Jean C. Solodiuk

A randomized controlled trial to evaluate S-Caine patch for reducing pain associated with vascular access in children.

Background:A randomized, double-blinded trial was performed to evaluate the efficacy and safety of the S-Caine Patch™ (ZARS, Inc., Salt Lake City, UT), a eutectic mixture of lidocaine and tetracaine, for pain relief during venipuncture in children. Methods:With institutional review board approval, parental consent, and patient assent, 64 children who were scheduled for medically indicated vascular access at two centers were randomly assigned (2:1) to receive either an S-Caine Patch™ or a placebo patch for 20 min before venipuncture procedures. The primary outcome measure was the child’s rating of pain during venipuncture using the Oucher pain scale. Additional measures of efficacy included the blinded investigator’s and an independent observer’s four-point categorical scores. Variables were compared between treatments using Mantel–Haenszel summary chi-square tests or Pearson chi-square tests. Results:The S-Caine Patch™ produced significantly greater pain relief compared with placebo (median Oucher scores of 0 vs. 60; P < 0.001). Fifty-nine percent of the children in the S-Caine Patch™ group reported no pain compared with 20% of the children in the placebo patch group. The investigator estimated that 76% of the children in the S-Caine Patch™ group experienced no pain during venipuncture versus 20% in the placebo patch group (P = 0.001). Independent observer ratings also favored the S-Caine Patch™ (P < 0.001). Mild skin erythema (< 38%) and edema (< 2%) occurred with similar frequencies between the groups. Conclusion:This study demonstrated that a 20-min application of the S-Caine Patch™ is effective in lessening pain associated with venipuncture procedures. Adverse events after S-Caine Patch™ application were mild and transient.

Pain assessment in nonverbal children with severe cognitive impairments: the individualized numeric rating scale (INRS)

Childrens Hospital Boston began a major pain assessment and management initiative 3 years ago: Pain assessment and management are considered one of the institutions primary standards of care. The initiative included State of the Science meetings with internationally renowned nursing pain researchers and clinicians. These meetings generated nursing staff interest in specific applications of what is known about pain; how evidence-based knowledge can be used to ask population-specific clinical questions; and how an evidence-based approach can be applied to systematically develop, implement, and assess interventions that suit a populations clinical needs. This article is an example of an evidence-based pain assessment project at Childrens Hospital Boston that focused on nonverbal children with cognitive impairments. After developing a clinical question, the authors did a literature review and a benchmarking analysis of best practice. The pilot of an adapted, existing pain assessment tool is described in this article.

Validation of the Individualized Numeric Rating Scale (INRS): A pain assessment tool for nonverbal children with intellectual disability

&NA; Clinical observations suggest that nonverbal children with severe intellectual disability exhibit pain in a wide variety yet uniquely individual ways. Here, we investigate the feasibility and describe the initial psychometrics properties of the Individualized Numeric Rating Scale (INRS), a personalized pain assessment tool for nonverbal children with intellectual disability based on the parents knowledge of the child. Parents of 50 nonverbal children with severe intellectual disability scheduled for surgery were able to complete the task of describing then rank ordering their childs usual and pain indicators. The parent, bedside nurse and research assistant (RA) triad then simultaneously yet independently scored the patients post‐operative pain using the INRS for a maximum of two sets of pre/post paired observations. A total of 170 triad assessments were completed before (n = 85) and after (n = 85) an intervention to manage the childs pain. INRS inter‐rater agreement between the parents and research nurse was high (ICC 0.82–0.87) across all ratings. Parent and bedside nurse agreement (ICC 0.65–0.74) and bedside nurse and research nurse agreement (ICC 0.74–0.80) also suggest good reliability. A moderate to strong correlation (0.63–0.73) between INRS ratings and NCCPC‐PV total scores provides evidence of convergent validity. These results provide preliminary data that the INRS is a valid and reliable tool for assessing pain in nonverbal children with severe intellectual disability in an acute care setting.

