Fiona Campbell

Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials

Effective therapeutic options for patients living with chronic pain are limited. The pain relieving effect of cannabinoids remains unclear. A systematic review of randomized controlled trials (RCTs) examining cannabinoids in the treatment of chronic non-cancer pain was conducted according to the PRISMA statement update on the QUORUM guidelines for reporting systematic reviews that evaluate health care interventions. Cannabinoids studied included smoked cannabis, oromucosal extracts of cannabis based medicine, nabilone, dronabinol and a novel THC analogue. Chronic non-cancer pain conditions included neuropathic pain, fibromyalgia, rheumatoid arthritis, and mixed chronic pain. Overall the quality of trials was excellent. Fifteen of the eighteen trials that met the inclusion criteria demonstrated a significant analgesic effect of cannabinoid as compared with placebo and several reported significant improvements in sleep. There were no serious adverse effects. Adverse effects most commonly reported were generally well tolerated, mild to moderate in severity and led to withdrawal from the studies in only a few cases. Overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis. The context of the need for additional treatments for chronic pain is reviewed. Further large studies of longer duration examining specific cannabinoids in homogeneous populations are required.

Pain in Hospitalized Children: A Prospective Cross-Sectional Survey of Pain Prevalence, Intensity, Assessment and Management in a Canadian Pediatric Teaching Hospital

BACKGROUND: Pain is under-recognised and undertreated. Although standards now exist for pain management, it is not known if this has improved care of hospitalized children.

A systematic review of the effect of waiting for treatment for chronic pain.

&NA; In many countries timely access to care is a growing problem. As medical costs escalate health care resources must be prioritized. In this context there is an increasing need for benchmarks and best practices in wait‐time management. The Canadian Pain Society struck a Task Force in December 2005 to identify benchmarks for acceptable wait‐times for treatment of chronic pain. As part of the mandate a systematic review of the literature regarding the relationship between waiting times, health status and health outcomes for patients awaiting treatment for chronic pain was undertaken. Twenty‐four studies met the inclusion criteria for the review. The current review supports that patients experience a significant deterioration in health related quality of life and psychological well being while waiting for treatment for chronic pain during the 6 months from the time of referral to treatment. It is unknown at what point this deterioration begins as results from the 14 trials involving wait‐times of 10 weeks or less yielded mixed results with wait‐times amounting to as little as 5 weeks, associated with deterioration. It was concluded that wait‐times for chronic pain treatment of 6 months or longer are medically unacceptable. Further study is necessary to determine at what stage the deterioration begins from the onset of pain to treatment and the impact of waiting on treatment outcomes. Most important is the need to improve access to appropriate care for patients with chronic pain, an escalating public health care problem with significant human and economic costs.

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, χ2) 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.

