Analgesia for children with acute abdominal pain: a survey of pediatric emergency physicians and pediatric surgeons

Factors that affect pain management in adults diagnosed with acute appendicitis in the emergency department: A retrospective study

BACKGROUND

Analgesic treatment, including with opioids, can safely be given to patients who are suspected of having appendicitis. The study examined factors which may influence the treatment of pain in appendicitis in the adult emergency department (ED). A secondary objective was to determine if analgesia affected clinical outcomes.

METHODS

This single-center retrospective study examined medical records of all adult patients with a discharge diagnosis of appendicitis. Patients were categorized based on the type of analgesia received in the ED. Variables included the day of week and staffing shift of presentation, gender, age, and triage pain scale, as well as time to ED discharge, imaging, operation, and hospital discharge. Univariable and multivariable logistic regression models were performed to determine which factors influenced treatment and affected outcomes.

RESULTS

Records of 1839 patients were categorized into three groups - 883 (48%) did not receive analgesia, 571 (31%) received only non-opioid medications, and 385 (21%) received at least one opioid. Patients with a higher triage pain level were significantly more likely to receive analgesia (4-6: OR = 1.85; 95% CI = 1.2-2.84, 7-9: OR = 3.36; 95% CI = 2.18-5.17, 10: OR = 10.78; 95% CI = 6.38-18.23) and at least one opioid (4-6: OR = 2.88; 95% CI = 1.13-7.34, 7-9: OR = 4.36; 95% CI = 1.73-11.01, 10: OR = 6.23; 95% CI = 2.42-16.09). Male gender was associated with a significantly lower likelihood of receiving analgesia (OR = 0.74; 95% CI = 0.61-0.9), but a significantly greater likelihood of receiving at least one opioid given that they received any pain medication (OR = 1.87; 95% CI = 1.41-2.48). Patients aged 25-64 years old were significantly more likely to receive at least one opioid if they received any pain medication (25-44: OR = 1.47; 95% CI = 1.08-2.02, 45-64: OR = 1.78; 95% CI = 1.15-2.76). Presentation to the ED on Sundays was associated with lower rates of opioid treatment (OR = 0.63; 95% CI = 0.42-0.94). Regarding clinical outcomes, patients who received analgesia waited longer for imaging (+0.58 h; 95% CI = 0.31-0.85), stayed longer in the ED (+2.2 h; 95% CI = 1.60-2.79), and had a slightly longer hospitalization (+0.62d; 95% CI = 0.34-0.90).

CONCLUSIONS

Almost half of patients with appendicitis didn't receive analgesia, with most of those treated receiving only non-opioid analgesia. Older age and Sunday presentations were associated with less opioid treatment. Patients who received analgesia waited longer for imaging, stayed longer in the ED, and had a longer hospitalization.

Clinical therapeutic effects of opioid analgesia for acute abdominal pain in children and young adults: A protocol for systematic review and meta-analysis

BACKGROUND

Nearly 10% of all patients who visit the emergency department report severe abdominal pain. Out of these, almost one-third are not diagnosed accurately. The conventional practice to care for such inpatients involves actively managed observation and repetitive clinical assessments at regular intervals. The aim of this study is to assess the clinical therapeutic effects of opioid analgesia in the treatment of severe abdominal pain in kids and adolescents.

METHODS

A comprehensive electronic search will be done on Web of Science, EMBASE, PubMed, WanFang database, Chinese National Knowledge Infrastructure, and the Cochrane Library from their establishment to May 2021. The search will identify and retrieve all randomized controlled trials that describe the clinical therapeutic effects of opioid analgesia to treat severe abdominal pain in adolescents and children. Two independent authors will shortlist studies that meet the inclusion criteria, extract data from selected studies, and evaluate the risk associated with bias in the selected articles. We will use RevMan (v: 5.3) to conduct all the data synthesis.

RESULTS

This meta-analysis will conduct a high-quality synthesis on present evidence related to the usage of opioid analgesia to treat severe abdominal pain in both kids and adolescents.

