John M. Saroyan

Assessing Resident Knowledge of Acute Pain Management in Hospitalized Children: A Pilot Study

This pilot study was undertaken to evaluate the hypotheses that there are differences in pediatric pain management (PPM) knowledge across resident specialties, that questions in the form of multiple-choice items could detect such differences, and that resident knowledge of analgesic-related adverse drug events (ADEs) would be greater than knowledge of PPM. Questions were based on two general categories of knowledge within acute pain management in hospitalized children: pediatric pain assessment and treatment, and identification of analgesic-related ADEs. As part of the pilot nature of this study, a convenience sample of 60 residents completed a 10-item PPM knowledge assessment prior to a PPM lecture. Twenty-six were pediatric residents (43%), 19 were orthopedic residents (32%), and 15 were anesthesiology residents (25%). All items had content validity. When controlling for resident year, performance by resident specialty was significantly different between anesthesia and orthopedics (P=0.006) and between anesthesia and pediatrics (P<0.001). Resident knowledge of analgesic-related ADEs was not greater than knowledge of PPM. The most difficult topics were opioid equianalgesia, assessment of the cognitively impaired child, and maximal acetaminophen doses. Repeated administration of the PPM knowledge assessment at multiple institutions will allow further evaluation of our initial findings, and with directed educational interventions, provide opportunity for measurement of improvement.

Use of a clinical pathway to improve the acute management of vaso‐occlusive crisis pain in pediatric sickle cell disease

The most common, debilitating morbidity of sickle cell disease (SCD) is vaso‐occlusive crisis (VOC) pain. Although guidelines exist for its management, they are generally not well‐followed, and research in other pediatric diseases has shown that clinical pathways improve care. The purpose of our study was to determine whether a clinical pathway improves the acute management of sickle cell vaso‐occlusive crisis (VOC) pain in the pediatric emergency department (PED).

Qualitative Analysis of Consults by a Pediatric Advanced Care Team During its First Year of Service

Phenomenologic analysis of initial consults provided during the first year of a new Pediatric Advanced Care Team (PACT) program provides essential understanding of the experience and inform program direction and future clinical research. Parents bring to the consult a desire to remain experts in their children’s lives yet experience vulnerability as they seek assistance in making critical decisions often under conditions of disquieting uncertainty. Dynamic communication efforts involving the referring providers, PACT team members, and family are a key influence in facilitating consults’ stated goals and in establishing the integrated palliative paradigm in a tertiary care environment. Validation was provided for a new research infrastructure that will function concurrently with the PACT clinical program in this rapidly evolving field.

The Use of Oral Ketamine for Analgesia with Dressing Change in an Infant with Epidermolysis Bullosa: Report of a Case

Abstract:  Epidermolysis bullosa (EB) describes a spectrum of disease from occasional bullae and callus formation to a debilitating life‐threatening condition. In this study, we report the use of intravenous ketamine given orally to an infant with a phenotypically severe form of EB simplex, Dowling‐Meara subtype, to achieve analgesia during painful dressing changes.

Sciatic neuropathy after lower-extremity trauma: successful treatment of an uncommon pain and disability syndrome in an adolescent

Saroyan JM, Winfree CJ, Schechter WS, Roye D, Gold AP: Sciatic neuropathy after lower-extremity trauma: successful treatment of an uncommon pain and disability syndrome in an adolescent. Am J Phys Med Rehabil 2007;86:597–600. Lower-extremity trauma is an uncommon but reported cause of sciatic nerve injury in children and adolescents. Failure to identify sciatic neuropathy after traumatic injury to the lower extremity may lead to the delayed institution of neuropathic pharmacotherapy, electrodiagnostic testing, physical therapy, and increased risk for the development of complex regional pain syndrome. This article presents a case of an adolescent male with neuropathic pain and weakness in the right lower extremity after traumatic injury. Spontaneous recovery of the injured nerve occurred with early institution of pharmacologic and physical therapies. Operative exploration and neurolysis were considered but were not ultimately necessary.

Interviewing and Urine Drug Toxicology Screening in a Pediatric Pain Management Center: An Analysis of Analgesic Nonadherence and Aberrant Behaviors in Adolescents and Young Adults.