Publication of abstracts presented at anaesthesia meetings

To determine the publication rate of abstracts as peer-reviewed manuscripts during the five years subsequent to their presentation, the rates of publication of abstracts that were presented at meetings of four anaesthesia societies (American Society of Anesthesiologists (ASA), International Anesthesia Research Society (IARS), Anaesthesia Research Society (ARS) and Canadian Anaesthetists’ Society (CAS), in 1985 were determined. Abstracts (total = 215) from each of the four meetings were selected (ASA n = 114/573 total, IARS n = 39/119, ARS n = 33/99 and CAS n = 29/58) and their appearances in the literature as peer-reviewed manuscripts were determined usingmedune for the years 1985 to 1990 under the surname of the presenting author. The contents of the abstracts were compared with those of the resultant manuscripts. The proportions of abstracts from each of the four societies that were published as manuscripts were compared. We found that the mean proportion of abstracts from all four societies that were published as manuscripts within three years of presentation was 44% and within five years 50%. The proportions of abstracts that were published as manuscripts from the four societies were similar. Of the abstracts that were published as manuscripts, 13% from the ASA, 16% from the IARS, 16% from the ARS and 0% from the CAS were published four or five years after abstract presentation. Although the overall proportion of abstracts that was published within five years of presentation did not differ from the rate of publication within three years, we recommend that a uniform policy with respect to the time interval for citation of abstracts be adopted for all anaesthesia journals.RésuméDans le but de déterminer te pourcentage des abstracts qui atteignent le stade de publication sous forme d’articles, nous avons fait un relevé d’abstracts présentés en 1985 à quatre sociétés d’anesthésistes. Ces abstracts avaient fait l’objet d’une présentation aux réunions de ces sociétés en 1985 et avaient été acceptés ultérieurement comme articles après révision par des comités de lecture. Les sociétés sont l’American Society of Anesthesiologists (ASA), L’International Anesthesia Research Society, l’Anaesthesia Research Society (ARS) et la Société Canadienne des Anesthésistes (SCA). Des abstracts (total = 215) provenant de chacune des quatre réunions ont été choisis (ASA n = 114/573, IARS n = 39/119, ARS n = 33/99 et SCA n = 29/58). Leur apparition dans la littérature a été retracée dans lemedune sous le nom de l’auteur principal pendant les années 1985–1990. Le contenu des abstracts a été comparé à celui des l’articles. La proportion des abstracts donnant naissance à des articles a été comparée pour chacune des sociétés. Pour les quatre sociétés, nous avons trouvé que la proportion moyenne de publications en-deça de trois ans de la présentation a été de 44% et de cinq ans de 50%. Cette proportion est la même pour les quatre sociétés. De l’ASA, 13%, de l’IARS, 16%, de l’ARS, 16% et de la SCA, 0% des abstracts ont produit à des articles après quatre ou cinq ans de leur présentation. Bien que la proportion générale des abstracts publiés en-deça de cinq ans de leur présentation ne soit pas différente de la proportion trouvée après trois ans, nous recommandons qu’une politique uniforme soit adoptée par toutes les revues d’anesthésie sur la limite de temps au cours de laquelle on peut utiliser un abstract comme référence.

Validation of the Numerical Rating Scale for Pain Intensity and Unpleasantness in Pediatric Acute Postoperative Pain: Sensitivity to Change Over Time

UNLABELLED This study evaluates the construct validity (including sensitivity to change) of the numerical rating scale (NRS) for pain intensity (I) and unpleasantness (U) and participant pain scale preferences in children/adolescents with acute postoperative pain. Eighty-three children aged 8 to 18 years (mean = 13.8, SD = 2.4) completed 3 pain scales including NRS, Verbal Rating Scale (VRS), and faces scales (Faces Pain Scale-Revised [FPS-R] and Facial Affective Scale [FAS], respectively) for pain intensity (I) and unpleasantness (U) 48 to 72 hours after major surgery, and the NRS, VRS and Functional Disability Index (FDI) 2 weeks after surgery. As predicted, the NRSI correlated highly with the VRSI and FPS-R and the NRSU correlated highly with the VRSU and FAS 48 to 72 hours after surgery. The FDI correlated moderately with the NRS at both time points. Scores on the NRSI and NRSU at 48 to 72 hours were significantly higher than at 2 weeks after surgery. Children found the faces scales the easiest to use while the VRS was liked the least and was the hardest to use. The NRS has adequate evidence of construct validity including sensitivity for both pain intensity and unpleasantness. This study further supports the validity of the NRS as a tool to measure both intensity and unpleasantness of acute pain in children. PERSPECTIVE This article evaluates the construct validity including sensitivity of the Numerical Rating Scale for pain intensity and pain unpleasantness over time in children after major surgery. The NRS could be used by clinicians to assess these 2 different dimensions of childrens pain experience in acute pain settings.

Identification of pain-related psychological risk factors for the development and maintenance of pediatric chronic postsurgical pain.

