Pain Medicine Milestones 2.0: a step into the future.

OBJECTIVE: To describe the process of revising the Pain Medicine Milestones 1.0 and implementing changes into the Pain Medicine Milestones 2.0 along with implications for pain medicine trainees. BACKGROUND: Competency-based medical education has been implemented in graduate medical education, including pain medicine. Milestones 1.0, introduced by the Accreditation Council for Graduate Medical Education (ACGME), has been used to assess learners in six competencies and respective sub-competencies. Recognizing areas for improvement in Milestones 1.0, the ACGME initiated the process of Milestones 2.0 and a working group was created to execute this task for pain medicine. The working group discussed revisions; consensus was sought when changes were introduced. Final milestones were agreed upon and made available for public comment prior to publication. RESULTS: Redundant sub-competencies were either merged or eliminated, reducing the number of sub-competencies. A maximum of three rows representing skill, knowledge, behavior and attitude were included for each sub-competency. Harmonized Milestones, aligning with other specialties in a predetermined ACGME framework, were adopted and modified to meet the needs of pain medicine. A supplemental guide was developed to assist educators in implementation of Milestones 2.0 and assessment of trainees. CONCLUSIONS: The intent of the Milestones 2.0 was to create an improved tool that is comprehensive, easier to utilize, and of increased value for pain medicine training programs. It is expected that implementation of Milestones 2.0 will streamline pain medicine trainee assessments by educators and prepare trainees for the future practice of pain medicine while serving to be the foundation of an iterative process to match the evolution of the specialty.

In-hospital and 90-day outcomes after total pancreatectomy with islet autotransplantation for pediatric chronic and acute recurrent pancreatitis.

Total pancreatectomy with islet autotransplantation (TPIAT) is used to treat debilitating chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) that has failed medical and endoscopic therapy. We performed a retrospective review of TPIAT patients at a free-standing children's hospital to evaluate perioperative outcomes. Twenty patients (median age 13, 65% female) underwent TPIAT (2015 through 2017). Of the 20 patients, 95% had CP and 1 patient (5%) had ARP alone. Seventy-five percent of the patients had a pancreatitis-associated genetic mutation; 40% had pancreas divisum. The median surgical time was 757 (IQR 657 to 835) minutes. Median islet equivalents per kg of body weight (IEQ/kg) were 6404 (IQR 5018 to 7554). At 90 days postoperatively vs preoperatively, significantly fewer patients were receiving parenteral nutrition (0% vs 25%, P = .006) and opioids (45% vs 75%, P = .01). Short Form 36-Item Health Survey (SF-36) physical health module scores and total scores improved (34.0 preoperatively vs 54.6 at 90 days, P = .008, and 47.1 vs 65.3, P = .007, respectively); SF-10 physical health scores also improved (13.4 vs 33.1, P = .02). Insulin requirement decreased from 0.5 unit/kg/day to 0.4 unit/kg/day between discharge and 90 days (P = .02). TPIAT is an effective option when debilitating disease persists despite maximal medical and endoscopic therapy. Opioid, parenteral nutrition, and exogenous insulin use can successfully be weaned within 90 days after TPIAT, with gains in health-related quality of life.

A guide to diagnoses, indications, and contraindications for interventions in pediatric chronic pain.

Although the painful conditions in children and young adults do not involve a broad spectrum of disorders, the treatment itself may pose a challenge. Taking care of psychosocial factors is equally important as taking care of physical aspects. Our simple suggestion is to start with basics and advance to more complex treatments if needed. Please review Figure 2 for suggested treatment algorithms.

Special considerations and recommendations for interventions for pediatric chronic pain.

In select cases, interventional pain management techniques can bean effective adjunct to the multidisciplinary care of pediatric patients with chronic pain. The secret to success stems in proper patient selection and in delineating clear goals and expectations­motivated patients do well. Comfort measures ranging from distraction through general anesthesia should be employed to alleviate anxiety and distress, and to provide optimal working conditions for the proceduralist. In the appropriate context, the occasion to provide interventional care can be a rewarding role for the anesthesiologist to play in chronic pediatric pain patient care.

