Michelle L. Czarnecki

Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial.

BACKGROUND: Gabapentin has opioid-sparing effects in adult surgical patients, but no reported studies have involved children and adolescents. In a double-blind, randomized, controlled trial, we examined whether gabapentin decreases postoperative opioid consumption for pediatric spinal fusion patients with idiopathic scoliosis. METHODS: Patients, aged 9 to 18 years, received preoperative gabapentin (15 mg/kg, treatment) or placebo. Anesthesia was standardized. After surgery, all patients received standardized patient-controlled analgesia opioid and continued on either gabapentin (5 mg/kg) or placebo 3 times per day for 5 days. Opioid use was calculated in mg/kg/time intervals. Pain scores and opioid side effects were recorded. RESULTS: Data from 59 patients (30 placebo and 29 gabapentin) did not differ in demographics. Total morphine consumption (mg/kg/h ± SD) was significantly lower in the gabapentin group in the recovery room (0.044 ± 0.017 vs 0.064 ± 0.031, P = 0.003), postoperative day 1 (0.046 ± 0.016 vs 0.055 ± 0.017, P = 0.051), and postoperative day 2 (0.036 ± 0.016 vs 0.047 ± 0.019, P = 0.018). In addition, gabapentin significantly reduced first pain scores in the recovery room (2.5 ± 2.8 vs 6.0 ± 2.4, P < 0.001) and the morning after surgery (3.2 ± 2.6 vs 5.0 ± 2.2, P < 0.05), but otherwise pain scores were not significantly different. There were no differences in opioid-related side effects over the course of the study. CONCLUSION: Perioperative oral gabapentin reduced the amount of morphine used for postoperative pain after spinal fusion surgery, but not overall opioid-related side effects. Initial pain scores were lower in the treatment group. Perioperative use of gabapentin seems to be an effective adjunct to improve pain control in the early stages of recovery in children and adolescents undergoing spinal fusion.

A prospective evaluation of opioid weaning in opioid-dependent pediatric critical care patients.

Critically ill children are treated with opioid medication in an attempt to decrease stress and alleviate pain during prolonged pediatric intensive care. This treatment plan places children at risk for opioid dependency. Once dependent, children need to be weaned or risk development of a withdrawal syndrome on abrupt cessation of medication. We enrolled opioid-dependent children into a prospective, randomized trial of 5- versus 10-day opioid weaning using oral methadone. Children exposed to opioids for an average of 3 wk showed no difference in the number of agitation events requiring opioid rescue (3 consecutive neonatal abstinence scores >8 every 2 h) in either wean group. Most of the events requiring rescue occurred on day 5 and 6 of the wean in both treatment groups. Patients may be able to be weaned successfully in 5 days once converted to oral methadone, with a follow-up period after medication wean to observe for a delayed withdrawal syndrome.

Parent/Nurse-controlled Analgesia for Children With Developmental Delay

BackgroundChildren with developmental delay are often unable to verbalize pain or advocate for themselves owing to cognitive, motor, or verbal limitations, which puts them at increased risk for poor pain assessment and management. Although patient-controlled analgesia has been shown to be safe, effective, and superior to intermittent opioid dosing, not all children can operate patient-controlled analgesia independently. Parent/nurse-controlled analgesia (PNCA) may be an option for these children. However, the safety and efficacy of PNCA have not been thoroughly evaluated and many practitioners are reluctant to use it. ObjectivesThe purpose of this study was to evaluate the outcomes associated with PNCA in pediatric patients with identified developmental delay. MethodsA retrospective review of treatment with PNCA was conducted from a convenience sample of charts for 71 children with developmental delay. Data were collected for 72 hours or until the PNCA was discontinued, whichever came first. ResultsMean pain scores were low, as was the amount of opioid required to keep patients comfortable. Side effects, with the exception of oxygen therapy, were similar to previous studies regarding PNCA. Somnolence and respiratory depression leading to the administration of naloxone occurred in 2.8% of patients, and potential causes were identified. DiscussionPain scores, side effects, and adverse events suggest that PNCA may be an effective method of pain control for children with developmental delay. Diligent monitoring and education are crucial to ensure safety.

Initial surgical and pain management outcomes after Nuss procedure

PURPOSE The purpose of this article was to report surgical and pain management outcomes of the initial Nuss procedure experience at the Childrens Hospital of Wisconsin (Milwaukee) and to place this experience in the context of the published literature. METHODS The initial 118 consecutive Nuss procedures in 117 patients were retrospectively reviewed with approval of the Childrens Hospital of Wisconsin human rights review board. Patient, surgical, complication, and pain descriptors were collected for each case. Statistical methods for comparison of pain strategies included the Kolmogorov-Smirnov test for normality, 1-way repeated measures analysis of variance, and paired t tests. RESULTS Patient, surgical, and complication descriptors were comparable to other large series. Complication rates were 7% early and 25% late. Epidural success rate was 96.4%. There was 1 episode of recurrence 2 years postbar removal (n = 114). CONCLUSIONS The institution of the Nuss procedure provides a highly desired result with significant complication rates. The ideal approach would deliver this result with lower risk. A pain service-driven epidural administration of morphine or hydromorphone with local anesthetic provides excellent analgesia for patients after Nuss procedure. The success of epidural analgesia is independent of catheter site and adjunctive medications. Ketorolac was an effective breakthrough medication.

