Effects of Gabapentin on Emergence Delirium in Pediatric Tonsillectomy/Adenoidectomy Patients: A Post-Hoc Analysis.

Emergence delirium (ED) is a significant source of both short- and long-term negative effects in the postoperative pediatric population, most notably following otolaryngology surgeries with an occurrence rate of 17.9%. Gabapentin, a gamma aminobutyric acid agonist, has been used for enhanced recovery in adult patients and for the purpose of decreasing ED in some pediatric patients undergoing strabismus surgery. This secondary analysis examined the effects of preoperative administration of gabapentin on the reduction of postoperative ED in pediatric patients between the ages of 3-18 undergoing elective tonsillectomy and adenoidectomy. The parent study randomized subjects to receive preoperative gabapentin vs placebo. Our chart review encompassed both objective and subjective measures to identify the incidence of ED. While we found no statistical significance between the treatment and control groups, there was a clinically significant reduction of ED behaviors in the gabapentin group. The limitations included nonstandardized intraoperative medication administration, small sample size, and the lack of a validated tool for documenting behaviors associated with ED in the immediate postoperative period. Based on the results of this analysis, further investigation is warranted into the potential benefit of gabapentin to reduce the incidence of postoperative ED in the pediatric patient.

Gabapentin Premedication to Reduce Postoperative Pain for Pediatric Tonsillectomy/Adenoidectomy: A Pilot Study.

PURPOSE: To examine the effects of preoperative gabapentin administration on postoperative pain in pediatric patients undergoing tonsillectomy/adenoidectomy (T/A) in a single ambulatory surgery location within a pediatric healthcare organization. DESIGN: This randomized, controlled pilot study enrolled patients age 3-18 years with American Society of Anesthesiologists (ASA) scores of I-II undergoing T/A. METHODS: Both gabapentin and placebo groups were given study medication preoperatively and received standard opiate regimens intraoperatively and postoperative pain instructions. Outcome measurements included: time to first analgesic medication in the postanesthesia care unit (PACU), mean acetaminophen, ibuprofen, and opiate doses in mg/kg. Additionally, we examined pain scores, medication use, and side effects reported by daily pain diaries completed by patients/families for 3 days postoperatively. FINDINGS: Forty-nine patients were included in final analysis (gabapentin n = 26, placebo n = 23). Demographic and clinical characteristics of both groups were similar; the majority (46 of 49) were under the age of 13. Both groups received opiates in PACU. Some patients in both groups received hydrocodone/acetaminophen postoperatively. There were no reported differences in side effects between groups. Gabapentin group reported less use of opiates, acetaminophen, and ibuprofen post-discharge. We identified small effect sizes for opiates and acetaminophen, and medium effect size for ibuprofen (80.1% gabapentin versus 100% placebo, RR 0.81 [95% CI 0.67-0.97]). Median pain scores were 4 on a scale of 10 for both groups for all 3 days of follow-up. Overall median satisfaction score was 9, with a mean difference of 0.35 (95% CI -0.78 - 1.37). Analysis of variance revealed no difference in pain scores or satisfaction per pain diaries between the groups in general and no difference in score trajectory. CONCLUSIONS: We were able to establish a rigorous process and feasibility to launch a larger, multi-center trial to examine this important issue. There remain few evidence-based options for acute pain relief in pediatric surgical populations besides opiates. Identifying opiate alternatives that are effective, cost efficient and safe are needed for pediatric tonsillectomy patients.

Facilitating Communication in a Pediatric Surgery Center: Implementation of an Interactive Communication Board.

BACKGROUND: Increasing linguistic diversity has important implications for providers serving limited English proficiency (LEP) populations. LEP patients have decreased understanding, increased risk for adverse events, and lower healthcare satisfaction. Limited interpreting methods affect nurses' ability to provide efficient, culturally competent care. OBJECTIVE: An interactive communication board was implemented to evaluate the perceived effectiveness of LEP patient communication and increase nurse satisfaction with communication in a pediatric ambulatory surgery center. METHODS: A pre-post survey design evaluated the implementation of an interactive communication board. After a 3-month implementation period, post-surveys assessed nurse satisfaction, perception of time required to interpret nursing tasks, and feasibility of the tool. RESULTS: Nurses reported a 64% increase (2.27 ± 0.88 pre; 3.57 ± 0.76 post; p = 0.0007) in satisfaction with the interpretation process and a 43% increase (2.07 ± 0.70 pre; 3.50 ± 0.76 post; p = 0.0001) in their self-perceived ability to communicate with LEP populations post-intervention. CONCLUSION: Communication boards and similar tools can improve nurse satisfaction and streamline the interpretation process in peri-operative periods. IMPLICATIONS FOR NURSING: Similar tools could be implemented in other healthcare settings to increase communication efficiency between nurses and LEP populations. Further projects must be conducted to evaluate the experience and efficacy of this tool from the patient/caregiver perspective.