Objectives:Many adolescents and young adults report having chronic pain. Urine drug toxicology (UDT) is not routinely used in the pediatric pain management population, despite more routine use in adults with pain, particularly those prescribed opioids. As a first step toward establishing monitoring practices in pediatric and adolescent pain management, the present study evaluated the role of UDT in conjunction with a standard clinical interview in identifying the rate of adherence to an established analgesic regimen. The study also aimed to assess the use of UDT in identifying possible aberrant behaviors in this population. Methods:Data were acquired from a convenience sample of 50 pediatric and adolescent pain management initial consultations, during which a clinical interview and UDT were conducted. Data were analyzed to determine adherence to an established analgesic prescription regimen, and for identification of aberrant behaviors including concurrent use of illicit substances and prescription medication misuse. Other pertinent demographic and clinical factors were examined as factors in adherence. Results:Opioid medications were prescribed for 42% of the sample receiving pain medications, and 22% of the sample was nonadherent to their prescription analgesic regimen. Factors associated with a higher likelihood of nonadherence were an older age and having an opioid prescription. The majority (90%) of those nonadherent to their analgesic regimen displayed some form of aberrant behavior. Among the nonadherent patients, 50% were identified by UDT alone, and 50% were identified by self-report during the clinical encounter. Conclusions:These results highlight the challenges of identifying nonadherence to a prescription regimen among adolescents with chronic pain. In addition, this preliminary work suggests that UDT could be used in conjunction with careful clinical interviewing to substantiate patient report and increase the likelihood of detecting analgesic nonadherence and aberrant behaviors.

Undetected Ultracet™ dependence in an adolescent with nonmalignant back pain.

Addiction to painkillers or other substances in pediatric and adolescent cases of noncancer chronic pain is an understudied phenomenon, even amidst documented increases in rates of prescription opioid use and misuse. Case studies can inform the training of clinicians in ethically negotiating a balance between optimizing analgesia and mitigating risk of aberrant drug-taking behaviors. This report discusses an 18-year-old woman with idiopathic scoliosis and clinical depression secondary to undertreated refractory chronic back pain who underwent surgery to correct pseudoarthrosis after a prior spinal instrumentation operation. This intervention in conjunction with a course of patient-controlled analgesia, hydromorphone, and outpatient tramadol, naproxen, methadone, and gabapentin was successful in addressing her long-standing lumbar pain. The patient, however, continued to complain to her pain management team of postsurgical discomfort and insisted on being prescribed Ultracet™ (acetaminophen-tramadol) rather than generic tramadol. The patients eventual disclosure of severe withdrawal discomfort and history of covert abuse of Ultracet™ is discussed with respect to key warning signs, gaps, and contingencies in the screening, surgical, and pain management processes.

Pentobarbital withdrawal and treatment in an infant in the pediatric cardiac intensive care unit

Withdrawal syndromes following administration of sedative and analgesic infusions represent a significant morbidity that is described increasingly in the pediatric critical care literature. However, there are few descriptions of pentobarbital withdrawal symptoms and their treatment in the pediatric population. We describe an infant receiving multiple sedative and analgesic medications, including pentobarbital, who was resistant to our institutions standard weaning protocol, but whose severe withdrawal symptoms responded dramatically to phenobarbital loading and maintenance.

Scratching beneath the surface: an integrative psychosocial approach to pediatric pruritus and pain.

Pruritus is prevalent in children with atopic dermatitis and associated with effects on mood, quality of life, sleep, scholastic performance, social and family functioning. In this study a 7-year-old African American female with severe atopic dermatitis, itching and pain refractory to multiple systemic and topical medications was referred for treatment. At baseline, the patient scratched to the point of bleeding, despite maximal doses of anti-histamines, antidepressant and topical therapies. The patient became progressively shy, anxious, and her scholastic performance suffered. A literature review prompted the implementation of a multi-modal program of family cognitive behavioral therapy, imagery, aromatherapy, drawing, and biofeedback. The results were that decreased itch, scratching, pain, and anxiety were seen within the first month. Fewer lesions and episodes of bleeding were observed with almost complete skin clearance by the fourth month. The article concludes that a short-term, integrative program including psychological, complementary and alternative medicine (CAM), and medical therapies may represent a novel, efficacious approach for children suffering from severe atopic dermatitis.