Incidence of Epidural Catheter-associated Infections after Continuous Epidural Analgesia in Children

Clinical observation suggests that the number of serious epidural catheter-associated infections have increased recently in children. This increase is likely attributed to an increase in reporting and in frequency of epidural analgesia usage. Estimates of infection rates are difficult to determine primarily because of insufficient study of large pediatric populations. In this retrospective study, the authors investigated the incidence of epidural catheter-associated soft tissue and epidural infections after use of continuous epidural analgesia spanning 17 yr. A total of 10,653 epidural catheters were used in 7,792 children. The majority of catheters, 10,437 (98%), were placed for the management of postoperative pain, and 216 (2%) were placed for the management of chronic pain. The authors identified 13 cases of infections (nine cellulitis, two paravertebral musculature infections, one epidural inflammation, and one epidural abscess) between 3 and 11 days after catheter insertion. The incidence of infection was significantly higher in patients treated for chronic pain (7 of 216 = 3.2%) compared with postoperative pain (6 of 10,437 = 0.06%; P < 0.0001). Surgical drainage of subcutaneous pus was performed in three patients, and medical therapy was administered in the remainder of patients; all patients recovered without sequelae. Although rare, epidural catheter-associated infections remain a serious concern in high-risk children who may benefit the most from epidural analgesia. The findings of the authors support the low rate of epidural infection previously reported despite growing concerns of serious infections in children. These findings highlight the importance of vigilance to early diagnostic indicators of infection and provide practitioners and families with incidence data to guide informed medical decision-making.

Parent described pain responses in nonverbal children with intellectual disability

BACKGROUND Assessing pain for nonverbal children with intellectual disability is challenging. These children are at risk for pain from complex medical conditions and the interventions to treat those conditions. Pain responses are often misunderstood, given that the children are nonverbal and limited by their physical abilities. OBJECTIVES The general purpose was to examine the words that parents of children with intellectual disability use to describe their childs pain response in order to improve pain recognition and management. Specifically, the aims were to: (1) identify common pain responses as reported by parents; (2) examine relationships between type of pain response and independent variables; (3) compare pain responses to those identified in the literature. DESIGN The study design includes: (1) a summative qualitative content analysis of the parent described pain responses; (2) quantitative analysis of the relationships between type of pain response and independent variables and; (3) a comparison of pain responses to those identified in the literature. SETTING A pediatric hospital in the northeastern United States. PARTICIPANTS Parents of 50 nonverbal children with intellectual disabilities ages 6-18 years. METHODS A non-directed summative content analysis identified patterns within 335 parent described pain responses. Chi square analysis was used to examine relationships between type of pain response and selected demographic factors. RESULTS Seven distinct categories of pain responses were identified. The most commonly reported pain responses were within the categories of: vocalization (39.4%), social behavior (21.8%) and facial expressions (16%). Four types of pain responses: vocalization, social behavior, muscle tone and activity level included opposite responses to pain. There were significant relationships between type of pain response and (1) pain severity; (2) causes of intellectual disabilities and; (3) sex of the child. Pain responses varied with severity. Patients with seizure disorders expressed pain more vocally. Females expressed pain with more social responses and males with more vocalizations. CONCLUSIONS The results support evidence that parents can articulate their childs pain responses. The study provides evidence of: (1) extremes of pain responses and (2) a significant relationship between type of responses and severity of pain, cause of intellectual disability and sex of child.

Publicly available online educational videos regarding pediatric needle pain: a scoping review.

Objectives:The objectives of this scoping review were to: (1) identify publicly available educational videos on needle pain management; and (2) evaluate the content of these videos. Methods:Reviewers screened publicly available educational videos on pediatric needle pain management available on YouTube and Google using a broad-based search strategy. Videos were categorized using the CRAAP Test: Current, Relevant, from a trustworthy source (Authority), Accurate and evidence-based, and for what Purpose does the source exist. Results:Twenty-five relevant, educational videos were identified. The intended audience for most videos was parents (n=16, 64%), followed by clinicians (n=6, 24%) and children (n=3, 12%). Common examples of needle pain included immunizations or IV insertion, with interventions appropriate for infants through school-aged children. The most frequently described techniques were parent-guided distraction and behavioral factors such as comfort holds and parent demeanor. Most videos were Current (96%), Relevant (100%), created by a trustworthy source: Authority (76%), and all were Accurate, with Purpose relating to needle pain management. None of the videos addressed the unique needs of children with a preexisting diagnosis of needle phobia. Discussion:Publicly available educational videos offer clinicians, parents, and children evidence-based techniques to manage pediatric needle pain. Further evaluation is needed to determine whether this form of education meets the needs of target audiences and whether this type of content can lead to improved management of pediatric needle pain.

