Triage Decision-Making in Interdisciplinary Pediatric Chronic Pain Programs.

BACKGROUND: Interdisciplinary pediatric chronic pain programs are ideal treatment settings for youth with chronic pain who are complex from a biopsychosocial perspective. There is currently no evidence-based clinical decision support to guide nurses triaging patients to such programs, which increases the risk for haphazard triage decisions. AIMS: To explore and describe the decision-making practices of and contextual influences on nurses triaging patients to interdisciplinary pediatric chronic pain programs. DESIGN: A qualitative exploratory descriptive design. SETTINGS: Interdisciplinary Pediatric Chronic Pain Programs. PARTICIPANTS/SUBJECTS: In all, 12 nurses across 11 different interdisciplinary pediatric chronic pain programs participated in this study. METHODS: Individual, semi-structured interviews were conducted, transcribed verbatim, and analyzed using concurrent content analysis, guided by the Cognitive Continuum Theory and the Theoretical Domains Framework. RESULTS: Findings focused on the complexity of the pediatric chronic pain population and the leading role nurses play in triage without evidence-based guidance. Analysis generated three prominent themes: (1) nurse-led triage determinants; (2) process of triage decision-making; and (3) external influences on triage decision-making. CONCLUSIONS: Triage decision making in the setting of interdisciplinary pediatric chronic pain programs is complex and often led by nurses. There is a desire amongst nurses to adopt an evidence-based clinical decision support triage tool (CDS), which may streamline the referral and triage process and foster a system whereby patients in highest need for interdisciplinary care are best prioritized.

A systematic review of the biopsychosocial dimensions affected by chronic pain in children and adolescents: identifying reliable and valid pediatric multidimensional chronic pain assessment tools.

Pediatric chronic pain is a complex experience that is often challenging to describe and measure. Multidimensional tools that evaluate the biopsychosocial impact of chronic pain in pediatric patients can help clinicians to prioritize and tailor interdisciplinary pain care; yet, the psychometric value and clinical utility of such tools has not yet been systematically studied in the literature. The purpose of this review was to identify multidimensional biopsychosocial tools used in pediatric chronic pain, synthesize their reliability and validity evidence, and draw on this evidence to describe the relationships between chronic pain and biopsychosocial domains. The search involved 2 phases to (1) identify eligible tools and (2) conduct a measured forward citation search of tool development articles. Tool eligibility was guided by the Multidimensional Biobehavioral Model of Pediatric Pain and study eligibility was focused on primary chronic pain diagnoses unrelated to disease. Data extraction was focused on reliability and validity evidence of eligible tools, guided by the Standards for Educational and Psychological Testing. Results yielded 6 tools that included 64 eligible studies, highlighting 84 significant relationships between pain and functional interference across 11 biopsychosocial variables. All tools were shown to have good internal consistency and evidence of validity, primarily through relationships to other variables. Of the 6 tools, the most brief and easy to use were the most under studied. Further psychometric research is warranted for these tools to investigate their clinical utility and psychometric properties in guiding and prioritizing pain care for children and adolescents.

Virtual psychoeducation for improvement of pain catastrophizing in pediatric presurgical patients and caregivers: a proof-of-concept study.

PURPOSE: Pain catastrophizing (PC) is the tendency to magnify the threat value of pain sensations and is associated with greater postsurgical pain intensity, functional disability, and pain chronicity. Higher parental PC predicts higher chronic postsurgical pain in youth. Treating PC in caregivers and youth prior to surgery may improve recovery and surgical outcomes. We developed and evaluated a psychoeducational workshop addressing PC for presurgical youth and their parents/caregivers. We hypothesized that parent/caregiver and youth PC scores would decrease over time. We also explored preintervention levels of youth anxiety and depression as moderators of outcome. METHODS: Youth (n = 43) and caregivers (n = 41) attended a virtual, group-based single-session intervention (SSI). Single-session intervention content addressed pain neuroscience, PC, and adaptive coping strategies for managing pain and PC drawn from cognitive-behavioural, acceptance and commitment, and dialectical behaviour therapy approaches. Participants completed questionnaires assessing PC at preintervention, postintervention, and two weeks postsurgery. Youth mood and anxiety were assessed at preintervention. RESULTS: Caregiver PC scores decreased from pre- to postintervention (P = 0.006), and this was maintained at postsurgery (P = 0.002). Youth PC scores decreased from preintervention to postsurgery, but only for those with higher preintervention anxiety (P = 0.01). CONCLUSION: Our results provide proof-of-concept support for a virtual SSI targeting caregivers and youth PC during the perioperative period. The present findings highlight the possible need to screen presurgical candidates for symptoms of anxiety. Replication with larger and more diverse samples, and a more robust design are warranted.