CONCLUSION

Our findings will summarize the present evidence and help judge whether opioid analgesia is an effective and safe line of treatment for severe abdominal pain.

ETHICS AND DISSEMINATION

This study will use pre-published data, and as such, it does not require ethics approval.

OSF REGISTRATION NUMBER

May 29, 2021.osf.io/fp9ym (https://osf.io/fp9ym/).

A two-centre survey of caregiver perspectives on opioid use for children's acute pain management

Background

Given the current opioid crisis, caregivers have mounting fears regarding the use of opioid medication in their children. We aimed to determine caregivers' a) willingness to accept, b) reasons for refusing, and c) past experiences with opioids.

Methods

A novel electronic survey of caregivers of children aged 4 to 16 years who had an acute musculoskeletal injury and presented to two Canadian paediatric emergency departments (ED) (March to November 2017). Primary outcome was caregiver willingness to accept opioids for moderate pain for their children.

Results

Five hundred and seventeen caregivers participated; mean age was 40.9 (SD 7.1) years with 70.0% (362/517) mothers. Children included 62.2% (321/516) males with a mean age of 10.0 (SD 3.6) years. 49.6% of caregivers (254/512) reported willingness to accept opioids for ongoing moderate pain in the ED, while 37.1% (190/512) were 'unsure'; 33.2% (170/512) of caregivers would accept opioids for at-home use, but 45.5% (233/512) were 'unsure'. Caregivers' primary concerns were side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.01 to 1.25) and side effects (OR 1.25, 95% CI 1.11 to 1.42) affected willingness to accept opioids in the emergency department; fears of addiction (OR 1.19, 95% CI 1.07 to 1.32), and overdose (OR 1.15, 95% CI 1.04 to 1.27) affected willingness to accept opioids for at-home use.

Conclusions

Only half of the caregivers would accept opioids for moderate pain, despite ongoing pain following nonopioid analgesics. Caregivers' fears of addiction, side effects, overdose, and masking diagnosis may have influenced their responses. These findings are a first step in understanding caregiver analgesic decision making.

Optimizing the treatment of pain and anxiety in pediatric emergencies: the role of accreditation

Pervasive disparities exist in the treatment of pain and anxiety in pediatric patients presenting to hospitals with emergency conditions. This finding has been demonstrated worldwide, and is especially exacerbated in general emergency departments, which treat both adults and children. Policies to promote appropriate analgesia in the context of pediatric emergency care have been developed by several professional societies and governmental agencies in the United States; however, progress has been uneven, and data regarding these questions is lacking.In their excellent article, Capua and her co-authors address this precise problem through a unique methodology, by surveying nurse directors of both pediatric accredited and non-accredited emergency departments. Survey questions focused on availability of pharmacological and non-pharmacological modalities, and on the prevalence with which providers administered both oral and parenteral medications. The results demonstrated widespread availability of evidence based analgesic and anxiolytic treatment, ranging from medical clowns and specific holding positions, to use of intravenous opiates and conscious sedation. No significant differences were found associated with accreditation.These results are surprising and seem to call into question the value of pediatric accreditation. However, an alternative hypothesis would be that accreditation has succeeded, and the results reflect a large spillover effect, in which providers trained in accredited institutions bring these advanced practices to their local departments. Regionalization has been promoted for emergency care of many acute conditions such as trauma, stroke, and myocardial infarction. These results suggest that for pediatric emergencies, at least in regard to analgesia, the answer likely lies in dissemination of knowledge, rather than super specialization. In other words, bring the expertise to the children, not the children to the experts. Further research in this area could focus on optimal ways to achieve such knowledge translation.

Effect of patient and nurse ethnicity on emergency department analgesia for children with appendicitis in israeli government hospitals

BACKGROUND

Ethnicity is a risk factor for disparate Emergency Department (ED) analgesia. We aimed to explore ethnic variations in the administration of ED analgesia to children with acute appendicitis in Israeli government hospitals.

