Tracy E. Harrison

Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: A study of 92,881 patients

Background:The objective of this study was to determine the incidence and outcome of perioperative cardiac arrest (CA) in children younger than 18 yr undergoing anesthesia for noncardiac and cardiac procedures at a tertiary care center. Methods:After institutional review board approval (Mayo Clinic, Rochester, Minnesota), all patients younger than 18 yr who had perioperative CA between November 1, 1988, and June 30, 2005, were identified. Perioperative CA was defined as a need for cardiopulmonary resuscitation or death during anesthesia care. A cardiac procedure was defined as a surgical procedure involving the heart or great vessels requiring an incision. Results:A total of 92,881 anesthetics were administered during the study period, of which 4,242 (5%) were for the repair of congenital heart malformations. The incidence of perioperative CA during noncardiac procedures was 2.9 per 10,000, and the incidence during cardiac procedures was 127 per 10,000. The incidence of perioperative CA attributable to anesthesia was 0.65 per 10,000 anesthetics, representing 7.5% of the 80 perioperative CAs. Both CA incidence and mortality were highest among neonates (0–30 days of life) undergoing cardiac procedures (incidence: 435 per 10,000; mortality: 389 per 10,000). Regardless of procedure type, most patients who experienced perioperative CA (88%) had congenital heart disease. Conclusion:The majority of perioperative CAs were caused by factors not attributed to anesthesia, in distinction to some recent reports. The incidence of perioperative CA is many-fold higher in children undergoing cardiac procedures, suggesting that definition of case mix is necessary to accurately interpret epidemiologic studies of perioperative CA in children.

Prevalence of moderate-severe pain in hospitalized children

Background:  Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown.

Adolescent Acceptance of Pain: Confirmatory Factor Analysis and Further Validation of the Chronic Pain Acceptance Questionnaire, Adolescent Version

UNLABELLED Preliminary reports suggest that acceptance of pain is an important construct when assessing and treating adolescents with chronic pain. Although the Chronic Pain Acceptance Questionnaire, Adolescent version (CPAQ-A) appears to be a promising tool, it has been evaluated in only 1 study. The current results present a confirmatory analysis of the CPAQ-A and validity data collected independently from the developers of the scale. A sample of 109 adolescents with chronic pain completed the CPAQ-A, as well as measures of pain characteristics, functional impairment, depression, anxiety, and pain self-efficacy. Results of the confirmatory factor analysis indicate the previously reported 2-factor solution provides a good fit to the data, and has acceptable internal consistency. The CPAQ-A correlated strongly with disability, depression, anxiety, and self-efficacy. It correlated only moderately with pain intensity and was not correlated with pain frequency or duration of pain. When entered last into a hierarchical regression model predicting disability, acceptance accounted for more variance than pain intensity, depression, anxiety, and self-efficacy. Results supported the internal consistency and validity of the CPAQ-A as a measure of pain acceptance in this sample of adolescents with chronic pain. Use of the CPAQ-A may provide valuable insight into the manner in which adolescents adapt to chronic pain and can guide acceptance-based treatment. PERSPECTIVE This article strengthens the psychometric support for a measure of chronic pain acceptance in adolescents. Acceptance-based treatment has been shown to reduce disability in preliminary research targeting adolescents with chronic pain; the CPAQ-A may be useful for assessing the degree to which acceptance-based approaches may be indicated for a given patient.

Management of neonatal abstinence syndrome from opioids.

Most infants at risk for neonatal abstinence syndrome have opioid plus another drug exposure; polypharmacy is the rule rather than the exception. Scales for evaluation of neonatal abstinence syndrome are primarily based for opioid withdrawal. A standard protocol to treat neonatal abstinence syndrome has not been developed. Institute nonpharmacologic strategies for all neonates at risk. The American Academy of Pediatrics recommends mechanism-directed therapy (treat opioid withdrawal with an opioid) as the first-line therapy. Second-line medications are currently under evaluation.

Getting Back to Living: Further Evidence for the Efficacy of an Interdisciplinary Pediatric Pain Treatment Program.

Objective: This study examined key functional outcomes following a 3-week interdisciplinary pediatric pain rehabilitation program for adolescents with chronic pain. Maintenance of gains was evaluated at 3-month follow-up. Methods: Participants included 171 adolescents (12 to 18 y of age) with chronic pain who completed a hospital-based outpatient pediatric pain rehabilitation program. Participants completed measures of functional disability, depressive symptoms, pain catastrophizing, opioid use, school attendance, and pain severity at admission, discharge, and at 3-month follow-up. Results: Similar to other interdisciplinary pediatric pain rehabilitation program outcome studies, significant improvements were observed at the end of the program. These improvements appeared to be maintained or further improved at 3-month follow-up. Nearly 14% of the patients were taking daily opioid medication at admission to the program. All adolescents were completely tapered off of these medications at the end of the 3-week program and remained abstinent at 3-month follow-up. Discussion: This study adds to the available data supporting interdisciplinary pediatric pain rehabilitation as effective in improving functioning and psychological distress even when discontinuing opioids. Implications for future research and limitations of the study are discussed.