RéSUMé: OBJECTIF: Le terme de dramatisation de la douleur décrit la tendance à amplifier la valeur de menace des sensations de douleur et est associée à une plus grande intensité de la douleur postopératoire, à une incapacité fonctionnelle et à une chronicité de la douleur. Une dramatisation parentale plus élevée de la douleur prédit une douleur postopératoire chronique plus élevée chez les jeunes. Le traitement de la dramatisation de la douleur chez les soignant·es et les jeunes avant la chirurgie peut améliorer le rétablissement et les devenirs chirurgicaux. Nous avons mis au point et évalué un atelier psychoéducatif sur la dramatisation de la douleur destiné aux jeunes en période préchirurgicale et à leurs parents/soignant·es. Nous avons émis l'hypothèse que les scores de dramatisation de la douleur des parents/soignant·es et des jeunes diminueraient avec le temps. Nous avons également exploré les niveaux d'anxiété et de dépression des jeunes avant l'intervention en tant qu'éléments modérateurs des résultats. MéTHODE: Des jeunes (n = 43) et les personnes en prenant soin (n = 41) ont participé à une seule intervention virtuelle en groupe. Le contenu de l'intervention unique portait sur les neurosciences de la douleur, la dramatisation de la douleur et les stratégies d'adaptation pour la prise en charge de la douleur et la dramatisation de la douleur tirées des approches cognitivo-comportementales, d'acceptation et d'engagement, et de thérapie comportementale dialectique. Les participant·es ont rempli des questionnaires évaluant la dramatisation de la douleur avant l'intervention, après l'intervention et deux semaines après la chirurgie. L'humeur et l'anxiété des jeunes ont été évaluées avant l'intervention. RéSULTATS: Les scores de dramatisation de la douleur des soignant·es ont diminué de la période précédant à la période suivant l'intervention (P = 0,006), et cela s'est maintenu après la chirurgie (P = 0,002). Les scores de dramatisation de la douleur des jeunes ont diminué de la période précédant l'intervention à la période postchirurgie, mais seulement chez les jeunes présentant une anxiété pré-intervention plus élevée (P = 0,01). CONCLUSION: Nos résultats appuient la preuve de concept pour une intervention virtuelle unique ciblant la dramatisation de la douleur chez les soignant·es et les jeunes en période périopératoire. Ces résultats soulignent la nécessité potentielle de dépister les symptômes d'anxiété chez les candidat·es avant la chirurgie. La réplication avec des échantillons plus grands et plus diversifiés et une conception plus robuste est justifiée.

Attaining expert consensus on diagnostic expectations of primary chronic pain diagnoses for patients referred to interdisciplinary pediatric chronic pain programs: A delphi study with pediatric chronic pain physicians and advanced practice nurses.

