Jeffrey L. Koh

Pain assessment in children with cognitive impairment. An exploration of self-report skills.

Prior to surgery, 47 children (ages 8 to 17) with borderline to profound cognitive impairment were administered tasks to evaluate their understanding of the concepts of magnitude and ordinal position and their abilities to use a 0 to 5 numerical scale to rate pain levels in schematic faces. Of the 111 children (ages 4 to 14) without cognitive impairment, were administered the same tasks. Nurses conducting preoperative evaluations predicted whether children would understand the numerical scale. Fifty percent (= 3) of children with borderline and 35% (n = 7) of children with mild cognitive impairment (and all children 8 years and older nonimpaired) correctly used the scale. Half of the children with cognitive impairment demonstrated skills (magnitude and ordinal position) that may allow them to use simpler pain rating methods. Nurses overestimated the abilities of cognitively impaired children (and younger children without cognitive impairment) to use the rating scale.

Central nervous system stem cell transplantation for children with neuronal ceroid lipofuscinosis

OBJECT Infantile and late-infantile neuronal ceroid lipofuscinoses (NCLs) are invariably fatal lysosomal storage diseases associated with defects in lysosomal enzyme palmitoyl-protein thioesterase 1 (PPT-1) or tripeptidyl peptidase 1 (TPP1) activity. Previous preclinical studies have demonstrated that human CNS stem cells (HuCNS-SCs) produce both PPT-1 and TPP1 and result in donor cell engraftment and reduced accumulation of storage material in the brain when tested in an NCL mouse model. METHODS HuCNS-SC transplantation was tested in an open-label dose-escalation Phase I clinical trial as a potential treatment for infantile and late-infantile NCL. Study design included direct neurosurgical transplantation of allogeneic HuCNS-SCs into the cerebral hemispheres and lateral ventricles accompanied by 12 months of immunosuppression. RESULTS Six children with either the infantile or late-infantile forms of NCL underwent low- (3 patients) and high- (3 patients) dose transplantation of HuCNS-SCs followed by immunosuppression. The surgery, immunosuppression, and cell transplantation were well tolerated. Adverse events following transplantation were consistent with the underlying disease, and none were directly attributed to the donor cells. Observations regarding efficacy of the intervention were limited by the enrollment criteria requiring that patients be in advanced stages of disease. CONCLUSIONS This study represents the first-in-human clinical trial involving transplantation of a purified population of human neural stem cells for a neurodegenerative disorder. The feasibility of this approach and absence of transplantation-related serious adverse events support further exploration of HuCNS-SC transplantation as a potential treatment for select subtypes of NCL, and possibly for other neurodegenerative disorders.

Objective and Subjective Assessment of Sleep in Adolescents With Chronic Pain Compared to Healthy Adolescents

ObjectivesThe purpose of this study was to compare sleep of adolescents with chronic pain and healthy adolescents using both subjective and objective sleep assessments, and to identify correlates of poor sleep. MethodsForty adolescents (n=20 with chronic pain and n=20 healthy adolescents), aged 12 to 17 years (72.5% female) participated. Adolescents completed self-report measures of pain, sleep quality and hygiene, presleep arousal/worry, and depressive symptoms. Sleep patterns were assessed over 7 consecutive days using an actigraph, a motion-monitoring device detecting sleep-wake patterns by measuring activity levels. Total sleep time, sleep efficiency, wake time, and wake bouts were derived from the actigraph and aggregated for analysis. ResultsCompared with healthy peers, adolescents with chronic pain demonstrated similar total sleep time as healthy adolescents, but significantly poorer sleep. In particular, adolescents with chronic pain subjectively reported poorer sleep quality and increased insomnia symptoms, and demonstrated lower actigraphic sleep efficiency and more wake bouts compared with their healthy peers. Depressive symptoms and worry at bedtime were significant predictors of subjectively reported sleep quality but not of actigraphic sleep. DiscussionAdolescents with chronic pain evidenced poorer sleep quality, increased insomnia symptoms, and less efficient sleep with more wake bouts in comparison with healthy adolescents, findings that require replication in a larger sample. Assessment and management of sleep disturbances is an important aspect of care for children and adolescents with chronic pain.

A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion.

Background : Topical anesthetics may help reduce discomfort associated with procedures involving needle‐puncture, such as intravenous (i.v.) insertions, in children. EMLA® cream has become a common, noninvasive therapy for topical anesthesia in children. ELA‐Max® is a recently introduced topical anesthetic cream marketed as being as effective in producing topical anesthesia after a 30‐min application as EMLA® is after a 60‐min application. The purpose of this research was to compare ELA‐Max® at 30 min with EMLA® at 60 min for providing topical anesthesia for i.v. insertions in children.

Analgesia following surgery in children with and without cognitive impairment

Abstract Both children and adults with cognitive impairment (CI) have historically been excluded from research examining pain. This is unfortunate since patients with CI may be at higher risk for experiencing pain or having their pain undertreated due to the difficulty of pain assessment and communication. There are now several published reports about the general pain experience of both adult and pediatric patients with cognitive impairment. The purpose of this study was to compare the amount and type of pain medication administered in children with and without CI after surgery to ascertain if there were any differences in analgesic administration patterns between these two groups. One hundred and fifty‐two children with borderline to profound CI and 138 non impaired (NI) children were recruited to participate. Analgesic administration data include type and amount of opioid, type of non‐opioid medication, and prescribed discharge medications. Results of this study show that children with CI undergoing surgery received less opioid in the perioperative period than children without CI. However, children with CI received comparable amounts and types of analgesics in the postoperative period as children without CI.