METHODS

Children discharged with an International Classification of Disease-Ninth Revision diagnosis of acute appendicitis between 2010 and 2015 were included. The association between patient ethnicity (Jewish, Arab) and analgesia administration (any, opioid) was assessed. Age, gender, triage category, pain score and time of arrival were tested as possible confounders. The effect of patient-nurse ethnic discordance (PNED) was examined.

RESULTS

Overall, 4714 children with acute appendicitis, 3520 Jewish and 1194 Arab, were cared for in the EDs; 1516 (32.2%) received any analgesia and 368 (7.8%) opioid analgesia. Stratified by pain score, no statistical differences were found in the administration of any or opioid analgesia between Jewish and Arab patients with either severe pain or moderate pain. In multivariate modelling adjusted for pain score and triage category, the rates of any analgesia for Arab and Jewish patients were 31.8% (95% CI, 30.9-32.6) and 36.5% (95% CI, 36.0-36.9), adjusted OR (aOR) = 1.16 (95% CI, 0.98-1.38), respectively. The rates of opioid analgesia for Arab and Jewish patients were 8.5% (95% CI, 8.2-8.9) and 7.9% (95% CI, 7.3-8.7), aOR = 0.77; (95% CI, 0.59-1.22), respectively. Jewish and Arab nurses treated proportionally fewer patients from the opposite ethnicity with any analgesia (p < 0.01).

CONCLUSION

Emergency Department analgesia was markedly low, and not associated with patient ethnicity. PNED was associated with decreased rates of analgesia.

SIGNIFICANCE

Emergency Department analgesia for children with acute appendicitis in Israeli government hospitals is markedly low. Patient-provider ethnic discordance may negatively influence the provision of analgesia. Significant efforts should be undertaken in order to increase analgesia provision rates and reduce social inequality.

Is caregiver refusal of analgesics a barrier to pediatric emergency pain management? A cross-sectional study in two Canadian centres

What is known about the topic?

Children’s pain in the emergency department (ED) continues to be under-recognized and sub-optimally managed.

What did this study ask?

We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.

What did this study find?

Of the 743 children who presented to the ED with a painful condition, 408 (54.9%) were offered analgesia. If offered in the ED, analgesia was accepted by 91% (373/408) of the caregivers/children.

Why does this study matter to clinicians?

This study suggests that caregiver/child refusal of analgesia is a not a major barrier to optimal pain management and highlights the importance of ED personnel in encouraging adequate analgesia.

Emergency Department Pain Management in Children With Appendicitis in a Biethnic Population

OBJECTIVES

Our goal was to examine factors associated with the administration of emergency department analgesia (any analgesia, opioid analgesia) in patients with acute appendicitis in a tertiary children's hospital in Israel, and to examine ethnic differences.

METHODS

A retrospective cohort study of children evaluated in the emergency department, who had International Classification Of Disease-Ninth Revision (ICD-9) diagnosis of acute appendicitis. Regression analysis was used to test the effect of multiple variables on the provision of analgesia. Medications were administered according to a nurse-driven pain protocol. Multivariate regression was performed to estimate the strength of association between ethnicity and provision of analgesia. The effect of patient-nurse ethnicity concordance was assessed.

RESULTS

During the 6-year study period, there were 715 children with acute appendicitis, 457 Jews and 258 Arabs. Overall, 289 (40.4%) received some form of analgesia, and 139 (19.4%) received opioid analgesia. Univariate analysis revealed that higher pain score (P<0.001) and higher triage acuity (P<0.001) were associated with administration of any type of analgesia and of opioid analgesia. When adjusted for age, weight, sex, triage category, pain score, and 24-hour time of arrival, Jewish and Arab patients had similar likelihood of receiving analgesia of any type 41.8% (95% confidence interval [CI], 40.3%-43.3%) versus 40.7% (95% CI, 38.7%-42.8%), and receiving opioid analgesia 26.1% (95% CI, 24.4%-27.8%) versus 25.3% (95% CI, 22.9%-27.7%). Similar proportions of Jewish and Arab patients received analgesia from Jewish and Arab nurses.