Objective: Pediatric primary chronic pain disorders come with diagnostic uncertainty, which may obscure diagnostic expectations for referring providers and the decision to accept or re-direct patients into interdisciplinary pediatric chronic pain programs based on diagnostic completeness. We aimed to attain expert consensus on diagnostic expectations for patients who are referred to interdisciplinary pediatric chronic pain programs with six common primary chronic pain diagnoses. Method: We conducted a modified Delphi study with pediatric chronic pain physicians, nurse practitioners and clinical nurse specialists to determine degree of importance on significant clinical indicators and diagnostic items relevant to each of the six primary chronic pain diagnoses. Items were identified through point of care databases and complimentary literature and were rated by participants on a 5-point Likert scale. Our consensus threshold was set at 70%. Results: Amongst 22 experts across 14 interdisciplinary programs in round one and 16 experts across 12 interdisciplinary programs in round two, consensus was reached on 84% of diagnostic items, where the highest degree of agreement was with Complex Regional Pain Syndrome (CRPS), Type 1 (100%) and the lowest with chronic pelvic pain (67%). Conclusion: This study demonstrated a general agreement amongst pediatric chronic pain experts regarding diagnostic expectations of patients referred to interdisciplinary chronic pain programs with primary chronic pain diagnoses. Study findings may help to clarify referral expectations and the decision to accept or re-direct patients into such programs based on diagnostic completeness while reducing the occurrence of unnecessary diagnostic tests and subsequent delays in accessing specialized care.

Partnering with Youth and Parents for the Greatest Impact of Top Patient-Oriented Priorities in Pediatric Chronic Pain Research, Care and Policy.

Our original patient-oriented research project identified the top 10 priorities for pediatric chronic pain research and care in Canada from the perspective of people with lived experience (patients), their family members and healthcare professionals through a modified James Lind Alliance Priority Setting Partnership. We undertook subsequent knowledge translation activities with youth, families, healthcare professionals, decision makers and researchers to (1) generate awareness and interest in the top 10 priorities and our partnership process, (2) facilitate collaborative dialogue and open innovation and (3) integrate and adopt the top 10 priorities into stakeholder activities. This paper describes our knowledge translation activities, outcomes and impact.

Experiences of Pediatric Pain Professionals Providing Care during the COVID-19 Pandemic: A Qualitative Study.

Chronic pain affects 1 in 5 youth, many of whom manage their pain using a biopsychosocial approach. The COVID-19 pandemic has impacted the way that healthcare is delivered. As part of a larger program of research, this study aimed to understand the impact of the pandemic on pediatric chronic pain care delivery including impact on patients' outcomes, from the perspective of pediatric healthcare providers. A qualitative descriptive study design was used and 21 healthcare providers from various professional roles, clinical settings, and geographic locations across Canada were interviewed. Using a reflexive thematic analysis approach 3 themes were developed: (1) duality of pandemic impact on youth with chronic pain (i.e., how the pandemic influenced self-management while also exacerbating existing socioeconomic inequalities); (2) changes to the healthcare system and clinical practices (i.e., triaging and access to care); (3) shift to virtual care (i.e., role of institutions and hybrid models of care). These findings outline provider perspectives on the positive and negative impacts of the pandemic on youth with chronic pain and highlight the role of socioeconomic status and access to care in relation to chronic pain management during the pandemic in a high-income country with a publicly funded healthcare system.

Dyadic analysis of adolescent friendships behaviours during pain: Comparison of those with chronic pain versus those without chronic pain.

BACKGROUND: Social context has been found to influence pain intensity and tolerance. The aims of this study were to determine the impact of one type of social context on the painful experiences of adolescents with and without chronic pain by examining interactions within and across friendship dyads during experimental pain. METHODS: Each adolescent in 61 same-sex friendship dyads (30 dyads with a chronic pain member) across three sites participated in the cold pressor task and acted as the observer during their friend's participation. They also completed a battery of measures to capture friendship features and pain outcomes. Pain intensity was measured using an 11-point numeric scale. Pain tolerance was measured by the length of time in the cold pressor device. Videotapes of their interactions were coded for verbal and non-verbal behaviours. A series of Actor Partner Independence Modelling, Hierarchical Multiple Regression and Multivariate Analysis of Covariance was used to analyse the data. RESULTS: Friendship features were not associated with pain intensity or tolerance. Both members of dyads with a chronic pain member used fewer non-attending behaviours when they were observing their friend resulting in participants in those dyads having lower pain tolerance. Moreover, within dyads, one's friend's behaviours when experiencing pain influenced pain tolerance but only for those dyads with a chronic pain member. CONCLUSIONS: Strategies aimed at improving social interactions for adolescents with chronic pain while they are experiencing pain are discussed. Research is needed to understand how different peer relationships influence pain tolerance in adolescents with chronic pain. SIGNIFICANCE OF THE RESEARCH: During pain, patterns of interactions differ within and between adolescent friendship dyads when one has chronic pain (CP) versus controls. Dyads with a CP member use fewer non-attending behaviours despite non-attending behaviours rated as more helpful. Pain intensity was solely related to the participant's behaviour. Amongst dyads with a CP member, pain tolerance was also influenced by their friend's behaviours. Friends of adolescents with pain engage in more unhelpful behaviours perhaps decreasing the ability of CP adolescents to engage in social activities.

