Caregiver-fabricated illness in a child prescribed long-term opioids and benzodiazepines.

Caregiver-fabricated illness in a child (CFIC) can result in unnecessary, potentially harmful medical investigations and treatment. As pediatric pain has historically been undertreated, the movement for more compassionate treatment has led to an increase in analgesic prescribing in children and adolescents. Overall, this has been a positive change but this may also lead to unintentional harm, partic-ularly if CFIC is not considered as a possibility in the presentation. We present a case in which CFIC was associated with long-term prescribing of opioids, benzodiazepines, and other central nervous system depressants.

Postoperative pain control following minimally invasive correction of pectus excavatum in pediatric patients: A systematic review.

PURPOSE: Surgery for pectus excavatum is associated with significant postoperative pain. The aim of this study was to summarize the current literature regarding postoperative pain control for pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS: A systematic search of Medline, Embase, PubMed, CINAHL, Web of Science, and the Cochrane Library for randomized controlled trials (RCT) comparing methods of pain control in pediatric patients undergoing MIRPE was conducted. Studies were restricted to the English language. RESULTS: After screening 1304 references, 9 randomized control trials (RCTs) enrolling 485 patients were included. The average age was 11.9 years (±3.1). Pain scores were decreased with ropivacaine compared to bupivacaine-based epidurals. In studies comparing ketamine to opioid based patient-controlled anesthesia (PCA) pumps, the results were variable. Intercostal and paravertebral nerve blocks had decreased pain scores in 75% of the studies compared to opioid-based PCA. Opioid consumption was decreased in 50% of the trials assessing ketamine-based infusions and 75% of the studies comparing intercostal and paravertebral nerve blocks. Nausea was decreased in several of the ketamine-based infusion and intercostal and paravertebral nerve block studies. CONCLUSION: Ketamine-including infusions or paravertebral and intercostal nerve blocks may represent superior methods of postoperative pain control for MIRPE. Further work is needed to confirm results. LEVEL OF EVIDENCE: 2A [1].

Attitudes and self-reported practices of orthopedic providers regarding prescription opioid use.

OBJECTIVE: Orthopedic surgeons are the third-highest opioid prescribers in the United States. Their prescribing practices can significantly affect the quantity of unconsumed opioids available to fuel the current opioid epidemic. The aim of this study was to identify prescribing patterns and knowledge gaps among orthopedic providers for targeted future interventions and investigation. DESIGN: An online survey describing six common orthopedic surgical scenarios was distributed electronically to determine opioid type and quantity prescribed at discharge, medication disposal instructions, and the use of prescription drug monitoring programs (PDMPs) in the prescription writing process. SETTING: Tertiary care academic hospitals. PARTICIPANTS: Orthopedic physicians and mid-level providers practicing at Johns Hopkins Medical Institutions and University of Maryland Medical System. Of 179 providers contacted, 127 (71 percent) completed the survey. MAIN OUTCOME MEASURES: Quantity of opioid prescribed, utilization of PDMPs, and provision of opioid disposal instructions. RESULTS: While statistically significant associations were identified between quantity of opioid prescribed and surgical procedure, for five of six scenarios 95 percent of respondents recommended prescribing >55 oxycodone 5 mg pill equivalents (PEs) at discharge. An inverse correlation between years of clinical practice and mean number of PEs prescribed was observed. Fewer than 40 percent of respondents modified prescribing when presented with clinically relevant changes in scenario (history of depression or drug abuse). Over 60 percent of respondents do not use PDMPs, and 79 percent do not provide opioid disposal instructions. CONCLUSIONS: Our findings support a need for targeted education to mitigate the role of orthopedic postoperative prescribing practices on the current opioid abuse epidemic.

Incidence, Distribution, and Cost of Lawn-Mower Injuries in the United States, 2006-2013.

OBJECTIVES: Characterization of the epidemiology and cost of lawn-mower injuries is potentially useful to inform injury prevention and health policy efforts. We examined the incidence, distribution, types and severity, and emergency department (ED) and hospitalization charges of lawn-mower injuries among all age groups across the United States. METHODS: This retrospective, cross-sectional study used nationally representative, population-based (all-payer) data from the US Nationwide Emergency Department Sample for lawn-mower-related ED visits and hospitalizations from January 1, 2006, through December 31, 2013. Lawn-mower injuries were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification code E920 (accidents caused by a powered lawn mower). We analyzed data on demographic characteristics, age, geographic distribution, type of injury, injury severity, and hospital charges. RESULTS: We calculated a weighted estimate of 51 151 lawn-mower injuries during the 8-year study period. The most common types of injuries were lacerations (n = 23 907, 46.7%), fractures (n = 11 433, 22.4%), and amputations (n = 11 013, 21.5%). The most common injury locations were wrist or hand (n = 33 477, 65.4%) and foot or toe (n = 10 122, 19.8%). Mean ED charges were $2482 per patient, and mean inpatient charges were $36 987 per patient. The most common procedures performed were wound irrigation or debridement (n = 1436, 29.9%) and amputation (n = 1230, 25.6%). CONCLUSIONS: Lawn-mower injuries occurred at a constant rate during the study period. Changes to nationwide industry safety standards are needed to reduce the frequency and severity of these preventable injuries.