CONCLUSIONS

Low rates of analgesia and opioid administration were found with no ethnic differences.

Pediatric procedural pain: how far have we come? An ethnographic account

The aim of this ethnographic study was to explore the pediatric procedural pain management practice of health care providers in a non-pediatric emergency department. Data were collected for 5 months and included more than 100 hours of observation. Six key informants were interviewed, and 44 pediatric procedural interactions with 27 health care providers during the treatment of children aged 2 to 8 years undergoing procedures were observed. Other information gathered included documents from the institution, and pain-related information from the patient's medical record. Two major themes with categories are discussed, the treatment of pain, and procedural pain. The findings of this study provide insight into the everyday practice of emergency department health care providers for pediatric pain in a non-pediatric setting, and identify practice issues that may adversely affect the management of pediatric procedural pain, notably the nonuse of pharmacologic techniques for simple needle procedures and the common use of physical restraint during painful procedures.

Pain management of acute appendicitis in Canadian pediatric emergency departments

OBJECTIVES

Children with suspected appendicitis are at risk for suboptimal pain management. We sought to describe pain management patterns for suspected appendicitis across Canadian pediatric emergency departments (PEDs).

METHODS

A retrospective medical record review was undertaken at 12 Canadian PEDs. Children ages 3 to 17 years who were admitted to the hospital in February or October 2010 with suspected appendicitis were included. Patients were excluded if partially assessed or treated at another hospital. Data were abstracted using a study-specific, standardized electronic data extraction tool. The primary outcome was the proportion of children who received analgesia while in the emergency department (ED). Secondary outcomes included the proportion of children receiving intravenous (IV) morphine and the timing of analgesic provision.

RESULTS

A total of 619 health records were abstracted; mean (SD) patient age was 11.4 (3.5) years. Sixty-one percent (381/616) of patients received analgesia in the ED; 42.8% (264/616) received IV morphine. Other analgesic agents provided included oral acetaminophen (23.5% [145/616]) and oral ibuprofen (5.8% [36/616]). The median (IQR) initial dose of IV morphine was 0.06 (0.04, 0.09) mg/kg. The median (IQR) time from triage to the initial dose of analgesia was 196 (101, 309.5) minutes. Forty-three percent (117/269) of children receiving analgesia received the initial dose following surgical consultation; 43.7% (121/277) received their first analgesic after abdominal ultrasound was performed.

CONCLUSIONS

Suboptimal and delayed analgesia remains a significant issue for children with suspected appendicitis in Canadian PEDs. This suggests a role for multidimensional knowledge translation interventions and care protocols to improve timely access to analgesia.

Appendicitis and Analgesia in the Pediatric Emergency Department: Are We Adequately Controlling Pain?

OBJECTIVES

The primary objective of the study was to compare analgesia-prescribing practices and timing of analgesia administration between pediatric emergency medicine (PEM) and general emergency medicine (GEM) practitioners for children with appendicitis. The secondary objective was to compare analgesia administration versus triage pain score, pediatric appendicitis score (PAS), and body mass index (BMI).

METHODS

This was a retrospective chart review of patients younger than 21 years who presented to either an urban pediatric emergency department (ED) or 2 general EDs and were diagnosed with appendicitis.

RESULTS

Two hundred eighteen charts were reviewed, 153 (70%) from the pediatric ED and 65 (30%) from the general EDs. The patients seen by PEM physicians were younger than the patients seen by GEM physicians (mean age, 12.8 vs 15.4 years; P = 0.002). The patients evaluated by GEM physicians were more likely to receive analgesia in the ED (82% vs 60%, P = 0.003) and received analgesia sooner (mean, 178 vs 239 minutes; P = 0.026) than the patients evaluated by PEM physicians. The patients with triage pain scores higher than 6 of 10 were more likely to receive analgesia than the patients with pain scores lower than 6 (71% vs 51%, P = 0.015). There was no association between PAS or BMI and analgesia administration or time to analgesia (P = not significant).