How do pediatric urology fellows learn outside of direct patient care? A qualitative study.

BACKGROUND: A large proportion of time during pediatric urology fellowship training is focused on surgical skill development. While fellows begin their fellowship training with some knowledge of pediatric urology from residency, they rely on self-directed learning to expand their knowledge base. OBJECTIVE: To assess how pediatric urology fellows learn about their field outside of direct patient care experiences. Additionally, we were interested in how the pandemic affected fellows self-directed learning. METHODS: First and second year pediatric urology fellows at Accreditation Council of Graduate Medical Education (ACGME)-accredited programs were asked to participate in the study. Individual virtual interviews were conducted and transcribed. Each transcript was coded shortly after transcription. Constructivist grounded theory was used in the data collection and analysis. As interviews progressed, a constant comparative analysis was used iteratively to generate themes. RESULTS: A convenience sample of thirteen fellows from programs across the U.S. agreed to participate; eight were male and five were female. The following four themes emerged from the interviews: most learning in fellowship is self-directed, fellows are not the target audience for didactics, fellows have little independent study time, and there is a lack of organization and guidance for formal didactics (Summary Table). Additionally, we found that teleconferences were used for the majority of teaching after the start of the coronavirus pandemic. CONCLUSION: Fellows in pediatric urology programs are independent learners who understand the need for self-directed learning outside of the setting of formal didactics in fellowship. However, many lack appropriate time, guidance and/or mentorship to facilitate self-directed learning. We identified a need for more structure in pediatric urology fellowship clinical didactics. Videoconferencing software may enable the creation of a national pediatric urology fellowship curriculum.

Ultrasound-Guided Nerve Blocks in the Head and Neck for Chronic Pain Management: The Anatomy, Sonoanatomy, and Procedure.

BACKGROUND: Ultrasound guided nerve blocks have become a popular tool in the armamentarium for pain physicians because of its advantages over fluoroscopy by offering portable, radiation-free and real-time imaging. But ultrasound guided procedures require training and practice to gain the expertise. There is a scarcity of review articles describing ultrasound guided injections techniques for nerve blocks of the head and neck. OBJECTIVE: To elucidate the anatomy, sonoanatomy, indications, techniques, side effects and complications for the most frequently utilized nerve blocks of the head and neck in chronic pain management. STUDY DESIGN: Narrative review. SETTING: Academic medical center. METHODS: Literature review of publications in English language of the related topics using Medline (Ovid) search engine. RESULTS: Deep cervical plexus block, cervical sympathetic ganglion block, trigeminal nerve and pterygopalatine ganglion block at the pterygopalatine fossa, greater occipital nerve block, third occipital nerve and medial branch block, and cervical selective nerve root block are discussed in this paper. The review begins with in depth discussion about the anatomy of the target nerve, followed by reviewing the available literature on the indications for the procedures. Detailed description of the procedure techniques is also presented. The volume and selection of medications is also discussed if there is available research. The review will conclude with summary of side effects, complications and precautions. LIMITATION: We only review those nerve blocks of the head and neck that would benefit from ultrasound guided injections in chronic pain management. Other nerve blocks such as transnasal sphenopalatine ganglion block, the interscalene brachial plexus block, superficial and intermediate cervical plexus block, anterior suprascapular nerve block, superficial trigeminal nerve block are not discussed due to either that ultrasound guidance is not warranted or they are rarely utilized in chronic pain management. This paper is not a systematic review, thus it might not include all the available evidence. Many of the available evidence is case series and case reports. More randomized control studies are warranted in the future to validate these techniques. CONCLUSION: Ultrasound guided nerve blocks of the head and neck are useful techniques for pain physicians to learn.

Real-time assessment of perioperative behaviors in children and parents: development and validation of the perioperative adult child behavioral interaction scale.

