Palliative Care for Patients with Kidney Disease.

Interest in palliative care has increased in recent times, particularly in its multidisciplinary approach developed to meet the needs of patients with a life-threatening disease and their families. Although the modern concept of palliative simultaneous care postulates the adoption of these qualitative treatments early on during the life-threatening disease (and potentially just after the diagnosis), palliative care is still reserved for patients at the end of their life in most of the clinical realities, and thus is consequently mistaken for hospice care. Patients with acute or chronic kidney disease (CKD) usually experience poor quality of life and decreased survival expectancy and thus may benefit from palliative care. Palliative care requires close collaboration among multiple health care providers, patients, and their families to share the diagnosis, prognosis, realistic treatment goals, and treatment decisions. Several approaches, such as conservative management, extracorporeal, and peritoneal palliative dialysis, can be attempted to globally meet the needs of patients with kidney disease (e.g., physical, social, psychological, or spiritual needs). Particularly for frail patients, pharmacologic management or peritoneal dialysis may be more appropriate than extracorporeal treatment. Extracorporeal dialysis treatment may be disproportionate in these patients and associated with a high burden of symptoms correlated with this invasive procedure. For those patients undergoing extracorporeal dialysis, individualized goal setting and a broader concept of adequacy should be considered as the foundations of extracorporeal palliative dialysis. Interestingly, little evidence is available on palliative and end of life care for acute kidney injury (AKI) patients. In this review, the main variables influencing medical decision-making about palliative care in patients with kidney disease are described, as well as the different approaches that can fulfill the needs of patients with CKD and AKI.

STOP Pain Project-Opioid Response in Pediatric Cancer Patients and Gene Polymorphisms of Cytokine Pathways.

Moderate to severe cancer pain treatment in children is based on the use of weak and strong opioids. Pharmacogenetics play a central role in developing personalized pain therapies, as well as avoiding treatment failure and/or intolerable adverse drug reactions. This observational study aimed to investigate the association between IL-6, IL-8, and TNFα genetic single nucleotide polymorphisms (SNPs) and response to opioid therapy in a cohort of pediatric cancer patients. Pain intensity before treatment (PIt0) significantly differed according to IL-6 rs1800797 SNP, with a higher PI for A/G and G/G individuals (p = 0.017), who required a higher dose of opioids (p = 0.047). Moreover, compared to G/G subjects, heterozygous or homozygous individuals for the A allele of IL-6 rs1800797 SNP had a lower risk of having a PIt0 > 4. Dose24h and Dosetot were both higher in G/G individuals for TNFα rs1800629 (p = 0.010 and p = 0.031, respectively), while risk of having a PIt0 > 4 and a ∆VAS > 2 was higher for G/G subjects for IL-6 rs1800795 SNP compared to carriers of the C allele. No statistically significant association between genotypes and safety outcomes was found. Thus, IL-6 and TNFα SNPs could be potential markers of baseline pain intensity and opioid dose requirements in pediatric cancer patients.

An Exploratory Study on the Effectiveness of Virtual Reality Analgesia for Children and Adolescents with Kidney Diseases Undergoing Venipuncture.

The current study evaluated the effectiveness of VR analgesia among pediatric and adolescent patients with kidney disease undergoing venipuncture. Patients at an Italian Children's hospital (N = 82, age range 7-17 years) undergoing venipuncture were randomly assigned to a No VR group (non-medical conversation) vs. a Yes VR group (VR analgesia). After the procedure, patients gave 0-10 Verbal Numeric Pain Scale ratings. Compared with patients in the No VR Group, patients in the Yes VR group reported significantly lower "Pain intensity"(No VR mean = 2.74, SD = 2.76 vs. Yes VR mean = 1.56, SD = 1.83) and the VR group also rated "Pain unpleasantness" significantly lower than the No VR group (No VR mean = 2.41, SD = 0.94 vs. Yes VR mean = 1.17, SD = 1.80). Patients distracted with VR also reported having significantly more fun during the venipuncture procedure. No side effects emerged. In addition to reducing pain intensity, VR has the potential to make venipuncture a more fun and less unpleasant experience for children with CKD, as measured in the present study for the first time. Finally, in exploratory analyses, children aged 7-11 in the VR group reported 55% lower worst pain than control subjects in the same age range, whereas children aged 12 to 17 in the VR group only reported 35% lower worst pain than control subjects. Additional research and development using more immersive VR is recommended.

Doctors and Nurses' Knowledge and Attitudes Towards Pediatric Pain Management: An Exploratory Survey in a Children's Hospital.