CONCLUSIONS

The patients with appendicitis evaluated by GEM physicians were more likely to receive analgesia and receive analgesia quicker than the patients evaluated by PEM physicians. The patients with higher pain scores were more likely to receive analgesia, but PAS and BMI did not affect analgesia administration.

Children receive less analgesia in general ERs than adults: A retrospective study

Background/Introduction: Oligoanalgesia is a common phenomenon in the Emergency Department (ED) with children being especially at risk. However, the extent to which pediatric patients are being undertreated for acute pain in relation to their adult counterparts is not well understood, especially in general (i.e., mixed adult and pediatric) EDs. This study was designed to compare the pain medication received by adult and pediatric patients with appendicitis presenting to a general ED. Methods: A retrospective chart review of 165 patients, 92 adult (mean age: 35.7 ± 15.7 years) and 73 pediatric (mean age: 11.0 ± 3.0 years) with a discharge diagnosis of “appendicitis” were included in this study. Demographic information as well as data regarding type, timing, and received amount of pain medication were collected. Adult and pediatric data were then compared using independent t-test or chi-square analysis. Effect sizes were also calculated. Results: Pediatric patients were significantly more likely than adult patients to not receive any analgesia during their ED stay (58.9% vs 20.7%, p>0.001, Cramer's V = 0.39). They were also significantly less likely to receive opioid analgesics, compared to adults (27.4% vs. 71.7%, p>0.001, Cramer's V = 0.44). Finally, mean pain scores recorded at presentation were significantly lower for children vs. adults (6.5 vs 7.2 out of 10, p = 0.015, r = 0.20). Conclusion: In this sample, pediatric patients with appendicitis presenting to a general emergency department received less opioid pain medication, and less pain medication in general, than their adult counterparts.

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments

Objectives

Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation.

Methods

Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman’s Tailored Design method was used to distribute the survey from June to July 2014.

Results

Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition.

Conclusions

Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.

Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis

OBJECTIVES

There are long-held concerns that analgesia in patients with acute abdominal pain may obscure the physical examination and lead to missing a diagnosis of appendicitis. Despite evidence to the contrary, analgesia continues to be underutilized and suboptimally dosed in children with acute abdominal pain. The objective of this systematic review and meta-analysis was to determine if opioids provide analgesia without an increase in side effects and appendicitis-related complications.

METHODS

Trials were identified through electronic searches of MEDLINE (1946-2013), EMBASE (1980-2013), Cochrane Central Register of Controlled Trials (2013), CINAHL (1981-2013), and Google Scholar (2013). All randomized controlled trials (RCTs) of children aged 0-18 years with acute abdominal pain that compared any opioid analgesic to placebo were included. The methodologic qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively.

RESULTS

Six RCTs met inclusion criteria, and each compared a single-dose parenteral opioid to a placebo, providing data on 342 children aged 5 to 18 years. The pooled mean pre/post difference in self-reported pain scores was 19.61 mm (95% confidence interval [CI] = -1.16 to 40.37 mm) lower in those receiving opioid analgesia. There was no significant increase in the risk of perforation or abscess associated with opioids in cases of appendicitis (relative risk [RR] = 1.03, 95% CI = 0.55 to 1.93). The risk of side effects was significantly greater in patients who received opioids (RR = 6.06, 95% CI = 1.10 to 33.49). Subtherapeutic dosing of opioids was detected in all six trials.

CONCLUSIONS

The use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects. However, there is no increased risk of perforation or abscess. The overall quality of evidence is low, suggesting the need for larger, high-quality trials that are powered to detect both serious complications of appendicitis and determine the most efficacious opioid dosing for children.