Pain Management for Nonsyndromic Craniosynostosis: Adequate Analgesia in a Pediatric Cohort?

BACKGROUND: Postoperative pain following open craniosynostosis repair has not been studied extensively and is sometimes thought to be inconsequential. The purpose of this study was to assess postoperative pain in this pediatric population. METHODS: We performed a retrospective chart review of patients (n = 54) undergoing primary open craniosynostosis repair from 2010 to 2016. Demographics, length of stay (LOS), pain scores, emesis events, and perioperative analgesics were reviewed. Multivariable regression models were designed to assess for independent predictors of LOS and emesis. RESULTS: A high proportion had moderate to severe pain on postoperative day 0 (56.5%) and day 1 (60.9%). Opioid administered in postoperative period was 1.40 mg/kg/d in morphine milligram equivalent (MME) (±1.07 mg/kg/d MME). Majority of patients transitioned to enteral opioids on postoperative day 1 (24.5%) or day 2 (49.1%). Ketorolac was administered to 11.1% (n = 6). Emesis was documented in 50% of patients. LOS revealed a positive association with age (P = 0.006), weight (P = 0.009), and day of transition to enteral opioids (P < 0.001); association with emesis was trending toward significance (P = 0.054). There was no association between overall LOS and amount of opioids administered postoperatively (P = 0.68). Postoperative emesis did not have any significant association with age, sex, weight, total amount of postoperative opioid administered, use of ketorolac, or intraoperative steroid use. CONCLUSION: Open craniosynostosis repair is associated with high levels of pain and low utilization of nonopioid analgesics. Strategies to improve pain, decrease emesis and LOS include implementation of multimodal analgesia period and avoidance of enteral medications in the first 24 hours after surgery.

Opioid Prescribing for the Treatment of Acute Pain in Children on Hospital Discharge.

BACKGROUND: The epidemic of nonmedical use of prescription opioids has been fueled by the availability of legitimately prescribed unconsumed opioids. The aim of this study was to better understand the contribution of prescriptions written for pediatric patients to this problem by quantifying how much opioid is dispensed and consumed to manage pain after hospital discharge, and whether leftover opioid is appropriately disposed of. Our secondary aim was to explore the association of patient factors with opioid dispensing, consumption, and medication remaining on completion of therapy. METHODS: Using a scripted 10-minute interview, parents of 343 pediatric inpatients (98% postoperative) treated at a university children's hospital were questioned within 48 hours and 10 to 14 days after discharge to determine amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. Multivariable linear regression was used to examine predictors of opioid prescribing, consumption, and doses remaining. RESULTS: Median number of opioid doses dispensed was 43 (interquartile range, 30-85 doses), and median duration of therapy was 4 days (interquartile range, 1-8 days). Children who underwent orthopedic or Nuss surgery consumed 25.42 (95% confidence interval, 19.16-31.68) more doses than those who underwent other types of surgery (P < .001), and number of doses consumed was positively associated with higher discharge pain scores (P = .032). Overall, 58% (95% confidence interval, 54%-63%) of doses dispensed were not consumed, and the strongest predictor of number of doses remaining was doses dispensed (P < .001). Nineteen percent of families were informed how to dispose of leftover opioid, but only 4% (8 of 211) did so. CONCLUSIONS: Pediatric providers frequently prescribed more opioid than needed to treat pain. This unconsumed opioid may contribute to the epidemic of nonmedical use of prescription opioids. Our findings underscore the need for further research to develop evidence-based opioid prescribing guidelines for physicians treating acute pain in children.

An analysis of errors, discrepancies, and variation in opioid prescriptions for adult outpatients at a teaching hospital.