Despite the existence of protocols for effective pain control, pediatric pain is still high, due to scarce knowledge of its treatment, especially regarding opioids. This study aimed to evaluate doctors and nurses' knowledge of pain treatment and the use of opioids in children, before and after the implementation of Law 38/2010, that represented an important step in guaranteeing patients' rights to gain access to appropriate services for pain control and palliative care in Italy and in establishing the obligation of specific training programs in this matter for health professionals. An ad hoc questionnaire was developed and administered before (investigation A) and after (investigation B) the issuance of the Law. In B both doctors and nurses showed a slight but significant increase in correct answers and a reduction in incorrect ones, mainly concerning the category Myths and Prejudices. In both investigations doctors and nurses showed adequate general knowledge, yet there were some gaps regarding the specific knowledge of opioid drugs. Most of the participants were not familiar with the Law and its provisions.Investigation B showed an improvement in health professionals' knowledge, perhaps due to a hospital environment that followed the provisions of Law 38/2010. Nevertheless, the establishment of training courses according to the Law is needed to improve the knowledge of opioids, as well as to dispel deeply rooted myths and prejudices on pediatric pain.

Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study.

Several studies have shown the efficacy of psychological interventions in reducing preoperative anxiety in children undergoing surgery. This study aims to investigate the effectiveness of a specific non-pharmacological technique, the relaxation-guided imagery, in reducing both preoperative anxiety and postoperative pain in a sample of 60 children (6-12 years old) undergoing minor surgery who were randomly assigned to the experimental group (N = 30) or the control group (N = 30). The first group received the relaxation-guided imagery, before the induction of general anesthesia; the second group received standard care. The levels of preoperative anxiety and postoperative pain were assessed using, respectively, the modified Yale Preoperative Anxiety Scale and the Face, Legs, Activity, Cry, and Consolability Scale. The results showed a statistically significant difference between groups, with less anxiety and less pain for children included in the experimental group (p < .001; p < .001).Conclusion: Results suggest that relaxation-guided imagery reduces preoperative anxiety and postoperative pain in children. Future studies should focus on developing protocols and studying the eventual reduction of administered drugs for anesthesia and pain. What is Known: • Literature suggests the usefulness of relaxation-guided imagery in reducing anxiety and pain in the perioperative period. • Stronger evidences are needed to support the application of relaxation-guided imagery as routine care in pediatric surgery. What is New: • To our knowledge, this is the first randomized study to investigate the efficacy of relaxation-guided imagery in reducing preoperative anxiety and postoperative pain within a single pediatric sample. • The present study provides stronger evidence in an area that is lacking in research.

The use of opioids in children receiving intrathecal baclofen therapy.

PURPOSE: We hypothesized that children on chronic intrathecal baclofen therapy (ITB) may require less analgesics for postoperative pain control and are at higher risk of developing opioid-induced respiratory depression postoperatively. The aims of this study are to review children on chronic intrathecal baclofen therapy receiving opioids after major surgery and to determine the incidence complications in this population. METHOD: We conducted a retrospective cohort study comparing 13 children on ITB, who underwent posterior spinal fusion surgery, to 17 children with spina bifida that received the same surgery. RESULTS: On postoperative day 0 (POD 0), four children (40%) had respiratory depression in the baclofen group compared to none in the control group. Desaturation was significantly more frequent in children in the ITB group compared to those of the control group on POD 0; oversedation was recorded in 8 (80%) children in the baclofen group vs. 3 (17.6%) in the control group. Desaturation, respiratory depression, and oversedation were significantly more frequent on POD 0 in children in the baclofen group compared with children in the control group. CONCLUSIONS: The findings of the current study suggest that children on chronic intrathecal baclofen therapy require lesser amounts of opioids for postoperative pain control and are at a greater risk of developing postoperative respiratory depression and excessive sedation compared to patients without baclofen therapy.

Opioid response in paediatric cancer patients and the Val158Met polymorphism of the human catechol-O-methyltransferase (COMT) gene: an Italian study on 87 cancer children and a systematic review.

