrument to measure the barriers to the conduct and application of research in complementary and alternative medicine: a Delphi study. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 18:335. [PMID: 30547785 PMCID: PMC6295050 DOI: 10.1186/s12906-018-2352-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 10/16/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND As Complementary and Alternative medicine (CAM) grows in popularity, there is overt recognition for research evidence to inform clinical practice. While various strategies have been trialed to overcome the barriers to such progress, it is important to first understand the extent to which these barriers impact the conduct and application of CAM research. This study aimed to garner consensus and agreement among CAM researchers and practitioners in refining and validating a preliminary survey instrument for measuring these barriers. METHODS A three-round Delphi study was undertaken with 22 international experts of CAM research and practice. Round one gathered consensus on 30 statements listing barriers to the application and conduct of CAM research. Only rounds two and three sought consensus on revised statements. Any statement demonstrating ≥ 70% agreement on a four-point Likert scale was determined to have reached consensus. RESULTS Consensus and agreement was achieved for all 30 statements listing the barriers to the application and conduct of research in CAM. Additional commentary by the Delphi participants directed whether a statement had to be split into two parts or reworded. This process resulted in the generation of the "BarrierS To the Application and Conduct of rEsearch" (oBSTACLES) instrument. CONCLUSION This study, the first of its kind on this topic, identified consensus and agreement on a series of evidence-informed statements to measure the barriers to the conduct and application of research in CAM. The uniqueness of the oBSTACLES instrument is its ability to measure barriers across the evidence-based continuum.
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Affiliation(s)
- Yasamin Veziari
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, SA 5000 Australia
| | - Saravana Kumar
- School of Health Sciences, University of South Australia, North Terrace, Adelaide, SA 5000 Australia
| | - Matthew Leach
- Department of Rural Health, University of South Australia, North Terrace, Adelaide, SA 5000 Australia
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Twycross A, Forgeron P, Chorne J, Backman C, Finley GA. Pain as the neglected patient safety concern: Five years on. J Child Health Care 2016; 20:537-541. [PMID: 27091955 DOI: 10.1177/1367493516643422] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Five years ago, we published a commentary in the Canadian Medical Association Journal arguing that inadequately managed pain in children should be considered an adverse event, a harmful patient outcome. We argued that inadequately managed pain meets the definition of an adverse event and further hypothesized that treating pain as an adverse event may improve care by raising health care administrators and quality improvement experts' awareness of this issue. In this article, we reflect on the progress made in both moving this proposition forward and testing out the concept. We then move on to look at what still needs to be done to ensure that children's pain is managed effectively.
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Affiliation(s)
- Alison Twycross
- 1 Department for Children's Nursing, London South Bank University, London, UK
| | - Paula Forgeron
- 2 School of Nursing, Faculty of Health Sciences, University of Ottawa, Ontario, Canada
| | - Jill Chorne
- 3 Departments of Anesthesia, Pain Management and Perioperative Medicine and Psychology and Neuroscience, Dalhousie University, Halifax, Canada.,4 Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada
| | - Chantal Backman
- 2 School of Nursing, Faculty of Health Sciences, University of Ottawa, Ontario, Canada.,5 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - G Allen Finley
- 3 Departments of Anesthesia, Pain Management and Perioperative Medicine and Psychology and Neuroscience, Dalhousie University, Halifax, Canada.,4 Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada
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Brenn BR, Choudhry DK, Sacks K, Como-Fluehr S, Strain R. Toward Better Pain Management: The Development of a "Pain Stewardship Program" in a Tertiary Children's Hospital. Hosp Pediatr 2016; 6:520-528. [PMID: 27493066 DOI: 10.1542/hpeds.2015-0215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Despite increased focus on pediatric pain, uncontrolled pain is still a problem for hospitalized pediatric inpatients. A program was designed to find patients with uncontrolled pain and develop a framework to oversee their pain management. This report details the development of a pain stewardship program with data from the first year of its activity. METHODS Hospitalized inpatients in a tertiary care pediatric center in the mid-Atlantic region were included in the study. Pain scores are recorded every 4 hours in the hospital electronic health record. A report was constructed to find all patients with an average pain score ≥7 in the preceding 12 hours. The charts of these patients were reviewed by our anesthesia pain service, and all patients were grouped into 1 of the following action categories: (1) no action required; (2) telephone call to the patient's attending physician; (3) one-time consultation; (4) consultation with ongoing management; or (5) patient was already on the anesthesia pain service. Demographic data, pain regimens, and outcomes were recorded in a prospectively collected database. RESULTS There were 843 records on 441 unique patients. Only 22% required action to be taken by the anesthesia pain service. The pain stewardship database revealed that patients with sickle cell disease or abdominal pain required more frequent attention. CONCLUSIONS An electronic health record-based pain stewardship program is an important step in identifying all children in the hospital with undermanaged pain, and it provides a warning system that may improve patient care, outcomes, and satisfaction.
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Affiliation(s)
| | | | | | | | - Robert Strain
- Nemours Health Informatics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
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Speer K, Chamblee T, Tidwell J. An evaluation of instruments for identifying acute pain among hospitalized pediatric patients: a systematic review protocol. ACTA ACUST UNITED AC 2015; 13:25-36. [DOI: 10.11124/jbisrir-2015-2002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 03/11/2015] [Accepted: 04/21/2015] [Indexed: 10/31/2022]
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Voepel-Lewis T. What They Don't Know Can Hurt Them: Risky Analgesic Use in Children. J Perianesth Nurs 2015. [PMID: 26210571 DOI: 10.1016/j.jopan.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Twycross A, Forgeron P, Williams A. Paediatric nurses’ postoperative pain management practices in hospital based non-critical care settings: A narrative review. Int J Nurs Stud 2015; 52:836-63. [DOI: 10.1016/j.ijnurstu.2015.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/16/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
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O'Donnell FT, Rosen KR. Pediatric pain management: a review. MISSOURI MEDICINE 2014; 111:231-237. [PMID: 25011346 PMCID: PMC6179554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Although the occurrence of pain in hospitalized children is common, assessment and treatment of pain presents unique challenges to practitioners who care for pediatric patients. Knowledge of drug mechanisms as well as metabolic differences in infants and children compared with adults is necessary for the successful treatment of acute and chronic pain syndromes. Recent reports of adverse events in children receiving both opioid and non-opioid analgesics have prompted re-examination of some long standing pain medication regimens and prescribing practices. We review advances in diagnosis and management of pain in pediatric populations.
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