OBJECTIVE: To determine opioid-prescribing patterns and rate of three types of errors, discrepancies, and variation from ideal practice. DESIGN: Retrospective review of opioid prescriptions processed at an outpatient pharmacy. SETTING: Tertiary institutional medical center. PATIENTS: We examined 510 consecutive opioid medication prescriptions for adult patients processed at an institutional outpatient pharmacy in June 2016 for patient, provider, and prescription characteristics. MAIN OUTCOME MEASURE(S): We analyzed prescriptions for deviation from best practice guidelines, lack of two patient identifiers, and noncompliance with Drug Enforcement Agency (DEA) rules. RESULTS: Mean patient age (standard deviation) was 47.5 years (17.4). The most commonly prescribed opioid was oxycodone (71 percent), usually not combined with acetaminophen. Practitioners prescribed tablet formulation to 92 percent of the sample, averaging 57 (47) pills. We identified at least one error on 42 percent of prescriptions. Among all prescriptions, 9 percent deviated from best practice guidelines, 21 percent failed to include two patient identifiers and 41 percent were noncompliant with DEA rules. Errors occurred in 89 percent of handwritten prescriptions, 0 percent of electronic health record (EHR) computer-generated prescriptions, and 12 percent of non-EHR computer-generated prescriptions. Interrater reliability by κ was 0.993. CONCLUSIONS: Inconsistencies in opioid prescribing remain common. Handwritten prescriptions continue to demonstrate higher associations of errors, discrepancies, and variation from ideal practice and government regulations. All computer-generated prescriptions adhered to best practice guidelines and contained two patient identifiers, and all EHR prescriptions were fully compliant with DEA rules.

The postoperative management of pain from intracranial surgery in pediatric neurosurgical patients.

Pain following intracranial surgery has historically been undertreated because of the concern that opioids, the analgesics most commonly used to treat moderate-to-severe pain, will interfere with the neurologic examination and adversely affect postoperative outcome. Over the past decade, accumulating evidence, primarily in adult patients, has revealed that moderate-to-severe pain is common in neurosurgical patients following surgery. Using the neurophysiology of pain as a blueprint, we have highlighted some of the drugs and drug families used in multimodal pain management. This analgesic method minimizes opioid-induced adverse side effects by maximizing pain control with smaller doses of opioids supplemented with neural blockade and nonopioid analgesics, such nonsteroidal antiinflammatory drugs, local anesthetics, corticosteroids, N-methyl-D-aspartate (NMDA) antagonists, α2 -adrenergic agonists, and/or anticonvulsants (gabapentin and pregabalin).

Ultrasound use in the pediatric airway: the time has come.

Advancements in ultrasonography and increasing familiarity with its use in the operating room (vascular access and regional neural blockade) suggest its feasibility as an adjunct in pediatric airway evaluation and intervention. We report 3 cases demonstrating the usefulness of ultrasound techniques in this setting. We show key elements of airway anatomy, noninvasive observation of vocal cord motion, and percutaneous periglottic steroid injection via the cricothyroid membrane in 3 different patients. This report reveals the possible usefulness of ultrasound imaging in clinical anesthesia care, specifically airway management, in children.

Epidemiology and clinical outcomes of acute spine trauma and spinal cord injury: experience from a specialized spine trauma center in Canada in comparison with a large national registry.

BACKGROUND: Because relevant changes in the epidemiology of the traumatic spinal cord injury (SCI) has been reported, we sought to examine the demographics, injury characteristics, and clinical outcomes of patients with spine trauma who have been treated in our spine trauma center. METHODS: All consecutive patients with acute spine trauma who were admitted in our center from 1996 to 2007 were included. Comparisons among the four triennia were performed for demographics, injury characteristics, and clinical outcomes. Also, our 2001/2002 SCI data were compared with the National Trauma Registry (NTR) dataset. RESULTS: There were 569 patients (394 males, 175 females; ages from 15 to 102 years, mean age of 50 years) who were admitted with acute spine trauma. Although demographic profile has been steady over the last four triennia, the frequency of more severe spine trauma at the lumbosacral levels due to falls has increased overtime. The mean length of stay and in-hospital mortality rates have not significantly changed during the past 12 years. Our in-hospital mortality rate (4%) was significantly lower than the provincial rate from the Ontario Trauma Registry (7.5%; p = 0.005). Comparisons between our SCI data and the NTR dataset showed significant differences regarding age groups. CONCLUSIONS: Our results indicate that significant differences in the characteristics of acute spine trauma but not demographics have occurred overtime in our institution. Also, there were significant differences between our database and the NTR regarding age distribution. Our reduced in-hospital mortality rates in comparison with the provincial data reinforce the recommendations for early management of SCI patients in a spine trauma center.

Thoracoscopic sympathetic clipping for hyperhidrosis: long-term results and reversibility.