BACKGROUND: Genetic polymorphisms in genes involved in pain modulation have been reported to be associated to opioid efficacy and safety in different clinical settings. METHODS: The association between COMT Val158Met polymorphism (rs4680) and the inter-individual differences in the response to opioid analgesic therapy was investigated in a cohort of 87 Italian paediatric patients receiving opioids for cancer pain (STOP Pain study). Furthermore, a systematic review of the association between opioid response in cancer patients and the COMT polymorphism was performed in accordance with the Cochrane Handbook and the Prisma Statement. RESULTS: In the 87 paediatric patients, pain intensity (total time needed to reach the lowest possible level) was significantly higher for G/G than A/G and A/A carriers (p-value = 0.042). In the 60 patients treated only with morphine, the mean of total dose to reach the same pain intensity was significantly higher for G/G than A/G and A/A carriers (p-value = 0.010). Systematic review identified five studies on adults, reporting that opioid dose (mg after 24 h of treatment from the first pain measurement) was higher for G/G compared to A/G and A/A carriers. CONCLUSIONS: Present research suggests that the A allele in COMT polymorphism could be a marker of opioid sensitivity in paediatric cancer patients (STOP Pain), as well as in adults (Systematic Review), indicating that the polymorphism impact could be not age-dependent in the cancer pain context. TRIAL REGISTRATION: Registration number: CRD42017057831 .

A Comparison of Nonpharmacologic Interventions on the Emotional State of Children in the Emergency Department.

OBJECTIVES: The majority of children and adolescents presenting to the emergency department are in pain and require painful procedures. This randomized study was to investigate the efficacy of 3 different nonpharmacologic interventions (clowns, dogs, and musicians) to reduce pain and analyze the perception of positive and negative affects after the presence of these activities in a short-stay observation unit (SSOU). METHODS: Participants were composed of 105 children (54 boys and 51 girls; aged 3-16 years) assigned randomly to an experimental group (N = 57) that was composed of patients who were present in the SSOU. They received one of the following nonpharmacologic interventions: clowns (n = 18), dogs (n = 24), or musicians (n = 15) or they were assigned to a control group (CG) (N = 48) that consists of the patients who were present in the SSOU without the presence of nonpharmacologic interventions. RESULTS: Differences among the groups did not emerge; in fact, the 3 interventions have a similar influence in a different way on a child's well-being. No significant main effect about pain emerged for both groups across age and sex. CONCLUSIONS: The presence of different nonpharmacologic interventions (clowns, dogs, and musicians) seemed to empower positive affect in children but did not influence the self-reported pain.

A systematic review of the risk factors for clinical response to opioids for all-age patients with cancer-related pain and presentation of the paediatric STOP pain study.

BACKGROUND: Inter-patient variability in response to opioids is well known but a comprehensive definition of its pathophysiological mechanism is still lacking and, more importantly, no studies have focused on children. The STOP Pain project aimed to evaluate the risk factors that contribute to clinical response and adverse drug reactions to opioids by means of a systematic review and a clinical investigation on paediatric oncological patients. METHODS: We conducted a systematic literature search in EMBASE and PubMed up to the 24th of November 2016 following Cochrane Handbook and PRISMA guidelines. Two independent reviewers screened titles and abstracts along with full-text papers; disagreements were resolved by discussion with two other independent reviewers. We used a data extraction form to provide details of the included studies, and conducted quality assessment using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. RESULTS: Young age, lung or gastrointestinal cancer, neuropathic or breakthrough pain and anxiety or sleep disturbance were associated to a worse response to opioid analgesia. No clear association was identified in literature regarding gender, ethnicity, weight, presence of metastases, biochemical or hematological factors. Studies in children were lacking. Between June 2011 and April 2014, the Italian STOP Pain project enrolled 87 paediatric cancer patients under treatment with opioids (morphine, codeine, oxycodone, fentanyl and tramadol). CONCLUSIONS: Future studies on cancer pain should be designed with consideration for the highlighted factors to enhance our understanding of opioid non-response and safety. Studies in children are mandatory. TRIAL REGISTRATION: CRD42017057740 .

Virtual Reality Analgesia During Venipuncture in Pediatric Patients With Onco-Hematological Diseases.

Background: Venipuncture is described by children as one of the most painful and frightening medical procedures. Objective: To evaluate the effectiveness of Virtual Reality (VR) as a distraction technique to help control pain in children and adolescents undergoing venipuncture. Methods: Using a within-subjects design, fifteen patients (mean age 10.92, SD = 2.64) suffering from oncological or hematological diseases received one venipuncture with "No VR" and one venipuncture with "Yes VR" on two separate days (treatment order randomized). "Time spent thinking about pain", "Pain Unpleasantness", "Worst pain" the quality of VR experience, fun during the venipuncture and nausea were measured. Results: During VR, patients reported significant reductions in "Time spent thinking about pain," "Pain unpleasantness," and "Worst pain". Patients also reported significantly more fun during VR, and reported a "Strong sense of going inside the computer-generated world" during VR. No side effects were reported. Conclusion: VR can be considered an effective distraction technique for children and adolescents' pain management during venipuncture. Moreover, VR may elicit positive emotions, more than traditional distraction techniques. This could help patients cope with venipuncture in a non-stressful manner. Additional research and development is needed.

