Here’s the latest research in pediatric pain control
Because pediatric patients are not in the same position as adult patients in terms of voicing concern for inadequate analgesia, they are particularly vulnerable to inadequate pain management, says Arthur M. Pancioli, MD, assistant professor for the department of emergency medicine at the University of Cincinnati College of Medicine. "Documenting the extent of a problem gives us a baseline from which to improve. In the case of pediatric analgesia, we have plenty of room for improvement," he notes.
Medical personnel should be more aggressive at identifying painful conditions, treating them quickly with adequate analgesics, and ensuring relief and adequacy of outpatient pain management, urges Pancioli.
Here are key findings of three recent studies that examined pediatric pain management in the ED:
o Analgesic use in children differed among EDs.
One study looked at analgesic use in children vs. adults in three types of ED settings: an academic center with separate adult/pediatrics EDs, a community academic medical center with combined adult/pediatrics ED, and a community hospital with a combined ED. Forty adult and 40 pediatric charts of patients presenting within 12 hours of an isolated long bone fracture were randomly selected for review at each of the institutions. The main findings were as follows:
• Overall, 63% of patients received some form of analgesia in the ED.
• The community ED offered less analgesia (51%) than the academic combined ED (73%) but not the separate ED (66%).
• Pediatric patients received significantly less analgesia than adults (53% vs. 73%). This difference was significant at the academic combined ED and the community ED but not the separate ED.
• 81% of patients received discharge analgesia, with no difference between pediatric and adult patients. However, pediatric patients (27%) were more likely than adult patients (3%) to receive inadequate doses of analgesics on discharge.1
"The good news is that the use of analgesics appears to be increasing," reports Emory Petrack, MD, MPH, chief of the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland and the study’s principal investigator. "This reflects an increasing recognition of the role of the ED in appropriately addressing painful injuries and procedures."
Unfortunately, there continues to be a gap in the provision of adequate analgesia to children when compared with adults, notes Petrack. "Continued education and discussion regarding the need for good pain management in infants and children is essential if this gap is to be eliminated. Child life specialists have played an increasingly important role in this effort."
o Protocols can improve management of painful conditions.
One study conducted at Children’s Hospital Medical Center of Cincinnati looked at ED management of three painful conditions: vasoocclusive crisis (VOC or sickle cell crisis), isolated lower-extremity fractures less than 12 hours old, and second-degree burns less than 12 hours old.2 The findings were as follows:
• Frequency of use: VOC 100%, fracture 31%, burns 26%.
• Use of recommended initial dose: VOC 78%, fracture 69%, burn 79%.
• Mean time in minutes to initial dose: VOC 52%, fracture 86%, burn 29%.
• Notation of pain relief in the chart:VOC 88%, fracture 19%, burn 29%.
• Instructions for home analgesic use: VOC 100%, fracture 74%, burn 27%.
Analgesic use was suboptimal in terms of frequency for burns and fractures; initial dosing was often below recommended initial doses; delays were relatively long for initial dosing; and too little documentation of pain relief and instructions for home pain control was found, says Pancioli, one of the study’s investigators. "It was very interesting to us that the best pain management occurred with VOC where there are protocols for managing this type of pain," he reports. "It may be that similar protocols would substantially improve pain management for other conditions."
o Parents’ perceptions of children’s pain management improves with staff education.
Parents often feel that their children’s pain management is inadequate. "Parents want relief for their child’s pain, but research has shown satisfaction rates as low as 33%," says Lisa Chan, MD, FACEP, assistant residency director at the department of emergency medicine at the University of Arizona in Tucson and the principal investigator for a study on parents’ perceptions of their children’s pain management.3
In a study on satisfaction of parents, charts were pulled for children who came to the ED with six painful diagnoses.4 "We telephoned the parent a week after the child was discharged and asked if they thought the pain was controlled adequately," says Chan. The satisfaction rate was 91%, which the researchers attribute to quarterly inservicing for ED staff that results in better pain management. Speakers address pain management in the ED. "As attendings, we remind the medical students and residents to treat pain while seeing patients," she says.
Staff education should include conferences, regular lectures, or informal inservicing, Chan recommends. Speakers at University of Arizona review dosing and different medications used for pediatrics.
"Children may not be able to verbalize the fact that they have pain, so we need to be proactive in treating it," she says. "In turn, this improves parents satisfaction with the care their child receives."
References
1. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: Patterns of analgesic utilization. Pediatrics 1997; 99:711-714.
2. Friedland LR, Pancioli AM, Duncan KM. Pediatric emergency department analgesic practice. Pediatr Emerg Care 1997; 13:103-106.
3. Wilson AE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989; 7:620-623.
4. Chan L, Russell TJ, Robak N. Parental perception of the adequacy of pain control in their child after discharge from the emergency department. Pediatr Emerg Care 1998; 14:251-253.
Sources
• Arthur Pancioli, MD, Department of Emergency Medicine, University of Cincinnati College of Medicine, Mail Location 670769, Cincinnati, OH 45267-0769. Telephone: (513) 558-8114. E-mail: pancioam@ ucmail.uc.edu.
• Emory Petrack, MD, MPH, Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave., Mail Stop MATH6097, Cleveland, OH 44106-6019. Telephone: (216) 844-8716. E-mail: [email protected].
• Lisa Chan, MD, FACEP, University of Arizona, 1501 N. Campbell, P.O. Box 245057, Tucson, AZ 85724-5057. Telephone: (520) 626-2542. Fax: (520) 626-2480. E-mail: [email protected].
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