Early analgesic treatment regimens for patients with acute abdominal pain: a nationwide survey among general surgeons

INTRODUCTION

Early pain relief in patients with acute nontraumatic abdominal pain in emergency departments has been discussed for years. Some randomized trials have addressed this issue but conclusive data are lacking. In this study, we assessed the current treatment practice in German hospitals in order to evaluate the necessity of a further clinical trial.

METHODS

An online survey containing 27 questions was sent to general and visceral surgeons at attending level using a mailing list provided by the Professional Board of German Surgeons (BDC) using a standard interview software. The questionnaire collected demographic data, current treatment policies about frequency of early analgesia, types of pain medication, and opinions about their use and effects.

RESULTS

Four hundred ninety-five completed questionnaires were returned. Many surgeons were cautious about early analgesia in the emergency department. Forty-five percent of the surgeons would provide analgesia prior to diagnosis to the majority of patients. Within the departments, differing opinions existed regarding the analgesic treatment (41 %). Thirty-two percent of all the respondents knew about a false diagnosis after early analgesia. There was heterogeneity in the estimation of the impact of pain medication on masking of clinical symptoms. A randomized controlled trial would be supported by the majority of respondents. As influencing factors for withdrawing early analgesia, we found the examiner being over 40 years of age (p < 0.05), low experience with the clinical picture of acute abdominal pain (p < 0.05), high estimation of the masking of clinical findings (p < 0.001), and knowing about a false diagnosis after early analgesia (p < 0.001) to be significant.

CONCLUSION

Discordance in the analgesic treatment regimens in patients with acute abdominal pain still exists in German hospitals. The topic remains subject of frequent discussions. More high quality data are needed before a clear guideline can be given for implementation in clinical routine management.

Analgesia in patients with acute abdominal pain

BACKGROUND

For decades, the indication of analgesia in patients with Acute Abdominal Pain (AAP) has been deferred until the definitive diagnosis has been made, for fear of masking symptoms, generating a change in the physical exploration or obstructing the diagnosis of a disease requiring surgical treatment. This strategy has been questioned by some studies that have shown that the use of analgesia in the initial evaluation of patients with AAP leads to a significant reduction in pain without affecting diagnostic accuracy.

OBJECTIVES

To determine whether the evidence available supports the use of opioid analgesics in the diagnostic process of patients with AAP.

SEARCH STRATEGY

Trials were identified through searches in Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library, issue 2, 2009), MEDLINE (1966 to 2009) and EMBASE (1980 to 2009). A randomised controlled trial (RCT) filter for a MEDLINE search was applied (with appropriate modification for an EMBASE search). Trials also were identified through "related articles". The search was not limited by language or publication status.

SELECTION CRITERIA

All published RCTs which included adult patients with AAP, without gender restriction, comparing any opioids analgesia regimen with the non-use of analgesic before any intervention and independent of the results.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the studies identified via the electronic search. Articles that were relevant and pertinent to the aims of the study were selected and their respective full-text versions were collected for subsequent blinded evaluation. The allocation concealment was considered in particular as an option to diminish the biases.The data collected from the studies were reviewed qualitatively and quantitatively using the Cochrane Collaboration statistical software RevMan 5.0. After performing the meta-analysis, the chi-squared test for heterogeneity was applied. In situations of significant clinical heterogeneity, statistical analyses were not applied to the pool of results. In situations of heterogeneity, the random effect model was used to perform the meta-analysis of the results. A sensitivity analysis was also applied based on the evaluation to the methodological quality of the primary studies.

MAIN RESULTS

Eight studies fulfilled the inclusion criteria. Differences with use of opioid analgesia were verified in variables: Change in the intensity of the pain, change in the patients comfort level.

AUTHORS' CONCLUSIONS

The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.

Knowledge, attitude and practices among health care professionals regarding pain

OBJECTIVE

To assess the knowledge, attitude and practices among health care professionals regarding pain in children.