BACKGROUND: Behavior in response to distressful events during outpatient pediatric surgery can contribute to postoperative maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, and attention seeking. Currently available perioperative behavioral assessment tools have limited utility in guiding interventions to ameliorate maladaptive behaviors because they cannot be used in real time, are only intended to be used during 1 phase of the experience (e.g., perioperative), or provide only a static assessment of the child (e.g., level of anxiety). A simple, reliable, real-time tool is needed to appropriately identify children and parents whose behaviors in response to distressful events at any point in the perioperative continuum could benefit from timely behavioral intervention. Our specific aims were to (1) refine the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to improve its reliability in identifying perioperative behaviors and (2) validate the refined PACBIS against several established instruments. METHODS: The PACBIS was used to assess the perioperative behaviors of 89 children aged 3 to 12 years presenting for adenotonsillectomy and their parents. Assessments using the PACBIS were made during perioperative events likely to prove distressing to children and/or parents (perioperative measurement of blood pressure, induction of anesthesia, and removal of the IV catheter before discharge). Static measurements of perioperative anxiety and behavioral compliance during anesthetic induction were made using the modified Yale Preoperative Anxiety Scale and the Induction Compliance Checklist (ICC). Each event was videotaped for later scoring using the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) and Observational Scale of Behavioral Distress (OSBD). Interrater reliability using linear weighted kappa (kappa(w)) and multiple validations using Spearman correlation coefficients were analyzed. RESULTS: The PACBIS demonstrated good to excellent interrater reliability, with kappa(w) ranging from 0.62 to 0.94. The Child Coping and Child Distress subscores of the PACBIS demonstrated strong concurrent correlations with the modified Yale Preoperative Anxiety Scale, ICC, CAMPIS-SF, and OSBD. The Parent Positive subscore of the PACBIS correlated strongly with the CAMPIS-SF and OSBD, whereas the Parent Negative subscore showed significant correlation with the ICC. The PACBIS has strong construct and predictive validities. CONCLUSIONS: The PACBIS is a simple, easy to use, real-time instrument to evaluate perioperative behaviors of both children and parents. It has good to excellent interrater reliability and strong concurrent validity against currently accepted scales. The PACBIS offers a means to identify maladaptive child or parental behaviors in real time, making it possible to intervene to modify such behaviors in a timely fashion.

Real-time assessment of perioperative behaviors and prediction of perioperative outcomes.

BACKGROUND AND AIMS: New onset maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, attention-seeking, and fear of being alone are common in children after outpatient surgery. Preoperative anxiety, fear and distress behaviors of children predict postoperative maladaptive behaviors as well as emergence delirium. Parental anxiety has also been found to influence children's preoperative anxiety. Currently, there is no real-time and feasible tool to effectively measure perioperative behaviors of children and parents. We developed a simple and real-time scale, the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to assess perioperative child and parent behaviors that might predict postoperative problematic behavior and emergence excitement. METHODS: We used the PACBIS to evaluate perioperative behaviors during anesthetic induction and recovery in a sample of 89 children undergoing tonsillectomies and adenoidectomies, and their parents. Preoperative anxiety with the modified Yale Preoperative Anxiety Scale, compliance with induction of anesthesia with Induction Compliance Checklist, and incidence of emergence excitement were also recorded. RESULTS: The PACBIS demonstrated good concurrent validity with modified Yale Preoperative Anxiety Scale and Induction Compliance Checklist and predicted postanesthetic emergence excitement. DISCUSSION: The PACBIS is the first real-time scoring instrument that evaluates children's and parents' perioperative behavior. The specific behaviors identified by the PACBIS might provide targets for interventions to improve perioperative experiences and postoperative outcomes.

An update on the safety of prescribing opioids in pediatrics.

INTRODUCTION: The opioid abuse epidemic and its toll on the adolescent population have heightened awareness for safer opioid prescribing practices in pediatric pain management. Opioids remain the mainstay of therapy for severe pain, although there is an emphasis on multimodal therapy. Areas covered: In this update, the authors present information on parenteral/oral opioids commonly used in pediatrics. Recommendations for opioid use in special circumstances including neonates and developmental pharmacokinetic concerns are discussed. Due to noticeable interindividual variability, pharmacogenomics may be important for tailoring pain regimens. In particular, the role of CYP2D6 phenotypes on opioid selection/dosing and clinical implications are discussed. A summary of adverse effects and opioid safety data, and the role of regulations, risk assessment, Centers for Disease Control and Prevention guidelines, follow-up, and monitoring for compliance in opioid prescribing, are detailed. Expert opinion: 'One size does not fit all' describes the need for public policies focused on pediatric pain and opioid use, as children are not 'little adults.' Clinical trials to evaluate pharmacokinetics-pharmacodynamics of opioids are currently lacking. Development of novel biased opioid agonists, clinical integration of genetics in informed decision-making, and emphasis on top-down approaches to pain management will be key to decrease opioid reliance.

