Use of a clinical pathway to improve the acute management of vaso-occlusive crisis pain in pediatric sickle cell disease.

BACKGROUND: The most common, debilitating morbidity of sickle cell disease (SCD) is vaso-occlusive crisis (VOC) pain. Although guidelines exist for its management, they are generally not well-followed, and research in other pediatric diseases has shown that clinical pathways improve care. The purpose of our study was to determine whether a clinical pathway improves the acute management of sickle cell vaso-occlusive crisis (VOC) pain in the pediatric emergency department (PED). PROCEDURE: Pain management practices were prospectively investigated before and after the initiation of a clinical pathway in the PED of an urban, tertiary care center with 50,000 ED visits per year and approximately 200 active sickle cell patients. The pathway included instructions for triage, monitoring, medication administration, and timing of assessments and interventions. Data were eligible from 35 pre-pathway and 33 post-pathway visits. Primary outcome was time interval to administration of first analgesic medication. Statistical analysis was by Student's t-test, using natural-log-transformed data for outcomes with skewed distribution curves. RESULTS: Time interval to first analgesic improved from 74 to 42 minutes (P = 0.012) and to first opioid from 94 to 46 minutes (P = 0.013). The percentage of patients who received ketorolac increased from 57% to 82% (P = 0.03). Decrease in time interval to subsequent pain score assessment was not statistically significant (110 to 72 minutes (P = 0.07)), and change in pain score was not different (P = 0.25). CONCLUSIONS: The use of a clinical pathway for sickle cell VOC in the PED can improve important aspects of pain management and merits further investigation and implementation.

Parent self-efficacy for managing pain in seriously ill children and adolescents nearing end of life.

OBJECTIVE: Using data from a multi-site study of parent-child symptom reporting concordance, this secondary analysis explored the role of parent self-efficacy related to pain management for seriously ill school-age children and adolescents. METHOD: In the initial study, 50 children and adolescents who were expected to survive 3 years or less were recruited along with their parent/primary caregiver. Parent self-report data were used in this secondary analysis to describe parent self-efficacy for managing their child's pain, caregiver strain, mood states, and perception of the child's pain; to explore relationships among these variables; and to determine predictors of greater self-efficacy. RESULTS: Parents expressed a wide range of self-efficacy levels (Chronic Pain Self-Efficacy Scale; possible range 10-100, mean 76.2, SD 14.7) and higher levels on average than reported previously by family caregivers of adult patients. Caregiver Strain Index scores were markedly high (possible range 0-13, mean 8.1, SD 3.8) and inversely correlated with self-efficacy (r = -0.44, p = 0.001). On the Profile of Mood States parents reported more negative moods (t = 4.0, p < 0.001) and less vigor (t = -5.0, p < 0.001) than adults in a normative sample, yet vigor rather than mood disturbance predicted self-efficacy. With the exception of child age, self-efficacy was not associated with demographics (child gender, ethnicity, household income, parent age, education, family size) or with the diagnostic groups (primarily cardiac and oncologic) comprising the sample. Younger child age, less caregiver strain, more parent vigor, and parent perception that child is without pain predicted more than half of the variance in parent self-efficacy (R2 = 0.51). SIGNIFICANCE OF RESULTS: Findings advance knowledge of parent self-efficacy in managing the pain of a child with life-threatening illness. Results can be used to design supportive interventions enhancing parents' caregiving roles during their child's last stages of life.

The use of oral ketamine for analgesia with dressing change in an infant with epidermolysis bullosa: report of a case.

Epidermolysis bullosa (EB) describes a spectrum of disease from occasional bullae and callus formation to a debilitating life-threatening condition. In this study, we report the use of intravenous ketamine given orally to an infant with a phenotypically severe form of EB simplex, Dowling-Meara subtype, to achieve analgesia during painful dressing changes.

Interviewing and Urine Drug Toxicology Screening in a Pediatric Pain Management Center: An Analysis of Analgesic Nonadherence and Aberrant Behaviors in Adolescents and Young Adults.