Interdisciplinary Treatment of Maladaptive Behaviors Associated with Postural Orthostatic Tachycardia Syndrome (POTS): A Case Report

Abstract The prevalence of postural orthostatic tachycardia syndrome (POTS) in adolescents and young adults has been increasing during the past decade. Despite this increase, documentation regarding treatment of these patients is just beginning to emerge. In addition, despite a call for a multidisciplinary or interdisciplinary approach, no studies have examined the efficacy of such an approach to treatment. This paper describes a case study of a 19-year-old male with debilitating POTS seen at a tertiary clinic for evaluation and subsequent intensive interdisciplinary treatment. The treatment approach is described and outcomes are presented.

Improvement in Functioning and Psychological Distress in Adolescents With Postural Orthostatic Tachycardia Syndrome Following Interdisciplinary Treatment

Significant functional impairment and psychological distress have been observed in adolescent patients with postural orthostatic tachycardia syndrome (POTS). Interdisciplinary rehabilitation programs have been shown to be beneficial in the treatment of chronic pain in adults and adolescents. Only preliminary data have examined interdisciplinary rehabilitation efforts in patients with POTS. This study evaluated the impact of an interdisciplinary rehabilitation program on the functional impairment and psychological distress in 33 adolescents diagnosed with POTS. Patients included in the study were adolescents ages 11 to 18 diagnosed with POTS. Measures completed at admission and discharge from the program included the Functional Disability Index, Center for Epidemiological Studies–Depression–Child scale, and the Pain Catastrophizing Scale for Children. After participation in the 3-week program, adolescents with POTS demonstrated a significant increase in overall functional ability and significant reductions in depression and catastrophizing.

Regionalization of pediatric anesthesia care: has the time come?

The most appropriate setting for the care of children has been and remains a subject of intense debate and discussion among pediatric providers including anesthesiologists and surgeons. Age-based subspecialty care delivered in a children’s hospital setting is seen as the ideal by most pediatric anesthesiologists and surgeons, whereas the generalists tend to believe that they are more than capable of providing care to all but the most complex and critically ill children. The data informing the debate are meager leaving the issue largely unresolved. In this issue of Pediatric Anesthesia, Mudumbai and colleagues provide an important addition to that body of knowledge (1). In a study of the more than 250 000 children under age 6 years, Mudumbai examined geographic variation in surgical care among 402 California hospitals with varying pediatric caseloads and capability. The intent of the study was to evaluate the feasibility of regionalizing anesthetic and surgical care. Hospitals were categorized as to size (low, intermediate, high), pediatric capability (California Children’s Service or not), and location (rural, urban) as well as distance from a high-volume center. Of the 402 hospitals, 90% of those hospitals were found to perform less than 100 pediatric anesthetics per year and also tend to be in close proximity to a larger more extensively equipped center. They estimate that excess of 40 000 children requiring inpatient anesthesia could have been transferred during the observation period to a higher-volume center (>100 cases per annum), of which half were infants. Based on their findings, the authors suggest that policy makers revise existing guidelines to further define the scope of care for hospitalized children. The debate for and against regionalization of care is by no means new nor is it confined to anesthesia (2–4). In the United States, regionalization has been limited to two primary areas: trauma and neonatal care. A recently published and, in the United States, controversial proposal from the American College of Surgeons seeks to extend the concept of regionalization to all pediatric surgical care (5). The American College of Surgeons Task Force for Children’s Surgical Care was created to serve as a platform for the development of guidelines for regionalization of pediatric surgical care. The task force was initially composed of primarily pediatric surgeons but has since gathered input from a variety of pediatric specialists including pediatric anesthesiologists. The guideline calls for hospitals to be stratified on three different tiers (basic, advanced, and comprehensive) contingent upon the scope of pediatric resources available. Each tier is progressively more capable of caring for increasingly complex pediatric surgical cases. Anesthesiologists would be designated either as those with pediatric expertise (generalist anesthesiologist) or as pediatric anesthesiologists (subspecialty board certified or eligible). In order to be designated as ‘comprehensive’, the facility is required to have a full complement of pediatric subspecialists, equipment, and facilities including pediatric anesthesiologists available 24/7/365. If implemented, the ACS guidelines will require ongoing accreditation and site inspection similar to that for trauma center designation. Other parts of the world have taken steps toward regionalization or are considering them. European countries are geographically relatively small when compared with the United States and are heterogeneous with regard to training, practice, and resource allocation ranging from an almost complete regionalization in the UK to its near complete absence in other European countries. The UK has been at the forefront of regionalization likely due to resource constraints imposed by the National Health Service (NHS) as well as due to the results of the National Confidential Enquiries into Perioperative Deaths (NCEPOD) (6). In the NHS model, health services for children are a national priority detailed in the Specialized Services Definition and are increasingly centralized (7,8). In addition and similar to the ACS, the Royal College of Surgeons recently updated and extended their original guidelines in the Standards for Children’s Surgery (9). These guidelines may have served as a model for those of the ACS. In Australia, healthcare governance is largely state based. Nationally over the last 6 years, pediatric health services have followed the development of a hub and spoke model where specialized tertiary pediatric services are provided within the metropolitan children’s hospital or hub. Peripheral/rural services form the spokes. Pediatric services provided peripherally or within rural environments are guided by a reasonably explicit State Clinical Services Capability Framework, defining the minimal requirements for services, including staffing and support services, based on patient and procedural complexity. This framework, as in Queensland, also guides care provided within both public and private institutions (10).