Decreased Wait Time and Increased Satisfaction With Bedside Pancreatic Enzyme Dosing for the Inpatient Adolescent With Cystic Fibrosis: A Quality Improvement Project Comparing Enzyme Self-Administration to Nurse Administration.

For children with cystic fibrosis (CF), enzymes are essential with meals to absorb nutrients and ensure adequate growth. When hospitalized, CF patients typically rely on nurse-administered medications. Recently, a pediatric hospital unit began allowing adolescents with CF enzymes at the bedside. Postimplementation, a satisfaction questionnaire was administered to participating patients and nurses measuring patient and nurse satisfaction with access to bedside enzymes versus nurse administration and overall time for enzyme delivery. The survey utilized a 5-point Likert scale. The wait time for pancreatic enzymes decreased for self-administered enzymes when compared to those that were nurse administered. All (11/11) patients and 86% (12/14) of nurses preferred the self-administration of enzymes. Hospitalized pediatric CF patients and nurses had higher levels of satisfaction with enzyme self-administration. Immediate access to enzymes in room safes impact patient autonomy, reflecting home self-care practices. Decreases in wait times optimize nutritional growth and healing while hospitalized. As a result, a new limited scope policy allowing patient-administered enzymes is now in place in the pediatric inpatient CF unit.

Oral Chemotherapy: An Evidence-Based Practice Change for Safe Handling of Patient Waste.

BACKGROUND: Safe handling practices for patient waste have focused on patients receiving IV chemotherapy, but these practices do not address safe handling for patients receiving oral chemotherapy. OBJECTIVES: The aim of this article is to evaluate evidence and formulate best practice recommendations for handling and disposing waste from patients receiving oral chemotherapy. METHODS: A literature search established a framework for the project. For healthcare providers and staff, procedures were established to access biohazard supplies and to follow safe handling of patient waste post-oral chemotherapy administration. Supply cost utilization was evaluated pre- and postimplementation. Staff perceptions were assessed six months after project implementation. FINDINGS: The cost of supplies per patient day increased minimally. Staff self-reported use of biohazard precautions when handling patients' waste increased. The majority of staff reported that they had access to supplies and were knowledgeable regarding safe handling procedures six months after this practice change.

A Pancreatic Enzyme Medication Self-Management Initiative.

This is the seventh article in a new series about evidence-based practice (EBP) that builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step-published between 2009 and 2011 (to access the series, go to http://links.lww.com/AJN/A133). This follow-up series features exemplars illustrating the various strategies that can be used to implement EBP changes-one of the most challenging steps in the EBP process.

Behavioral Coping Plans: One Inter-Professional Team's Approach to Patient-Centered Care.

BACKGROUND: Surgical encounters for children with Autism Spectrum Disorder (ASD) are stressful to patients, families and health care providers. It is recognized that parents best anticipate needs of children with ASD. Including a family in the plan of care for the child is imperative. In response to the need for targeted, tailored care, an inter-professional surgical services team convened to determine best practices for addressing a behavioral and developmental plan for children with ASD in the surgical services arena. PURPOSE: This evidence based practice project was conducted to optimize best practices for perioperative staff in caring for children with ASD through a targeted, individualized plan of care for the autistic child and his or her family. METHODS: Psychosocial and medical care strategies were utilized to create a coping plan with standardized questions. The coping plan allowed for tailored interventions specific to each child's needs. CONCLUSION: Actively reducing the anxiety a child experiences in a current encounter is paramount to the success of future visits. The coping plan is a formalized summary aimed at helping healthcare providers give individualized care, thereby decreasing the anxiety of both the parent and child. The individualized plan outlines the needs of the patient and allows for the medical team to make adaptations to lessen the stressors a health care visit can present. Plans are shared with the medical team, documented, and updated in the electronic medical record for future encounters. Information captured includes: previous healthcare experiences, sensory sensitivities, communication methods, stressors and coping suggestions. Utilizing best practice, patients are able to receive individualized care to foster positive coping experiences within healthcare.