METHODS

This was a prospective descriptive survey conducted at a tertiary care hospital in north India. A semi structured questionnaire regarding pain in children was administered to pediatric residents and nurses in a teaching hospital. The questionnaire consisted of 24 items, of which 18 items were rated on a 5-point scale ('strongly agree' to 'strongly disagree') and 6 items were open-ended questions.

RESULTS

The response rate was 89.5%. Of 77 participants, 47 (61.1%) were nurses and 30 (38.9%) were pediatric residents. The knowledge about pain scales among the studied healthcare professionals was not widespread. Majority of respondents believed that the best judge of intensity of pain is the child. Nearly two-thirds of the respondents felt that non-pharmacological measures were better to control pain and also their practices showed that most were willing to allow the parental presence during minor invasive procedures.

CONCLUSION

There is need to improve the knowledge of health care personnel regarding pain assessment and management in children.

Pain Management Practices in a Pediatric Emergency Room (PAMPER) Study: interventions with nurses

BACKGROUND AND AIM

Children's pain in emergency departments (EDs) is poorly managed by nurses, despite evidence that pain is one of the most commonly presenting complaints of children attending the ED. Our objectives were 2-fold: to verify if tailored educational interventions with emergency pediatric nurses would improve nurses' knowledge of pain management and nurses' pain management practices (documentation of pain, administration of analgesics, nonpharmacological interventions).

METHODS

This intervention study with a pre-post design (baseline, immediately after the intervention [T-2], and 6 months after intervention [T-3]) used a sample of nurses (N = 50) and retrospective chart reviews of children (N = 450; 150 charts reviewed each at baseline, T-2, and T-3) who presented themselves in the ED with a diagnosis known to generate moderate to severe pain (burns, acute abdominal pain, deep lacerations, fracture, sprain). Principal outcomes: nurses' knowledge of pain management (Pediatric Nurses Knowledge and Attitudes Survey [PNKAS] on pain) and nurses' clinical practices of pain management (Pain Management Experience Evaluation [PMEE]).

RESULTS

Response rate on the PNKAS was 84% (42/50) at baseline and 50% (21/42) at T-2. Mean scores on PNKAS were 28.2 (SD, 4.9; max, 42.0) at baseline and 31.0 (SD, 4.6) at T-2. Results from paired t test showed significant difference between both times (t = -3.129, P = 0.005). Nurses who participated in the capsules improved their documentation of pain from baseline (59.3%) to T-2 (80.8%; chi = 12.993, P < 0.001) as well as from baseline (59.3%) to T-3 (89.1%; chi = 29.436, P < 0.001). In addition, nurses increased their nonpharmacological interventions from baseline (16.7%) to T-3 (31.9%; chi = 8.623, P = 0.003). Finally, we obtained significant differences on pain documentation between the group of nurses who attended at least 1 capsule and the group of nurses who did not attend any capsule at both times (T-2 and T-3; chi = 20.424, P < 0.001; chi = 33.333, P < 0.001, respectively).

CONCLUSIONS

The interventions contributed to the improvement of the nurses' knowledge of pain management and some of the practices over time. We believe that an intervention tailored to nurses' needs and schedule has more impact than just passive diffusion of educational content.

Analgesia in patients with acute abdominal pain

BACKGROUND

For decades, analgesia for patients with acute abdominal pain was withheld until a definitive diagnosis was established for fear of masking the symptoms, changing physical findings or ultimately delaying diagnosis and treatment of a surgical condition. This non-evidence-based approach has been challenged by recent studies demonstrating that the use of analgesia in the initial evaluation of patients with acute abdominal pain leads to significant pain reduction without affecting diagnostic accuracy. However, early administration of analgesia to such patients can greatly reduce their pain and does not interfere with a diagnosis, which may even be facilitated due to the severity of physical symptoms being reduced.

OBJECTIVES

To determine if the currently available evidence supports the use of opioid analgesia in patient management with acute abdominal pain; and to assess changes in a patient comfort while awaiting definitive diagnosis and final treatment decisions.