Experience with an anesthesiologist interventional model for endoscopy in a pediatric hospital.

Background Endoscopy is now a routine part of the work-up for many patients with gastrointestinal symptoms. Adults tolerate these procedures well, with either no sedation or a relatively light level. In contrast, children often require deep sedation or a general anesthetic to successfully perform these procedures. Therefore, pediatric endoscopies may require more time, personnel, and monitoring equipment to provide optimal conditions for the patient. The goals of this retrospective case series were to describe the anesthesia times and recovery duration of the different procedures, the types and amounts of medications commonly used, and the types and rates of complications experienced. Methods Patients (2,306) who underwent endoscopy in the Arkansas Children’s Hospital endoscopy suite during a 4-year period were identified. A random sample of 720 charts was reviewed retrospectively. Results Patients ranged in age from younger than 1 year to 29 years. Patients most often had abdominal pain or multiple gastrointestinal symptoms. Sixty-eight percent of patients underwent esophagogastroduodenoscopies; 30% colonoscopy or a combination of the two. Ninety-five percent of patients received a propofol-based anesthetic. Midazolam, fentanyl, and alfentanil were frequently used as supplemental agents. Complications occurred infrequently and were airway related. All complications were easily treated, with no adverse sequelae. Conclusions This model of anesthesiologist-provided sedation/anesthesia for gastrointestinal endoscopy procedures has been extremely successful in the Arkansas Children’s Hospital and has served to heighten awareness of many issues surrounding sedation and anesthesia outside of the operating room, while ensuring a high level of care is provided.

Efficacy of Parental Application of Eutectic Mixture of Local Anesthetics for Intravenous Insertion

Objective. To demonstrate that parent application of eutectic mixture of local anesthetics (EMLA) results in equal reduction of the pain of intravenous (IV) placement compared with clinician application of EMLA, and to assess potential difficulties with parental application. Study Design. A 2 × 2 randomized block design was used, with 41 children divided into two age groups (5–12 years vs 13–18 years) and randomized to one of two experimental groups (parent-applied EMLA vs clinician-applied EMLA). Methods. All children were scheduled to have outpatient gastrointestinal endoscopies with IV sedation. EMLA was placed at least 60 minutes before IV insertion either by the parent or a clinician, depending on the experimental group assignment. Outcome measures were child pain ratings and observed behavioral distress ratings. Parents and children were interviewed to determine parent and child anxiety levels in anticipation of the IV insertion, previous needle stick experience, and previous difficulty coping. Feasibility outcomes included technical difficulty with application of EMLA and appearance of the EMLA cream and occlusive covering. Results. Pain ratings and behavioral distress ratings were generally in the low to moderate range for all groups and were consistent with previous empiric reports of EMLA outcome. There were no significant differences in pain or distress ratings for either the age or the experimental groups. Parent ratings of their childs previous difficulty coping was related to the level of behavioral distress exhibited before (r = .50), during (r = .32) and after (r = .44) the IV insertion. In addition, childrens anxiety ratings about IV insertion seemed to differ among groups (although not statistically significant for post hoc comparisons), with the most anxiety reported by the younger children when clinicians applied the EMLA and by older children when parents applied the EMLA. Conclusion. Parent application of EMLA appears to be as effective as clinician application in reducing childrens pain and distress associated with IV insertion. Permitting parents to apply the EMLA at home can allow children who are having procedures on an outpatient basis to benefit from topical anesthesia without having to arrive early to the clinic or hospital. Additionally, application by parents may result in less anticipatory anxiety for younger children.

Intraoperative opioid dosing in children with and without cerebral palsy

Objective:  To describe the differences in intraoperative opioid dosing and associated outcomes in children with and without cerebral palsy (CP).

A comparison of laser-assisted drug delivery at two output energies for enhancing the delivery of topically applied LMX-4 cream prior to venipuncture.

BACKGROUND:Laser-assisted drug delivery (LAD) has the potential for facilitating topical anesthesia with reduced onset time. METHODS:In this randomized, double-blind, crossover study we compared the efficacy and adverse event profile of LAD for topical anesthesia before venipuncture using two output energies (2.0 and 3.5 J/cm2). RESULTS:Mean Visual Analog Scale pain scores were not statistically different (P = 0.57) between the low-energy (mean = 6.7) and high-energy (mean = 8.1) lasers. CONCLUSIONS:LAD at an energy of 2.0 J/cm2 (570 mJ) is as effective, with similar adverse events, as an energy of 3.5 J/cm2 (1000 mJ) in facilitating topical anesthesia.

Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children

Opioids are often prescribed to children for pain relief related to procedures, acute injuries, and chronic conditions. Round-the-clock dosing of opioids can produce opioid dependence within 5 days. According to a 2001 Consensus Paper from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, dependence is defined as “a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.” Although the experience of many children undergoing iatrogenically induced withdrawal may be mild or goes unreported, there is currently no guidance for recognition or management of withdrawal for this population. Guidance on this subject is available only for adults and primarily for adults with substance use disorders. The guideline will summarize existing literature and provide readers with information currently not available in any single source specific for this vulnerable pediatric population.