Canadian surveillance study of complex regional pain syndrome in children.

ABSTRACT: This study describes the minimum incidence of pediatric complex regional pain syndrome (CRPS), clinical features, and treatments recommended by pediatricians and pain clinics in Canada. Participants in the Canadian Paediatric Surveillance Program reported new cases of CRPS aged 2 to 18 years monthly and completed a detailed case reporting questionnaire from September 2017 to August 2019. Descriptive analysis was completed, and the annual incidence of CRPS by sex and age groupings was estimated. A total of 198 cases were reported to the Canadian Paediatric Surveillance Program, and 168 (84.8%) met the case definition. The minimum Canadian incidence of CRPS is estimated at 1.14/100,000 (95% confidence interval 0.93-1.35/100,000) children per year. Incidence was highest among girls 12 years and older (3.10, 95% confidence interval 2.76-3.44/100,000). The mean age of CRPS diagnosis was 12.2 years (SD = 2.4), with the mean time from symptom onset to diagnosis of 5.6 months (SD = 9.9) and no known inciting event for 19.6% of cases. Most cases had lower limb involvement (79.8%). Nonsteroidal anti-inflammatory drugs (82.7%) and acetaminophen (66.0%) were prescribed more commonly than antiepileptic drugs (52.3%) and antidepressants (32.0%). Referrals most commonly included physical therapy (83.3%) and multidisciplinary pain clinics (72.6%); a small number of patients withdrew from treatment because of pain exacerbation (5.3%). Pain education was recommended for only 65.6% of cases. Treatment variability highlights the need for empiric data to support treatment of pediatric CRPS and development of treatment consensus guidelines.

Are They Still Friends? Friendship Stability of Adolescents With Chronic Pain: 1-Year Follow-Up.

Most adolescents identify their best friend as their main source of social support. Adolescents with chronic pain (ACP) report the loss of friendships due to pain. Friendships protect against loneliness and depression, yet adolescents with pain experience increased levels of loneliness and depression compared to peers. This longitudinal study examines the friendship stability of dyads that included an adolescent with chronic pain compared to non-pain friendship dyads as well as the factors contributing to a friendship breakup. Eighty-three participants from 61 same-sex friendship dyads across 3 sites participated in a 1-year follow-up survey designed to capture friendship features, indices of social-emotional well-being, pain characteristics, and friendship stability. Chi-square, repeated measures ANOVA, and logistic regression were used to analyze the data. Dyads that included an ACP experienced higher rates of friendship breakup. The shorter length of friendship and having chronic pain predicted a friendship breakup at time 2. ACP continues to experience worse scores on indices of social-emotional well-being that are not predicted with a friendship breakup. Understanding what contributes to positive long-term friendships for those with pain may inform strategies to maintain and improve friendships for those with pain and who experience social challenges.

Partnering For Pain: a Priority Setting Partnership to identify patient-oriented research priorities for pediatric chronic pain in Canada.