OBJECTIVES: Many adolescents and young adults report having chronic pain. Urine drug toxicology (UDT) is not routinely used in the pediatric pain management population, despite more routine use in adults with pain, particularly those prescribed opioids. As a first step toward establishing monitoring practices in pediatric and adolescent pain management, the present study evaluated the role of UDT in conjunction with a standard clinical interview in identifying the rate of adherence to an established analgesic regimen. The study also aimed to assess the use of UDT in identifying possible aberrant behaviors in this population. METHODS: Data were acquired from a convenience sample of 50 pediatric and adolescent pain management initial consultations, during which a clinical interview and UDT were conducted. Data were analyzed to determine adherence to an established analgesic prescription regimen, and for identification of aberrant behaviors including concurrent use of illicit substances and prescription medication misuse. Other pertinent demographic and clinical factors were examined as factors in adherence. RESULTS: Opioid medications were prescribed for 42% of the sample receiving pain medications, and 22% of the sample was nonadherent to their prescription analgesic regimen. Factors associated with a higher likelihood of nonadherence were an older age and having an opioid prescription. The majority (90%) of those nonadherent to their analgesic regimen displayed some form of aberrant behavior. Among the nonadherent patients, 50% were identified by UDT alone, and 50% were identified by self-report during the clinical encounter. CONCLUSIONS: These results highlight the challenges of identifying nonadherence to a prescription regimen among adolescents with chronic pain. In addition, this preliminary work suggests that UDT could be used in conjunction with careful clinical interviewing to substantiate patient report and increase the likelihood of detecting analgesic nonadherence and aberrant behaviors.

Pentobarbital withdrawal and treatment in an infant in the pediatric cardiac intensive care unit.

Withdrawal syndromes following administration of sedative and analgesic infusions represent a significant morbidity that is described increasingly in the pediatric critical care literature. However, there are few descriptions of pentobarbital withdrawal symptoms and their treatment in the pediatric population. We describe an infant receiving multiple sedative and analgesic medications, including pentobarbital, who was resistant to our institution's standard weaning protocol, but whose severe withdrawal symptoms responded dramatically to phenobarbital loading and maintenance.

Undetected Ultracet™ dependence in an adolescent with nonmalignant back pain.

Addiction to painkillers or other substances in pediatric and adolescent cases of noncancer chronic pain is an understudied phenomenon, even amidst documented increases in rates of prescription opioid use and misuse. Case studies can inform the training of clinicians in ethically negotiating a balance between optimizing analgesia and mitigating risk of aberrant drug-taking behaviors. This report discusses an 18-year-old woman with idiopathic scoliosis and clinical depression secondary to undertreated refractory chronic back pain who underwent surgery to correct pseudoarthrosis after a prior spinal instrumentation operation. This intervention in conjunction with a course of patient-controlled analgesia, hydromorphone, and outpatient tramadol, naproxen, methadone, and gabapentin was successful in addressing her long-standing lumbar pain. The patient, however, continued to complain to her pain management team of postsurgical discomfort and insisted on being prescribed Ultracet™ (acetaminophen-tramadol) rather than generic tramadol. The patient's eventual disclosure of severe withdrawal discomfort and history of covert abuse of Ultracet™ is discussed with respect to key warning signs, gaps, and contingencies in the screening, surgical, and pain management processes.

"Scratching" beneath the surface: an integrative psychosocial approach to pediatric pruritus and pain.

Pruritus is prevalent in children with atopic dermatitis and associated with effects on mood, quality of life, sleep, scholastic performance, social and family functioning. In this study a 7-year-old African American female with severe atopic dermatitis, itching and pain refractory to multiple systemic and topical medications was referred for treatment. At baseline, the patient scratched to the point of bleeding, despite maximal doses of anti-histamines, antidepressant and topical therapies. The patient became progressively shy, anxious, and her scholastic performance suffered. A literature review prompted the implementation of a multi-modal program of family cognitive behavioral therapy, imagery, aromatherapy, drawing, and biofeedback. The results were that decreased itch, scratching, pain, and anxiety were seen within the first month. Fewer lesions and episodes of bleeding were observed with almost complete skin clearance by the fourth month. The article concludes that a short-term, integrative program including psychological, complementary and alternative medicine (CAM), and medical therapies may represent a novel, efficacious approach for children suffering from severe atopic dermatitis.

Select practice behaviors of clinicians on the use of opioids for adolescents with subacute and chronic nonmalignant pain.

