Epidemiology and management of painful procedures in children in Canadian hospitals.

BACKGROUND: Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management. METHODS: We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ(2)) analyses. RESULTS: Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered. INTERPRETATION: For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.

Evidence-based approach to manage persistent wound-related pain.

PURPOSE OF REVIEW: Pain is a significant concern in people with chronic wounds. A systematized approach is recommended for the management of wound-associated pain with the objectives to address pain relief, increase function, and restore overall quality of life. RECENT FINDINGS: Combinations of pharmacological agents are often recommended based on varying degree of pain severity, coexisting nociceptive and neuropathic pain, and chronic inflammation related to wound-associated pain. Topical agents including morphine, tricyclic antidepressants (e.g., amitriptyline), nonsteroidal anti-inflammatory drugs (NSAIDs), capsaicin, ketamine, and lidocaine/prilocaine provide pain relief with minimal side effects. Mindful dressing selection to minimize trauma, handle excess fluid, and prevent periwound skin damage has been shown to reduce persistent wound pain. To avoid nocebo hyperalgesia, it is important to address emotions, anticipation or negative expectation of discomfort. SUMMARY: Pain is a complex biopsychosocial phenomenon that requires multiple pharmacological and nonpharmacological management approach.

Health care professionals' pain narratives in hospitalized children's medical records. Part 1: pain descriptors.

BACKGROUND: Although documentation of children's pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children. OBJECTIVES: To describe health care professionals' use of written language related to the quality and quantity of pain experienced by hospitalized children. METHODS: Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used. RESULTS: Pain narratives were documented a total of 5390 times in 1518 of the 3822 children's medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (e.g., vocal, motor, facial and activities cues), affective and physiological cues, and children's descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers. CONCLUSIONS: The richness and complexity of vocabulary used by clinicians to document children's pain lend support to the concept that the word 'pain' is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children's pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.

Pain assessment and intensity in hospitalized children in Canada.

UNLABELLED: Numerous acute pediatric pain assessment measures exist; however, pain assessment is not consistently performed in hospitalized children. The objective of this study was to determine the nature and frequency of acute pain assessment in Canadian pediatric hospitals and factors influencing it. Pain assessment practices and pain intensity scores documented during a 24-hour period were collected from 3,822 children aged 0 to 18 years hospitalized on 32 inpatient units in 8 Canadian pediatric hospitals. Pain assessment was documented at least once within the 24 hours for 2,615/3,822 (68.4%) children; 1,097 (28.7%) with a pain measure alone, 1,006 (26.3%) using pain narratives alone, and 512 (13.4%) with both a measure and narrative. Twenty-eight percent of assessments were conducted with validated measures. The mean standardized pain intensity score was 2.6/10 (SD 2.8); however, 33% of the children had either moderate (4-6/10) or severe (7-10/10) pain intensity recorded. Children who were older, ventilated, or hospitalized in surgical units were more likely to have a pain assessment score documented. Considerable variability in the nature and frequency of documented pain assessment in Canadian pediatric hospitals was found. These inconsistent practices and significant pain intensity in one-third of children warrant further research and practice change. PERSPECTIVE: This article presents current pediatric pain assessment practices and data on pain intensity in children in Canadian pediatric hospitals. These results highlight the variability in pain assessment practices and the prevalence of significant pain in hospitalized children, highlighting the need to effectively manage pain in this population.