BACKGROUND: Chronic pain affects 1-3 million Canadian children and adolescents and their families. The primary objective of the Partnering For Pain project was to collaboratively identify the top 10 research priorities in pediatric chronic pain. METHODS: Partnering For Pain took a patient-oriented research approach and followed a modified James Lind Alliance Priority Setting Partnership (PSP) to identify the top research priorities in pediatric chronic pain according to people with lived experience (patients), family members and health care providers (clinicians). The PSP was completed in 4 phases between May and December 2018: 1) national survey of stakeholders, including those with lived experience with pediatric chronic pain, family members and clinicians who treat children with chronic pain, to gather priorities, 2) data processing, 3) interim prioritization by invited patients, family members and clinicians (former research participants or identified through pediatric chronic pain programs, patient partner organizations and steering committee member networks) and 4) in-person priority-setting workshop involving patients, family members and clinicians identified via steering committee networks and partner organizations, with evaluation of patient engagement. The process was led by a national steering committee of patient and parent partners, researchers and clinicians engaged in codesign, analysis and translation of project findings. RESULTS: In phase 1, 215 Canadians (86 patients [40.0%], 56 family members [26.0%] and 73 clinicians [34.0%]) submitted 540 potential priorities that were developed into 112 unique research questions (phase 2). Of the 112 questions, 63 were rated for importance by 57 participants (19 patients [33%], 17 family members [30%] and 21 clinicians [37%]) in phase 3. In phase 4, 20 participants (6 patients [30%], 6 family members [30%] and 8 clinicians [40%]) discussed the 25 most highly rated questions and reached consensus on the final top 10. INTERPRETATION: The final priorities address pediatric chronic pain prevention, impact and treatment, as well as delivery, access and coordination of care. The priorities reflect a directed and collaborative call to action to improve existing pediatric pain research and care. PLAIN LANGUAGE SUMMARY: Chronic pain affects 1 in 5 children and teens. This means that 1-3 million Canadian youth deal with pain lasting months to years. This pain gets in the way of being active, sleeping, going to school, and getting along with friends and family. Youth with chronic pain and their families are experts on what it's like to live with pain, but, until now, research has not asked what issues they care about most. The goal of the Partnering For Pain project was to develop a list of the 10 most important things we still need to learn about chronic pain during childhood according to people who live with it, their families and health care providers. We did this in 4 steps: 1) a survey with 215 people who shared 540 concerns they have about chronic pain in childhood, 2) turning those concerns into questions that can be answered by research, 3) a survey with 57 people who ranked how important each research question was and 4) an in-person discussion with 20 people who chose the top 10 research priorities. Each step included Canadians who have had chronic pain during childhood, their families and health care providers. The final top 10 list has questions about how to better prevent and care for children and teens with chronic pain. These priorities make sure that future research focuses on what is most important to people who will use it in their everyday lives. Project video: https://youtu.be/wA-RwrFiSPk. Project website: www.partneringforpain.com.

Sensitivity, specificity, and reliability of the Get Active Questionnaire for identifying children with medically necessary special considerations for physical activity.

Physical activity is promoted for optimal health but may carry risks for children who require medically necessary activity restrictions. The sensitivity, specificity, and reliability of the Get Active Questionnaire (GAQ) for identifying children needing special considerations during physical activity was evaluated among parents of 207 children aged 3 to 14 years (97 (47%) female, mean age of 8.4 ± 3.7 years). GAQ responses were compared with reports obtained directly from the treating physician (n = 192/207) and information in the medical chart (clinic notes/physician letter, n = 111/207). Parent GAQ responses (either "No to all questions" or "Yes to 1 or more questions") agreed with physician (κ = 0.16, p = 0.003) and medical record (κ = 0.15, p = 0.003) reports regarding the need for special consideration during physical activity (Yes/No). Sensitivity was 71% (20/28) and specificity was 59% (96/164), with few false-negative responses. The GAQ was most effective for rheumatology and cardiology patients. False positives were 29% to 46%, except among chronic pain (80%) and rehabilitation (75%) patients. Test-retest reliability was moderate (Cronbach's α = 0.70) among 57 parents who repeated the GAQ 1 week later. The GAQ effectively identified children not requiring physical activity restrictions and those with medical conditions similar to those of concern among adults. Additional questions from a qualified exercise professional, as recommended for a "Yes" response on the GAQ, should reduce the false-positive burden. Indicating the timeframe of reference for each question and including an option to describe other special considerations (e.g., medication, supervision) are recommended.