Occupational exposure to nitrous oxide during procedural pain control in children: a comparison of different inhalation techniques and scavenging systems.

BACKGROUND: Nitrous oxide (N2 O 50% in oxygen) is commonly used for painful procedures in children. Potential negative health effects associated with chronic workplace exposure limit its use. Safe occupational N2 O exposure concentrations are below 25 ppm environmental concentration as a time-weighted average (TWA) and below 200 ppm as a short-time exposure level (STEL) of 15 min. AIM: The aim was to assess occupational exposure of staff during nitrous oxide administration to children using different inhalation delivery devices and scavenging systems. METHODS: Staff nitrous oxide exposure during use of a double face mask (DFM) with or without a demand valve (DV) was compared with a conventional single face mask (FM). We also compared exposure using the hospital central scavenging system with a portable evacuation system. N2 O concentrations, representing exposure values, were monitored within proximity to staff. Urine N2 O concentration was measured in staff administering the N2 O at the end of the procedural session. RESULTS: The mean and median values of TWA and STEL within the working area were lower than recommended values in the DFM (10.8, 11.6 ppm for TWA; 13.9, 11.0 ppm for STEL) and DFM-DV groups (2.3, 2.8 ppm for TWA; 4.4, 3.5 ppm for STEL) using the portable evacuation system. The N2 O urine exposure in DFM-DV group was lower than DFM group: a mean difference of 9.56 ppm (95% CI 2.65-16.46). Staff N2 O urinary concentrations were within safe biological limits in both the DFM and DFM-DV groups. High exposure concentrations to N2 O were recorded in all FM and FM-DV environmental and biological samples. CONCLUSIONS: The DFM system, with or without a DV, connected to a portable evacuation system during N2 O administration to children for painful procedures kept N2 O levels within the local environment below recommended limits.

Can presence of a dog reduce pain and distress in children during venipuncture?

The aim of this study was to investigate the effectiveness of animal-assisted intervention as distraction for reducing children's pain and distress before, during, and after standard blood collection procedure. Fifty children (ages 4-11 years) undergoing venipuncture were randomly assigned to the experimental group (EG; n = 25) or to the control group (CG; n = 25). The blood collection procedure was carried on the children in the EG arm in the presence of a dog, whereas no dog was present when venipuncture was conducted on children in CG. In both cases, parents accompanied the child in the procedure room. Distress experienced by the child was measured with the Amended Observation Scale of Behavioral Distress, while perceived pain was measured with a visual analog scale or the Wong Baker Scale (Faces Scale); levels of cortisol in blood also were analyzed. Parental anxiety during the procedure was measured with State Trait Anxiety Inventory. Children assigned to the EG group reacted with less distress than children in the CG arm. Furthermore, cortisol levels were lower in the EG group compared with the CG group. There were no significant differences in pain ratings and in the level of parental anxiety. It appears that the presence of dogs during blood draw procedures reduces distress in children.

Pain and anxiety management in minimally invasive repair of pectus excavatum.

The Nuss procedure for the correction of Pectus Excavatum (PE) is associated with intense postoperative pain. Our strategy to control early postoperative pain is to combine epidural with intravenous analgesia. Our aim was to analyse our pain control strategy by reviewing all the PE cases treated at our institution. Sixty consecutive patients, aged between 12 and 26 years old, received the PE operation at our institution from January, 2007 to September, 2010. The median age was 16 (12-27) with a male/female ratio of about 7/1. An epidural catheter was employed in all the cases, with 38 patients (63%) requiring additional drugs to control pain, which remained in place for 74 hours (72-96). The pain score was higher in male patients, but lower in those younger than 16 years old. Moreover, patients that consumed benzodiazepines had a significant decrease in cumulative opioid intake (P = 0.0408). Both gender and age had an impact on pain control, while we noticed a synergistic effect between opiates and tranquillizers.

Assessing pain in hospital in-patients: a cross-sectional study in Tuscany, Italy.