The interplay of parent and adolescent catastrophizing and its impact on adolescents' pain, functioning, and pain behavior.

OBJECTIVES: Catastrophizing is a coping style linked to poorer patient outcomes. Little attention has focused on the parent-adolescent dyad and catastrophizing as a shared coping style. The purpose of this study was to: (1) examine the effects of adolescent and parent pain catastrophizing on adolescent functioning and (2) explore concordance in catastrophizing in parent-adolescent dyads, with equal interest in outcomes of dyads with discordant coping styles. METHODS: Pain intensity, catastrophizing, depressive symptoms, quality of life, and pain behaviors were assessed in adolescents (ages 11 to 17) presenting to a pediatric chronic pain clinic (N=240). RESULTS: Significant correlations between (1) parent and adolescent catastrophizing; (2) catastrophizing and pain behaviors; and (3) catastrophizing and adolescent outcomes were found. Parents and adolescents were classified into concordant or discordant dyads based on catastrophizing with a majority of dyads (>70%) showing concordant coping styles. Among discordant dyads, functional disability and depressive symptoms were significantly higher in a dyad with a high catastrophizing adolescent and low catastrophizing parent. DISCUSSION: Results provide further support for catastrophizing being a maladaptive coping strategy for adolescents with pain and their parents. Greater adolescent catastrophizing was related to increased pain behaviors and poorer adolescent functioning. Parent catastrophizing also seems related to poorer adolescent outcomes, and most parent-adolescent dyads showed concordance in use of catastrophizing, which may suggest a shared tendency for adaptive or maladaptive styles of coping with pain. Future research should investigate pain coping at a dyadic or family level to explore how family coping styles magnify distress and disability or buffer adolescents from such problems.

Comparison of postoperative analgesia with epidural butorphanol/bupivacaine versus fentanyl/bupivacaine following pediatric urological procedures.

BACKGROUND: The aim of this retrospective study is to compare safety and efficacy of postoperative epidural butorphanol/bupivacaine with the gold-standard epidural analgesic infusion fentanyl/bupivacaine in children. METHODS: With the Institutional Review Board's approval, the authors searched their Pain Management Database and divided children who received epidural analgesia into two groups. Each butorphanol group subject was matched with two fentanyl group subjects. Demographic data, pain scores, epidural interventions, epidural side effects, use of rescue opioid analgesia and adjuvant analgesics, causes of epidural failure, time of first oral intake and ambulation, and length of stay were statistically compared. RESULTS: A total of 191 patients were identified between 2000 and 2007; 58 in epidural butorphanol/bupivacaine and 133 in fentanyl/bupivacaine groups. Demographic data were comparable between the groups. The number of children with good pain control on postoperative days 1 and 2 in butorphanol (84 and 82 percent) and fentanyl (93 and 91 percent) groups were statistically similar (p = 0.06 and 0.13, respectively). Incidences of epidural side effects, especially pruritus, were significantly higher in the fentanyl group. Significantly more children in the butorphanol group required epidural rate changes when compared with those in the fentanyl group. Incidence of failed epidurals was significantly higher in the fentanyl group when compared with that in the butorphanol group. Clinically significant respiratory depression occurred in two children in the fentanyl group and in none of the children in the butorphanol group (p > 0.99). CONCLUSIONS: Epidural butorphanol provided similar analgesia to epidural fentanyl after urological procedures in children, but butorphanol caused less pruritus than fentanyl. IMPLICATION STATEMENT: Epidural analgesia with butorphanol/bupivacaine is effective in children undergoing urological procedures. When compared with epidural fentanyl, epidural butorphanol causes significantly less itching.