OBJECTIVES: To characterize the opioid prescribing and monitoring practices of providers for chronic nonmalignant pain (CNP) and subacute postoperative pain (SAPOP) in adolescents. DESIGN: Web-based cross-sectional self-report survey. SETTING: Free-standing pediatric tertiary academic center. PARTICIPANTS: A total of 183 physicians and nurse practitioners were eligible. Of 115 (62.8 percent) participants who responded, 108 (93.9 percent) completed the survey. MAIN OUTCOME MEASURES: Self-reported frequency of opioid prescription for SAPOP and CNP conditions and frequency of associated monitoring practices. RESULTS: For 10 of the 13 pain conditions included, some participants endorsed "monthly or more opioid prescriptions" while others endorsed "opioids do not represent appropriate management." Opioid prescribing is present for almost all pain conditions but is substantially more common for nonacute vaso-occlusive-related sickle cell disease, scoliosis correction, and video-assisted pectus excavatum-related pains. When compared with the reference group, CNP with no identifiable pathology, the odds ratio (OR) of an opioid being prescribed for CNP states with identifiable pathology was not significantly higher. The OR for SAPOP was significantly higher (p < 0.0001). None of the opioid prescribers reported collecting urine toxicology before or during opioid therapy. CONCLUSIONS: This survey identifies a diversity of self-reported clinician opioid prescribing practices for adolescents with CNP and SAPOP. Urine collection for drug toxicology screening is not utilized by opioid prescribers. Surveys of similar clinician practice behaviors at other institutions are warranted to replicate this finding and to establish common clinicalpractice for usage and monitoring of opioids in conditions where guidelines do not yet exist.

Balancing Knowledge Among Resident Specialties: Lecture-Based Training and the OUCH Card to Treat Children's Pain.

BACKGROUND: There are well-established deficiencies in residents' knowledge of acute-pain assessment and treatment in hospitalized children. METHODS: Among residents in 3 specialties (anesthesiology, orthopedics, and pediatrics), we investigated whether a pediatric pain management (PPM) curriculum that offered a lecture combined with a demonstration of how to use the OUCH card would yield higher performance on a subsequent PPM knowledge assessment. The OUCH card was created as a portable reference tool for trainees to provide analgesic dosing information, pain-assessment tools, and treatment of opioid-induced adverse effects. There was an initial convenience sample of 60 residents randomized to Form A or B of the pretest. From this, 39 residents (15 anesthesiology, 13 orthopedic, 11 pediatric) completed a PPM knowledge posttest approximately 4 weeks after the pretest, PPM lecture, and OUCH card instruction. RESULTS: Using a repeated measure design, the interaction of resident specialty and pretest to posttest scores was significant (P  =  .01) along with the covariate of residency year (P  =  .026). CONCLUSIONS: These preliminary data based on a convenience sample of residents suggest that PPM training along with use of the OUCH card may help to reduce knowledge differences among residents. Faculty whose clinical practice includes children with acute pain should consider including learning or performance aids like the OUCH card in education and clinical care for its potential benefit in resident learning.

Assessing resident knowledge of acute pain management in hospitalized children: a pilot study.

This pilot study was undertaken to evaluate the hypotheses that there are differences in pediatric pain management (PPM) knowledge across resident specialties, that questions in the form of multiple-choice items could detect such differences, and that resident knowledge of analgesic-related adverse drug events (ADEs) would be greater than knowledge of PPM. Questions were based on two general categories of knowledge within acute pain management in hospitalized children: pediatric pain assessment and treatment, and identification of analgesic-related ADEs. As part of the pilot nature of this study, a convenience sample of 60 residents completed a 10-item PPM knowledge assessment prior to a PPM lecture. Twenty-six were pediatric residents (43%), 19 were orthopedic residents (32%), and 15 were anesthesiology residents (25%). All items had content validity. When controlling for resident year, performance by resident specialty was significantly different between anesthesia and orthopedics (P=0.006) and between anesthesia and pediatrics (P<0.001). Resident knowledge of analgesic-related ADEs was not greater than knowledge of PPM. The most difficult topics were opioid equianalgesia, assessment of the cognitively impaired child, and maximal acetaminophen doses. Repeated administration of the PPM knowledge assessment at multiple institutions will allow further evaluation of our initial findings, and with directed educational interventions, provide opportunity for measurement of improvement.

Sciatic neuropathy after lower-extremity trauma: successful treatment of an uncommon pain and disability syndrome in an adolescent.

Lower-extremity trauma is an uncommon but reported cause of sciatic nerve injury in children and adolescents. Failure to identify sciatic neuropathy after traumatic injury to the lower extremity may lead to the delayed institution of neuropathic pharmacotherapy, electrodiagnostic testing, physical therapy, and increased risk for the development of complex regional pain syndrome. This article presents a case of an adolescent male with neuropathic pain and weakness in the right lower extremity after traumatic injury. Spontaneous recovery of the injured nerve occurred with early institution of pharmacologic and physical therapies. Operative exploration and neurolysis were considered but were not ultimately necessary.