Marijuana and Chronic Nonmalignant Pain in Adolescents

C hronic nonmalignant pain in children and adolescents occurs worldwide and can be associated with a lower selfreported quality of life. Headache, abdominal pain, or musculoskeletal pain is the most common complaint. Comorbid symptoms such as fatigue, sleep disturbance, depression, and anxietymay exacerbate pain andcontribute tonotable disability, psychological distress, and impaired functioning. Patients may find it difficult to attend school, concentrate on homework, socialize with friends, or engage in physical activityd ie, activities at the core of being a normal adolescent (patients 13-17 years of age)ddue to ongoing pain. In affected adolescents, evaluations and medical tests may be undertaken over months or longer, with protracted investigations often failing to determine the etiology. Many patients have had unsuccessful medication trials and procedures engendering frustration that “something is being missed.” Patients expect a “quick fix” that, when not forthcoming, may cause them to turn to alternative treatments. Marijuana is one such treatment. Given its widespread availability throughout the United States and expanded use for medical conditions, it is reasonable to anticipate increasing numbers of adolescents turning to marijuana to treat chronic pain. There is a paucity of original research data regarding risks and benefits of marijuana use for treating chronic pain in adults, and there is even less data for treating adolescents. Although benefits may accrue in specific conditions, adverse effects influencing daily functioning (eg, impaired concentration or lengthened reaction time when performing tasks) often limit treatment. More studies are needed in all ages of patients to determine if marijuana effectively reduces chronic nonmalignant pain, withoutmajor adverse effects worsening debility. We could find only one study describing marijuana use to manage pain, mood, and sleep disturbances in an adolescent population. A limitation of this study was its failure to describe participants’ ability to function daily while using marijuana. In this commentary, we describe how marijuana use in 3 adolescent patients presenting to a pediatric chronic pain clinic may have contributed to their functional difficulties. We offer speculative synthesis about the consequences of marijuana consumption and appropriate methods for patient management. During their evaluations, the described patients volunteered that they used marijuana regularly. Urine drug screens are not routinely performed in our clinic and were not used to evaluate these 3 patients. Institutional review board approval was obtained before reporting.

Pain Relief as a Primary Treatment Goal: at What Point does Functioning and Well-Being Become more Important? a Case Study of an Adolescent with Debilitating Chronic Pain

BACKGROUND Pediatric chronic pain is a common problem with significant economic implications and devastating consequences on quality of life. The present report describes a case involving a 15-year-old girl with severe and debilitating chronic pain. RESULTS Before her referral to a pain rehabilitation program, the patient saw numerous specialists who treated her with an aggressive medical regimen and two spinal cord stimulators. She was then referred for intensive interdisciplinary treatment and, after three weeks of rehabilitation, she reported clinically significant changes in anxiety, pain catastrophizing and functional disability. The patient was successfully titrated off all of her opioid medications and, eventually, both neurostimulator implants were removed. DISCUSSION Interdisciplinary pain rehabilitation is a useful treatment for patients with chronic pain. With its primary emphasis on functional restoration as opposed to strictly pain reduction, patients can regain a higher quality of life with reduced pain and fewer medications, surgeries and hospitalizations.