A preliminary report of parent/nurse-controlled analgesia (PNCA) in infants and preschoolers.

BackgroundInfants and young children are often unable to verbalize pain or advocate for themselves which may increase their risk for poor pain assessment and management. Although patient-controlled analgesia (PCA) has been shown to be safe, effective, and superior to intermittent opioid dosing, infants and young children are not able to operate PCA independently. Allowing a parent or nurse to operate the PCA for the child [parent/nurse-controlled analgesia (PNCA)] may be an option for these children. However, the use of PNCA has been heavily scrutinized and more evidence of safety is needed to support this practice. ObjectivesThe primary purpose of this study was to evaluate safety outcomes associated with PNCA for infants and preschool aged children. Secondary outcomes regarding the frequency of untoward side effects and clinical effectiveness were also examined. MethodsA retrospective review of treatment with PNCA was conducted from a convenience sample of charts for 107 infants and preschoolers. Data were collected for 72 hours or until the PNCA was discontinued. ResultsOne hundred and seven infants and preschoolers with a mean age of 19.6 months (±12.12) were represented in this study. Mean pain scores were low, as was the number of PNCA injections and attempts and amount of opioid administered. Common opioid side effects were reported. Naloxone was administered to 1.9% of patients for respiratory depression, and potential contributing factors were identified. DiscussionDiligent monitoring and education are crucial to ensure safety. Untoward side effects adverse events and pain scores suggest PNCA may be an effective method of pain control for this patient population.

Is there an alternative to continuous opioid infusion for neonatal pain control? A preliminary report of parent/nurse-controlled analgesia in the neonatal intensive care unit.

Continuous opioid infusion (COI) remains the mainstay of analgesic therapy in the neonatal intensive care unit (NICU). Parent/nurse‐controlled analgesia (PNCA) has been accepted as safe and effective for pediatric patients, but few reports include use in neonates. This study sought to compare outcomes of PNCA and COI in postsurgical neonates and young infants.

Opioid Administration for Postoperative Pain in Children With Developmental Delay: Parent and Nurse Satisfaction

Introduction Parent-/nurse-controlled analgesia (PNCA) has been shown to be safe and effective for a variety of pediatric patient populations, yet no studies were found that assessed parent or nurse satisfaction with this opioid delivery system. The purpose of this study was to explore parent and nurse satisfaction and factors influencing satisfaction with three opioid delivery systems: PNCA with and without a basal infusion and intravenous, as needed (PRN) opioids for children with developmental delay. Methods As part of a randomized controlled trial, parent satisfaction was measured using a modified Parent Total Quality Pain Management Instrument (Foster & Varni, 2002). Nurses were asked to complete an investigator-developed survey each shift. Results Parents reported high levels of satisfaction regardless of the opioid delivery system, but parents in the PRN group reported longer wait times for medication and wanted more of a say in their child’s pain management. PNCA was described by parents as convenient and fast, whereas PRN opioids were described as inconvenient and burdensome for nurses. Nurses’ satisfaction was significantly lower for PRN opioids than PNCA owing to significantly longer administration times and less parental involvement. Discussion To our knowledge, this is the first randomized controlled trial to explore parent and nurse satisfaction with various opioid delivery systems. Whereas all three systems resulted in high levels of parent satisfaction, nurses were more satisfied with PNCA. Adding this element of satisfaction with PNCA to the already established efficacy and safety adds support for the consideration of PNCA for children with developmental delay.

On the Difficulties of Studying Pain Management in Individuals with Developmental Delay—Response

Czarnecki et al. [1] are to be congratulated on attempting this prospective randomized controlled trial (RCT) to investigate what is undoubtedly a difficult medical problem and a difficult topic to study. RCT is frequently viewed as one of the most reliable methodologies and therefore among the highest levels of evidence when correctly conducted and interpreted. Although it is always disappointing when minimum recruitment targets are not met, the publication and careful interpretation of such data still adds to the contemporary knowledge base and may contribute to future analyses. Czarnecki et al. [1] found “no difference” in side effects, including RD, between their three groups, which might well have been expected given the small sample size and (thankfully) low incidence of this problem. Nevertheless, this is in accordance with our data.