Dyadic differences in friendships of adolescents with chronic pain compared with pain-free peers.

A multisite cross-sectional study was conducted to examine dyadic friendship features between adolescents with chronic pain (ACP) and their friends compared with non-pain adolescent friendship dyads and the association of these friendship features with loneliness and depressive symptoms. Participants completed a battery of standardized measures to capture friendship features (friendship quality, closeness, and perceived social support from friends) and indices of social-emotional well-being. Sixty-one same sex friendship dyads (122 adolescents) participated; 30 friendship dyads included an adolescent with chronic pain and 52 dyads were female. Adolescents with chronic pain scored significantly higher on measures of loneliness and depressive symptoms compared with all other participants. Hierarchical Multiple Regression analysis revealed that friendship features predicted loneliness and depressive symptoms. Chronic pain predicted loneliness and depressive symptoms above and beyond friendship features. Actor Partner Interdependence Modeling found perceived social support from friends had differing associations on loneliness and depressive symptoms for dyads with a chronic pain member compared with pain-free control dyads. Friendship features were associated with loneliness and depressive symptoms for adolescents, but friendship features alone did not explain loneliness and depressive symptoms for ACP. Further research is needed to understand whether pain-related social support improves loneliness and depressive symptoms for ACP. Furthermore, a more nuanced understanding of loneliness in this population is warranted. Strategies to help ACP garner needed social support from friends are needed to decrease rates of loneliness to improve long-term outcomes.

The impact of electronic consultation on a Canadian tertiary care pediatric specialty referral system: A prospective single-center observational study.

BACKGROUND: Champlain BASE™ (Building Access to Specialists through eConsultation) is a web-based asynchronous electronic communication service that allows primary-care- practitioners (PCPs) to submit "elective" clinical questions to a specialist. For adults, PCPs have reported improved access and timeliness to specialist advice, averted face-to-face specialist referrals in up to 40% of cases and high provider satisfaction. OBJECTIVE: To determine whether the expansion of eConsult to a pediatric setting would result in similar measures of improved healthcare system process and high provider acceptance reported in adults. DESIGN: Prospective observational cohort study. SETTING: Single Canadian tertiary-care academic pediatric hospital (June 2014-16) servicing 1.2 million people. PARTICIPANTS: 1. PCPs already using eConsult. 2.Volunteer pediatric specialists provided services in addition to their regular workload. 3.Pediatric patients (< 18 years-old) referred for none-acute care conditions. MAIN OUTCOMES AND MEASURES: Specialty service utilization and access, impact on PCP course-of-action and referral-patterns and survey-based provider satisfaction data were collected. RESULTS: 1064 eConsult requests from 367 PCPs were answered by 23 pediatric specialists representing 14 specialty-services. The top three specialties represented were: General Pediatrics 393 cases (36.9%), Orthopedics 162 (15.2%) and Psychiatry 123 (11.6%). Median specialist response time was 0.9 days (range <1 hour-27 days), most consults (63.2%) required <10minutes to complete and 21/21(100%) specialist survey-respondents reported minimal workload burden. For 515/1064(48.4%) referrals, PCPs received advice for a new or additional course of action; 391/1064(36.7%) referrals resulted in an averted face-to-face specialist visit. In 9 specialties with complete data, the median wait-time was significantly less (p<0.001) for an eConsult (1 day, 95%CI:0.9-1.2) compared with a face-to-face referral (132 days; 95%CI:127-136). The majority (>93.3%) of PCPs rated eConsult as very good/excellent value for both patients and themselves. All specialist survey-respondents indicated eConsult should be a continued service. CONCLUSIONS AND RELEVANCE: Similar to adults, eConsult improves PCP access and timeliness to elective pediatric specialist advice and influences their care decisions, while reporting high end-user satisfaction. Further study is warranted to assess impact on resource utilization and clinical outcomes.