Documented Electronic Medical Record-Based Pain Intensity Scores at a Tertiary Pediatric Medical Center: A Cohort Analysis

CONTEXT Previous surveys have suggested that pain in hospitalized patients remains undertreated. However, little is known about those with persistently high pain scores. OBJECTIVES To document the distribution of scores and analyze the clinical characteristics of outliers with persistently high pain scores. METHODS With institutional review board approval, a retrospective cohort analysis of more than 1.5 million documented scores was completed in a tertiary pediatric medical center during a three-year period. Patients with persistently high pain scores were identified for subgroup analysis. RESULTS The median score was 0 (all years), and the means were 1.46, 1.34, and 1.3 in 2010, 2011, and 2012, respectively. Approximately 68% of admissions had at least one score of 4 or greater, although this level did not persist. Only 9% had mean scores of 4 or greater, and 1% (n = 492) had mean scores of 7 or greater. Scores remained high in patients within identifiable groups, that is, those with chronic pain (n = 311), sickle cell vaso-occlusive episodes (n = 52), and pain in children with developmental and neuromuscular disorders (n = 32). Few had persistently high scores with acute pain but without known comorbidities (n = 56). CONCLUSION Detailed review of clinical characteristics of patients with persistently high scores led to the strong impression that, in most cases, persistently high pain was not simply because of inadequate administration of opioids. Instead, the first step in improving pain management of hospitalized children may be the identification of outliers with high pain scores to direct efforts on the development of interventions for patient groups with mechanistically similar pain.

A Single Institution's Effort to Translate Codeine Knowledge Into Specific Clinical Practice

BACKGROUND Codeine is an unpredictable analgesic because of its variable pharmacokinetic, pharmacodynamic, and pharmacogenetic properties. This variability may lead to ineffective analgesia in some and respiratory depression in others. Despite this, codeine is still widely used. At a pediatric tertiary medical institution, codeine was prescribed despite efforts to inform prescribers of the potentially unpredictable analgesia and serious side effects. MEASURES A retrospective/prospective metric was introduced to determine the frequency of codeine orders as compared with similar institutions using Pediatric Health Information Systems data. INTERVENTION Interventions included formal and informal education to prescribers, and replacing codeine with oxycodone for patients aged older than six months and an age-appropriate medication for those patients younger than six months within ordersets. Identifying and addressing the major barriers to change also was a key part of the process. OUTCOMES Codeine use was reduced by 97% from the first quarter of 2008 through the third quarter of 2012. This was accomplished through orderset changes and education. Codeine was completely eliminated from the hospital formulary in January 2013. CONCLUSIONS/LESSONS LEARNED This quality improvement initiative was successful in eliminating codeine from the hospital formulary. Although education decreased codeine orders, understanding and addressing the barriers to change and directly changing the ordersets were the most effective and efficient for knowledge translation.

Nurse Practitioner-Administered Chloroprocaine in Children with Postoperative Pain

Background: Pain is a complex physical and emotional experience. Therefore, assessment of acute pain requires self‐report when possible, observations of emotional and behavioral responses and changes in vital signs. Peripheral nerve and epidural catheters often provide postoperative analgesia in children. Administration of chloroprocaine (a short acting local anesthetic) via a peripheral nerve or epidural catheter allows for a comparison of pain scores, observations of emotional and behavioral responses and changes in vital signs to determine catheter function. Aims: The aims of this study are to describe the use chloroprocaine injections for testing catheters; patient response; and how changes to pain management are guided by the patient response. Methods: This study describes the use of chloroprocaine injections to manage pain and assess the function of peripheral nerve or epidural catheters in a pediatric population. We examined 128 surgical patients, (0–25 years old), who received chloroprocaine injections for testing peripheral nerve or epidural catheters. Patient outcomes included: blood pressure, respiratory rate, heart rate and pain intensity scores. Results: There were no significant adverse events. The injection guided intervention by determining the function of regional analgesia in the majority (98.5%) of patients. Discussion: Chloroprocaine injections appear to be useful to evaluate functionality of peripheral nerve and epidural catheters after surgery in a pediatric population.