"Persistent Post-Operative Pain in Children - An Argument for a Transitional Pain Service in Pediatrics".

BACKGROUND: Persistent post-operative pain continues to occur in pediatric patients. Despite the growing amount of literature on causes, there is little discussion on treatment and prevention with a majority of studies focusing on specific surgeries. AIM: The aim of this retrospective chart study is to identify risk factors and clinical features of persistent post-operative pain after any surgery in a pediatric quaternary complex pain service, describe the pharmacologic and non-pharmacologic management in children, and explore options to improve outcomes, in particular, the introduction of a transitional pain service. METHODS: A retrospective chart review recorded demographics, gender, age, pain location and surgery type, treatment, and outcomes of 31 children identified through relevant registers over a 2-year period. RESULTS: A total of 31 children were positively identified as having persistent post-operative pain and were seen in the complex pain clinic. Consistent with the literature, most cases represented neuropathic pain and persistent post-operative pain was most commonly seen after orthopedic surgery. All but four children had resolution of their pain after implementing the pain management plan. Management was characterized by early intervention, emphasis on non-pharmacologic strategies, and conservative use of opioids. CONCLUSIONS: Identifying risk factors is useful, however putting strategies into place for prevention is necessary. Early intervention and the implementation of strategies before and immediately after are best provided by a transitional pain service.

Complex Pain in Young Children.

Objective: Early childhood is a time of rapid development, particularly of the central nervous system, and can set a foundation for the entire life course. Complex pain in young children can impact the quality of life through limiting physical and social development, compromising psychological well-being, and disrupting sleep. The aim of this review is to identify the needs of young children who present to a tertiary-level pain service, what services they require, and their treatment outcomes. There are limited data on this vulnerable population, which may be due to small numbers represented and the complexities of pain assessment in this age group. Methods: A retrospective chart review recorded demographics, gender, pain location and etiology, treatment, and outcomes of 28 children younger than age eight years attending a pediatric pain clinic over a three-year period. Results: All but two young children had an obvious physical pathology as an explanation for pain; this is in contrast to studies of pain clinics servicing adolescents. A diverse range of conditions, some rare, were identified, requiring a high level of pediatric understanding of the disease process and an ability to work with primary teams with expertise in disease-modifying strategies.

The Management of Complex Pain in Children Referred to a Pain Clinic at a Tertiary Children's Hospital in Australia.

Synopsis One of the key aspects of good health care for children and young people is the prevention and management of pain. The experience of persistent pain in children and adolescents not only has a major impact on physical, emotional, social, and developmental well-being, but also impacts the broader world, which includes family, school, and social networks. The multidisciplinary pediatric pain clinic adopts a holistic approach to care through a biopsychosocial model. One outcome of an initial pediatric pain clinic review is the creation of a pain management plan that addresses the pharmacological, physical, psychological, and other domains of care. Pediatric pain clinics are improving access by embracing technology through tele-health and internet-based treatment options. Outcome measurement will guide the development of models of care in the future. J Orthop Sports Phys Ther 2017;47(10):806-813. Epub 12 Sep 2017. doi:10.2519/jospt.2017.7355.

Profile of children with developmental disabilities attending a complex pain clinic of a children's hospital in Australia.

AIM: To document the profile and management of children with developmental disabilities (DD) attending an outpatient complex pain clinic at a Children's Hospital in Sydney, Australia. METHODS: Children with DD from 2011 to 2014 were identified from a clinic database, and pain relevant data was collected. RESULTS: A total of 107 (19.6%) of 544 children were identified with DD, and accounted for one-third of clinic attendances. The median age was 14 years (interquartile range: 11-16) and females were slightly over-represented (62, 57.9%). About one-third of children had cerebral palsy (CP) from a variety of prenatal, natal and post-neonatal causes. The lower limb was the most common site for pain in children with CP, while back pain was more frequent in children with other disabilities. Comorbid emotional disorders were significantly associated with the non-CP disabilities. Children who required more than four clinic attendances were more likely to have comorbid anxiety/depression and to be reviewed by multiple specialists. CONCLUSIONS: Long-term persistent pain in children with DD forms a significant cohort of children requiring tertiary level paediatric pain services. Multisystem comorbidities and emotional disorders predict greater service utilisation. Further research into the effectiveness of multidisciplinary pain teams and interventions in this cohort of children is required.

Providers and consumers support the Western Australian Audit of Surgical Mortality.

BACKGROUND: The Western Australian Audit of Surgical Mortality (WAASM) was established in June 2001 to independently peer-review all surgical deaths in Western Australia. The objectives of this study were (i) to evaluate whether participation in the WAASM has influenced clinical and hospital practice; and (ii) to ascertain the support and relevance of the WAASM to surgeons, hospitals and consumers. METHODS: Three qualitative questionnaires were designed to evaluate the response of surgeons, hospital administrators and consumers to the WAASM. The outcomes measured included audit participation, value and use of feedback provided, changes to clinical and hospital practice and the future role of the WAASM. RESULTS: The key findings were that 138 (73%) of 190 surgeons participating in the WAASM had changed their clinical practice in at least one way, 44 (24%) were aware of changes in hospital practice and 21 (11%) were aware of changes in a colleague's practice. Particular areas where changes in surgical practice had occurred included attention to deep vein thrombosis prophylaxis (81, 44%), increased constructive discussion among peers (78, 42%) and quality of documentation in case notes (68, 37%). All groups supported the continuation of the WAASM. Hospital executives and consumers recommended that the WAASM be included in accreditation. CONCLUSION: Surgeons, hospitals and consumers supported the concept of independent peer review of surgical care. They confirmed the ability of audit to influence and change surgical and hospital practice. It strengthens the intention of the Royal Australasian College of Surgeons to extend the WAASM project throughout Australia and New Zealand.

The Western Australian Audit of Surgical Mortality: advancing surgical accountability.

OBJECTIVE: To describe the peer review process of the Western Australian Audit of Surgical Mortality (WAASM), selected outcomes and recommendations. STUDY DESIGN: Prospective audit using peer review of all cases of patients who died while under the care of a Western Australian surgeon between 1 January 2002 and 30 June 2004. Audit reviews were current to 30 September 2004. PARTICIPANTS AND SETTING: 194 of 202 surgeons participated after a patient died under their care. MAIN OUTCOME MEASURES: Surgeon participation, deficiencies of care, deep vein thrombosis (DVT) prophylaxis, futile surgery, postmortem reviews, proportion of operations performed by consultant surgeons. RESULTS: The audit process was complete for 896 of 1647 reported deaths (54%), while a further 503 (31%) were still under review at 30 September 2004. Twenty deaths associated with terminal care were excluded from analysis. Median patient age was 80 years, and 799 of the 876 patients who died (91%) had significant comorbidities that increased the risk of death. Deficiencies of care were reported in 179/876 (20%). In 45/876 deaths (5%) the deficiency of care was assessed to have caused the death, and 15 deaths were considered preventable. The risk of a deficiency of care was 1.9 times higher in elective admissions than emergency admissions. Autopsy was undertaken in 83/768 (11%) deaths with complete data. Changes in practice were noted in some areas targeted by WAASM, such as improved DVT prophylaxis. A problem with fluid management was recorded. CONCLUSION: Most patients who died were elderly, had complex comorbidities and were treated appropriately. The WAASM has helped to change surgical practice and emphasises the importance of ongoing systematic audit. The participation of surgeons demonstrates their commitment to accountability and supports the intention of the Royal Australasian College of Surgeons to extend the process throughout Australia and New Zealand.