Celecoxib pharmacogenetics and pediatric adenotonsillectomy: a double-blinded randomized controlled study.

BACKGROUND: Pediatric adenotonsillectomy (A&T) is associated with prolonged pain and functional limitation. Celecoxib is an effective analgesic in adult surgery patients; however, its analgesic efficacy on pain and functional recovery in pediatric A&T patients is unknown. METHODS: During 2009-2012, children (age 2-18 yr) scheduled for elective A&T were enrolled in a single-centre double-blind randomized controlled trial. Study participants received either oral placebo or celecoxib 6 mg·kg(-1) preoperatively, followed by 3 mg·kg(-1) twice daily for five doses. The primary outcome was the mean "worst 24-hr pain" scores during postoperative days (PODs) 0-2 on a 100-mm visual analogue scale (VAS). Secondary outcomes for PODs 0-7 included co-analgesic consumption, adverse events, and functional recovery. The impact of the CYP2C9*3 allele - associated with reduced celecoxib hepatic metabolism - on recovery was considered. RESULTS: Of the 282 children enrolled, 195 (celecoxib = 101, placebo = 94) were included in the primary outcome analysis. While on treatment, children receiving celecoxib experienced a modest reduction in the average pain experienced over PODs 0-2 (7 mm on a VAS; 95% confidence interval [CI]: 0.3 to 14; P = 0.04) and a "clinically significant" reduction (≥ 10 mm on a VAS; P ≤ 0.01) on PODs 0 and 1. During PODs 0-2, the mean acetaminophen consumption was lower in the celecoxib group vs the placebo group (78 mg·kg(-1); 95% CI: 68 to 89 vs 97 mg·kg(-1); 95% CI: 85 to 109, respectively; P = 0.03). No differences in adverse events, functional recovery, or satisfaction were observed by POD 7. The CYP2C9*3 allele was associated with less pain and improved functional recovery. CONCLUSIONS: A three-day course of oral celecoxib reduces early pain and co-analgesic consumption; however, an increase in dose, dose frequency, and duration of dose may be required for sustained pain relief in the pediatric setting. The CYP2C9*3 allele may influence recovery. This trial was registered at: ClinicalTrials.gov: NCT00849966.

Pain prevalence in a pediatric hospital: raising awareness during Pain Awareness Week.

BACKGROUND: Despite the evidence and availability of numerous validated pain assessment tools and pain management strategies for infants and children, their use remains inconsistent in clinical practice. OBJECTIVES: To describe the prevalence of pain, pain assessment and pain management practices at a tertiary pediatric hospital in Canada. METHODS: The cross-sectional study design involved a combination of interviews with children and/or caregivers, and chart audits in five inpatient units. Information regarding pain intensity, painful procedures and pain management strategies was obtained from children and/or caregivers by interview. Patient charts were reviewed for information regarding pain assessment, pain scores, and pharmacological and nonpharmacological interventions. RESULTS: Sixty-two children (four days to 17 years of age) participated. Most children or their caregivers (n=51 [84%]) reported that pain was experienced during their hospitalization, with 40 (66%) reporting their worst pain as moderate or severe. Almost one-half reported analgesics were administered before or during their most recent painful procedure. Nineteen (32%) reported sucrose, topical anesthetics or nonpharmacological interventions were used; however, they were documented in only 17% of charts. Pain scores were documented in 34 (55%) charts in the previous 24 h. The majority of the children or their caregiver (n=44 [71%]) were satisfied with pain management at the study hospital. CONCLUSIONS: Most infants and children had experienced moderate or severe pain during their hospitalization. Analgesics were frequently used, and although nonpharmacological strategies were reported to be used, they were rarely documented. Most parents and children were satisfied with their pain management.

Improved practices for safe administration of intravenous bolus morphine in a pediatric setting.