Guidelines Towards a Pain-Free Hospital, published in 2001 in Italy, determined an increasing spread of No-Pain Hospital Committees across the country and supported a more effective pain control in hospital. However, few hospitals adopted such protocols. To date, a thorough investigation on quality of pain management documentation is lacking. The present survey aimed to evaluate the quality of pain management documentation reported in medical and hospital discharge records. The study reviewed records of 2,459 patients discharged every Wednesday of November 2006 in 29 Tuscany hospitals. Among 2,459 patients, 51.5 % were males. Patients were aged between 0 and 90 years or above and were mostly (24.93 %) between 70 and 79 years; most of them (47.1 %) were hospitalized in Medicine ward. At hospital admission, less than half of examined records (40.3 %) reported pain-related items, and only 8.1 % reported how it was treated. During hospitalization, 39.6 % of the records reported the use of scales for measuring pain intensity and 49.7 % reported the pharmacological therapy. The present study highlights the lack of an exhaustive documentation of pain recording and management in the hospital setting. Therefore, healthcare providers should pay close attention to this relevant issue, and the quality of such documentation should be constantly monitored.

Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option?

BACKGROUND AND OBJECTIVES: A significant number of children undergo surgery experience high levels of anxiety in the presurgical period. The aim of this study is to investigate which intervention is more effective in reducing preoperative anxiety. METHODS/MATERIALS: The sample was composed of 75 subjects (aged 5-12 years) who had to undergo minor day surgery. Children were randomly assigned to: the Clowns group (N = 25) accompanied to the preoperative room by the clowns and by a parent; Premedication group (N = 25) premedicated with oral midazolam and accompanied to the preoperative room by one parent; or the Control group (N = 25) only accompanied by one parent. Anxiety in the preoperative period was measured by using the Modified Yale Preoperative Anxiety Scale (m-YPAS). Parental anxiety was measured by using the State-Trait Anxiety Inventory (STAI Y-1/Y-2). RESULTS: The Clown group was significantly less anxious during the induction of anesthesia compared with Premedication group and Control group. There were not any significant differences between Control group and Premedication group. There was an increased level of anxiety in the induction room in comparison with the waiting room: this difference was statistically significant for Control group and Premedication group, whereas it was not significant in Clown group. CONCLUSIONS: PPIA+clown intervention is more effective in reducing anxiety in children during the preoperative period than PPIA alone or PPIA+oral midazolam.

End-of-life decisions in pediatric intensive care. Recommendations of the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care (SARNePI).

End-of-life decisions represent one of the most complex and challenging issues in pediatric intensive care. These recommendations aim to offer Italian pediatric intensive care unit (PICU) teams a framework for the end-of-life decision-making process. The paper proposes a process based on the principle that the use of a diagnostic or therapeutic tool must comply with a 'criterion of proportionality'. Appropriately informed parents, as natural interpreters and advocates of the best interests of their child, can contribute in assessing the burdensomeness of the treatment and determining its proportionality. The decision to limit, withdraw or withhold life-sustaining treatments considered disproportionate represents a clinically and ethically correct choice. This decision should be made (a) collectively by PICU team and the other caregivers, (b) with the explicit involvement of parents, and (c) noting in the patient's clinical record the decisions taken and the reasons behind them. The withdrawing or withholding of life support can never entail the abandonment of the patient nor the withdrawal of any therapy aimed at treating any form of suffering. No action aimed at deliberately hastening the death of the patient is ever acceptable. These recommendations advocate a decision as far as possible shared by patient (whenever feasible), parents and caregivers. Ensuring that all involved are kept fully informed and that there is open and timely communication between them is the key to achieving this. It is the physician in charge of the patient's care and the head of the unit who bear the main responsibility for the final decision.

Interactive music as a treatment for pain and stress in children during venipuncture: a randomized prospective study.

OBJECTIVE: The experience of venipuncture is seen by children as one of the most fearful experiences during hospitalization. Children experience anxiety both before and during the procedure. Therefore, any intervention aiming to prevent or reduce distress should focus on the entire experience of the procedure, including waiting, actual preparation, and conclusion. This study was designed to determine whether the presence of musicians, who had attended specific training to work in medical settings, could reduce distress and pain in children undergoing blood tests. METHODS: Our sample population was composed of 108 unpremedicated children (4-13 years of age) undergoing blood tests. They were randomly assigned to a music group (n=54), in which the child underwent the procedure while interacting with the musicians in the presence of a parent or to a control group (n=54), in which only the parent provided support to the child during the procedure. The distress experienced by the child before, during and after the blood test was assessed with the Amended Form of the Observation Scale of Behavioral Distress, and pain experience with FACES scale (Wong Baker Scale) only after the venipuncture. RESULTS: Our results show that distress and pain intensity was significantly lower (p<.001; p<.05) in the music group compared with the control group before, during, and after blood sampling. CONCLUSIONS: This controlled study demonstrates that songs and music, performed by "professional" musicians, have a beneficial effect in reducing distress before, during, and after blood tests. This study shows, moreover, that the presence of musicians has a minor, but yet significant, effect on pain due to needle insertion.