OBJECTIVE: The study objectives were to assess 1) postoperative satisfaction and the occurrence of compensatory sweating after endoscopic thoracic sympathetic clipping in a consecutive series of patients and 2) the reversibility of adverse effects by removing the surgical clips. METHODS: Between June 1998 and March 2006, 727 patients undergoing bilateral endoscopic thoracic sympathetic clipping for hyperhidrosis or facial blushing were prospectively followed for postoperative satisfaction and subjective compensatory sweating. The effect of removing the surgical clips was assessed in 34 patients who underwent a subsequent reversal procedure after endoscopic thoracic sympathetic clipping. Satisfaction and compensatory sweating were assessed using a visual analogue scale ranging from 0 to 10, with 10 indicating the highest degree. RESULTS: Follow-up was complete in 666 patients (92%). The median age was 26.9 years, and 383 (53%) were men. The level of sympathetic clipping was T2 in 399 patients (55%), T2+3 in 55 patients (8%), and T3+4 in 273 patients (38%). Median follow-up was 10.4 months (range 0-83 months). Excellent satisfaction (8-10 on visual analogue scale) was seen at last follow-up in 288 (74%) of the T2 group, 33 (62%) of the T2+3 group, and 184 (85%) of the T3+4 group. Postoperative satisfaction was significantly higher in the T3+4 group when compared with the T2 or T2+3 groups (P < .01). Severe compensatory sweating (8-10 on the visual analogue scale) was reported in 42 (13%) of the T2 group, 11 (28%) of the T2+3 group, and 17 (8%) of the T3+4 group. Postoperative compensatory sweating was significantly lower in the T3+4 group when compared with the T2 or T2+3 groups (P < .05). Thirty-four patients have subsequently undergone removal of the surgical clips after endoscopic thoracic sympathetic clipping. Follow-up was complete in 31 patients. The reasons for removal included severe compensatory sweating in 32 patients, anhydrosis of the upper limb in 4 patients, lack of improvement or recurrence of hyperhidrosis in 5 patients, and other adverse symptoms in 5 patients. The reversal procedure was done after a median time of 11.0 months (range 1-57 months) after endoscopic thoracic sympathetic clipping. The initial level of clipping was T2 in 21 patients, T2+3 in 7 patients, and T3+4 in 6 patients. There was a trend toward fewer subsequent reversal procedures in the T3+4 group when compared with the T2 or T2+3 groups (P = .06). Fifteen patients (48%) reported a substantial decrease in their compensatory sweating (5-10 on the visual analogue scale) after reversal. Thirteen patients (42%) reported that their initial hyperhidrosis or facial blushing has remained well controlled (8-10 on the visual analogue scale) after reversal. There was no significant relationship between the original level of clipping and the interval between endoscopic thoracic sympathetic clipping and the subsequent reversal and reversibility of symptoms. CONCLUSION: When compared with endoscopic thoracic sympathetic clipping at the T2 or T2+3 levels, endoscopic thoracic sympathetic clipping at the T3+4 level was associated with a higher satisfaction rate, a lower rate of severe compensatory sweating, and a trend toward fewer subsequent reversal procedures. Subjective reversibility of adverse effects after endoscopic thoracic sympathetic clipping was seen in approximately half of the patients who underwent endoscopic removal of surgical clips. Although yet to be supported by electrophysiologic studies, reversal of sympathetic clipping seems to provide acceptable results and should be considered in selected patients.

The impact of co-morbidities on age-related differences in mortality after acute traumatic spinal cord injury.

Despite the shift in demographics of spinal cord injury (SCI) due to an aging population, relatively little has been reported regarding the effect of age on outcomes after SCI. This study examines the potential confounding effect of co-morbidities on the age-related differences in the hospital mortality following acute traumatic SCI. All consecutive patients with SCI who were admitted to our spine center from 1996 to 2007 were included. Co-morbidities were classified using the Charlson Co-morbidity Index (CCI), Cumulative Illness Rating Scale, and the number of ICD-9 codes. Major potential confounders included age, gender, co-morbidity, and level and severity of SCI. There were 217 males and 80 females with ages from 15 to 96 years. Most patients had an incomplete cervical SCI following falls or motor vehicle accidents. The mean in-hospital mortality rate was 5.7%. Using univariate analyses, older age, relevant pre-existing medical conditions, and motor complete SCI were major risk factors for in-hospital death after acute SCI. Among the three co-morbidity assessments, the CCI was the most reliable co-morbidity index for prediction of hospital mortality in SCI patients after controlling for age in the Cox proportional hazard modeling. In addition, the CCI appears to be a major confounder, which accounts for the majority of age-related differences in mortality following SCI. Our findings have implications for future clinical trials of therapies for adult patients with acute SCI and for management strategies of elderly individuals with SCI.