Background The goals of this study were to examine the trajectory of pediatric chronic postsurgical pain (CPSP) over the first year after surgery and to identify acute postsurgical predictors of CPSP. Methods Eighty-three children aged 8–18 years (mean 13.8, standard deviation 2.4) who underwent major orthopedic or general surgery completed pain and pain-related psychological measures at 48–72 hours, 2 weeks (pain anxiety and pain measures only), and 6 and 12 months after surgery. Results Results showed that 1 year after surgery, 22% of children developed moderate to severe CPSP with minimal functional disability. Children who reported a Numeric Rating Scale pain-intensity score ≥ 3 out of 10 two weeks after discharge were more than three times as likely to develop moderate/severe CPSP at 6 months and more than twice as likely to develop moderate/severe CPSP at 12 months than those who reported a Numeric Rating Scale pain score < 3 (6-month relative risk 3.3, 95% confidence interval 1.2–9.0 and 12-month relative risk 2.5, 95% confidence interval 0.9–7.5). Pain unpleasantness predicted the transition from acute to moderate/severe CPSP, whereas anxiety sensitivity predicted the maintenance of moderate/severe CPSP from 6 to 12 months after surgery. Conclusions This study highlights the prevalence of pediatric CPSP and the role played by psychological variables in its development/maintenance. Risk factors that are associated with the development of CPSP are different from those that maintain it.

End-tidal carbon dioxide measurement in infants and children during and after general anaesthesia

We have examined the reliability of end-tidal carbon dioxide (PetCO2) monitoring as an estimate of arterial carbon dioxide tension (PaCO2) in spontaneously breathing infants and children. Forty patients were studied in the post-anaesthetic care unit; 20 < 12 kg and 20 ≥12 kg. ThePetCO2 was sampled via a 5 cm 16 gauge catheter taped below an external naris and this measurement was compared with the PaCO2 of a sample drawn from an indwelling arterial line. Twenty additional patients were studied during inhalational anaesthesia. ThePetCO2 was measured both from the proximal end of the elbow connector and from a 5 cm cannula inserted through the elbow. An arterial blood gas sample was obtained simultaneously. The arterial to end-tidal (Pa-ET) differences were compared between the two sites. Patients studied in the post-anaesthetic care unit showed good correlation betweenPetCO2 and PaCO2 regardless of weight: Pa-EtCO2 of −0.6 ±3.6 (< 12 kg) and −1.1 ±2.8 mm Hg (≥12 kg). Patients studied during mask anaesthesia showed better correlation betweenPetCO2 and PaCO2 whenPetCO2 was sampled from thte cannula: Pa-ETCO2 of 3.5 ±4.8 mm Hg (cannula), 8.6 ±4.5 (elbow) (P < 0.05). These results suggest that end-tidal CO2 monitoring is a useful and reliable method for assessing adequacy of ventilation in spontaneously breathing children weighing between 5.2 and 35 kg.RésuméCette étude vise à évaluer, en ventilation spontanée, la fiabilité du monitorage du CO2 téléexpiratoire (PetCO2) comme mesure de la tension du gaz carbonique artériel (PaCO2) chez des nourrissons et des enfants. Une étude est réalisée d’abord à l’unité des soins postopératoires chez 40 patients: 20 < 12 kg et 20 ≥12 kg. L’échantillonnage de laPetCO2 se fait par un cathéter 16G de 5 cm fixé sous une narine et la comparaison est établie avec un prélévement artériel. Vingt patients additionnels sont étudiés pendant une anesthésie inhalatoire. LaPetCO2 est mesurée à la fois à l’extrémité proximate du raccord coudé et par une canule de 5 cm insérée a travers le raccord. (Un échantillon de sang artériel est prélevé simultanément. La différence artério-téléexpiratoire (Pa-ET) est comparée au niveau des deux sites. A l’unité des soins postopératoires, la corrélation entrePetCO2 et PaCO2 est bonne et indépendante du poids: Pa-EtCO2 = −0,6 ±3,6 (< 12 kg) et −1,1 ±2,8 mm Hg (≥12 kg). Pendant l’anesthésie au masque, la corrélation a été meilleure entrePetCO2 et PaCO2 quand laPetCO2 est prélevée par la canule: Pa-EtCO2 de 3,5 ±4,8 mm Hg (canule), 8,6 ±4,5 (raccord) (P < 0,05). Ces résultats suggèrent que le monitorage du CO2 téléexpiratoire est utile et liable pour évaluer la suffisance de la ventilation chez des enfants pesant de 5,2 à 35 kg.