Postoperative pain control is a clinical imperative, for which morphine is a preferred opioid. However, interpatient variability and drug accumulation with repeated doses, as well as medication errors, may result in respiratory arrest with this medication. Early detection of respiratory depression is essential for safe use of morphine, following both initial and repeated doses. A multidisciplinary team contributed to development of an intravenous (IV) bolus morphine monitoring guideline that reflects current knowledge of morphine pharmacokinetics. Monitoring over a 22-week period in a postsurgical unit was then assessed via record review. A total of 270 postsurgical patients received a first dose of IV bolus morphine, with 784 subsequent doses also administered. Complete monitoring (heart rate, respiratory rate, blood pressure, sedation score, oxygen saturation, and pain score) after the morphine bolus was documented at baseline and 10 and 20 minutes for 34%, 30%, and 23%, respectively, of the patients; partial monitoring (respiratory rate and oxygen saturation) was documented for an additional 22%, 15%, and 9% of patients; 43% of subsequent morphine doses were followed with complete monitoring, and an additional 30% with at least partial monitoring. Adherence to the monitoring procedure fluctuated over the study period with no consistent upward or downward trend. A small number of children exhibited a reduced respiratory rate potentially indicating respiratory depression, but no child required antidote or respiratory support. Despite suboptimal guideline adherence, potential signs of respiratory depression were detected that might otherwise have gone unnoticed. This validates the improved guideline and suggests that some incidents may have remained undetected. Front-line staff must be involved to optimize change, champion the initiative, and promote patient safety.

Review of prescribing practices for intermittent bolus administration of morphine.

BACKGROUND: Several changes to medication safety practices were proposed in a pediatric hospital, including changing the period of patient observation after administration of opioids and limiting the availability of various concentrations of morphine in the patient care unit. OBJECTIVE: To document and review postoperative pain management for children on a surgical ward, specifically with regard to intermittent IV bolus administration of morphine, to help in assessing the impact of the proposed nursing practice changes. METHODS: Data were collected from records for narcotics and controlled drugs for the surgical ward over a 3-month period (April to June 2006). For each patient, data had been recorded for up to 7 consecutive days after surgery. A patient's data were included in the review if he or she had received at least 2 doses of morphine by IV bolus, except for the review of weight-based dosing pattern (mg/kg), for which all patients who had received at least one dose of IV morphine were included. RESULTS: Charts for 193 patients were audited. Of these, 163 patients (84.5%) had recieved up to 0.1 mg/kg per dose, and 53 (27.5%) had received only one dose of morphine. Among patients who received more than one dose, the median dose was 0.080 mg/kg on day 1, with a decrease by day 5 to 0.065 mg/kg. Most patients received morphine over the first 2 days after surgery. The median time elapsed between doses was 4.3 h on day 1 and 6.2 h on day 2. Of the 1020 doses included in the analysis, most (801 [78.5%]) were 4 mg or less. CONCLUSION: The intermittent administration of IV bolus doses of morphine at the study hospital followed common standards for the treatment of postoperative pain. Most doses were no more than 4 mg. On the basis of this information, only 2-mg vials of morphine are now stocked on the ward. The hospital's change in monitoring practices will increase the surveillance of patients receiving IV bolus doses of morphine.

Evaluation of a continuous epidural analgesia program for postoperative pain in children.

A continuous epidural analgesia (CEA) program was developed for pediatric patients cared for outside of a critical care environment. Stable patients can be successfully monitored in the inpatient areas provided sufficient education and support is offered to allow for safe administration, monitoring, and evaluation of patient outcomes. The CEA program was developed in collaboration with the departments of nursing, anesthesiology, and pharmacy and was introduced on a 1-year trial basis on the surgical patient service unit. A retrospective record review was conducted of patients offered CEA over the first 2 years of the program to determine the safety and efficacy of the program. This article describes the development, implementation, and evaluation of the CEA program for surgical patients in a tertiary pediatric hospital. The safety and efficacy of the program as well as the benefits, challenges, and lessons learned are discussed.