Analgesic efficacy and safety of a caudal bupivacaine-fentanyl mixture in children

The analgesic efficacy and safety of a single caudal injection of a bupivacainefentanyl mixture was investigated in this prospective, controlled, tripleblinded study of 34 children, aged 1–11 yr and of ASA physical status I-II undergoing urological surgery. After induction of anaesthesia and before surgery, the children were randomly assigned to receive a caudal injection of 1.0 ml · kg−1 bupivacaine 0.125% with epinephrine 1:400,000 and either fentanyl 1.0 μg · kg−1 in 1.0 ml of normal saline or 1.0 ml of normal saline. After completion of surgery, patients were assessed in the recovery room for six hours from the time of the caudal injection and for a further 18 hr on the ward. While in the recovery room arterial oxygen saturation and respiratory rate were monitored continuously and recorded hourly together with endtidal carbon dioxide, pain and sedation scores. Other complications were also recorded. While on the ward, pain and sedation scores, respiratory rate and side effects were recorded every two hours. Postoperative analgesia was provided by intravenous morphine. Analgesic requirements were recorded for the 24-hr study period. Pain and sedation scores did not differ between groups. Respiratory depression or hypoxia did not occur. The incidences of other side effects did not differ. There were no differences in the numbers of patients requiring morphine within eight hours, the time to first morphine administration or the total morphine requirements. We conclude that a single caudal injection of a bupivacainefentanyl mixture with epinephrine administered prior to surgery, while safe, offers no advantage over an injection of bupivacaine 0.125% with epinephrine for paediatric urological surgery.RésuméCette etude controlee prospective a triple inconnue ivalue l’efficacité analgesique et la securité de l’injection caudale d’un mélange bupivacaïnefentanyl effectuée chez des enfants de 1–11 ans, de classe ASA I et II, subissant une chirurgie urologique. Après l’induction de l’anesthésie et immédiatement avant la chirurgie, les enfants on été assignés au hasard à recevoir par injection caudale simple 1,0 μg · kg−1 de bupivacaïne 0.125% adrénalinée à 1:400,000 associée à du fentanyl 1.0 μg dans 1.0 ml de soluté physiologique ou à 1.0 ml de soluté physiologique. Après la chirurgie, les patients ont été surveillés à la salle de réveil pendant les six heures qui ont suivi l’injection, et à l’étage pour les dixhuit heures subséquentes. A la salle de réveil, la saturation oxyhémoglobininée et la fréquence ventilatoire ont été monitorés continuellement et enregistrées à toutes les heures de mime que l’anhydride carbonique en fin de d’expiration, le niveau de perception douloureuse et de sédation sur des échelles appropriées. On a aussi noté les complications. A l’étage, les échelles d’évaluation de la douleur et de la sédation on été enregistrées à toutes les deux heures, de même que la fréquence ventilatoire et les effets secondaires. La morphine intraveineuse a assuré l’analgésie postopératoire. Le besoin d’analgésiques a été enregistré pendant la période d’étude de 24 heures. Les degrés de douleur et de sédation ont été identiques dans les groupes. Il n’y a pas eu de dépression respiratoire, ni d’hypoxie. L’incidence des autres effets secondaires n’a pas différé. Le nombre de patient pour lesquels la morphine a été requise pendant les huit premières heures, le délai requis avant la première injection et la dose totale ont été les mêmes. Nous en concluons que l’injection caudale simple d’un mélange de bupivacaïnefentanyl avec épinéphrine administrée avant la chirurgie, tout en étant sans danger, n’offre pas plus d’avantages que l’injection de bupivacaïne 0.125% avec épinéphrine dans un contexte de chirurgie urologique en pédiatrie.

iCanCope with Pain™: User-Centred Design of a Web- and Mobile-Based Self-Management Program for Youth with Chronic Pain Based on Identified Health Care Needs

Chronic pain self-management involves providing patients with knowledge, coping strategies and social support that help them to manage their pain. This type of intervention has been shown to be useful in treating chronic pain; however, many eligible chronic pain patients never receive such treatment due to limited accessibility and high cost. The use of Internet-based cognitive behavioural therapy has the potential to change this. In this study, the authors report their progress in the development of an Internet- and smartphone-based application for chronic pain self-management.