SEARCH STRATEGY

Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 4, 2006), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). Randomized controlled trial filter for MEDLINE and EMBASE search. Trials will also be identified by "related articles". The searches were not limited by language or publication status.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that include adult patients with acute abdominal pain, without gender restriction, comparing any opioid analgesia regime to no analgesia administered prior to any intervention regardless of outcomes.

DATA COLLECTION AND ANALYSIS

Two authors looked independently at the titles and abstracts of reports. Potentially relevant studies selected by at least one reviewer were retrieved in full text versions for potential inclusion. Allocation concealment was important to avoid bias and was graded using the Cochrane approach. The data from studies included was reviewed qualitatively and quantitatively using the Cochrane Collaborations methodology and statistical software RevMan Analysis 1.0.5. In the case of homogeneity or non- worrying heterogeneity, a random effects model was used. Sensitivity analysis was performed based on quality assessment.

MAIN RESULTS

Six studies fulfilled the inclusion criteria. Improvement with use of opioid analgesia was verified in variables patient comfort, reduction of pain, changes in physical examination.

AUTHORS' CONCLUSIONS

The review provide some evidence to support the notion that the use of opioid analgesics in patients with acute abdominal pain is helpful in terms of patient comfort and does not retard decisions to treat.

[Use of opioid analgesics in diagnosis and decision-making in patients with acute nontraumatic abdominal pain. A systematic review of the literature]

INTRODUCTION

The use of analgesics during the diagnosis and decision-making process in patients with acute nontraumatic abdominal pain is controversial. The aim of the present study was to determine whether the use of opioid analgesics in patients with acute nontraumatic abdominal pain increases the risk of diagnostic error.

METHOD

We performed a systematic review of the literature. Randomized clinical trials (RTCs) comparing the use of opioid analgesics with placebo administered before any procedure in patients with acute nontraumatic abdominal pain were included. There was no restriction on language. RTCs unrelated to this subject were excluded. The variables analyzed were age, gender, and the percentage of adverse effects, appendicitis, changes on physical examination and diagnostic error, modification of pain severity measured by a visual analog scale, and methodological quality of the studies. A search was performed in the MEDLINE and Cochrane databases, using MeSH terms. Each article was analyzed by applying a methodological quality score through which weighted means were applied for each variable. The Chi-square and Student's t-test were applied to compare the groups.

RESULTS

Six articles meeting the selection criteria were found. The mean methodological quality score was 21.6 points. The studies represented a population of 363 patients treated with opioids and 336 patients treated with placebo. There were no differences in the mean age of the patients (39.4 vs 39.6 years), distribution by gender, prevalence of acute appendicitis (23.3% vs 24%) or diagnostic error (15.6% vs 21.1%; p = 0.0637). Differences were found in the variable of pain reduction (27.2 vs 7.2 mm, respectively; p = 0.0167).

CONCLUSIONS

The use of opioid analgesics in patients with acute nontraumatic abdominal pain does not increase the risk of diagnostic error and reduces pain during the decision-making process.

Methods and practices of investigators for determining participants' decisional capacity and comprehension of protocols

ETHICISTS RECOMMEND THAT investigators assess subjects' comprehension prior to accepting their consent as valid. Because children represent an at-risk population, ensuring adequate comprehension in pediatric research is vital. We surveyed all corresponding authors of research articles published over a six-month period in five leading adult and pediatric journals. Our goal was to assess how often subject's comprehension or decisional capacity was assessed in the consent process, whether there was any difference between adult and pediatric research projects, and the rate at which investigators use formal or validated tools to assess capacity. Responses from 102 authors were analyzed (response rate 56%). Approximately two-thirds of respondents stated that they assessed comprehension or decisional capacity prior to accepting consent, and we found no difference between adult and pediatric researchers. Nine investigators used a formal questionnaire, and three used a validated tool. These findings suggest that fewer than expected investigators assess comprehension and decisional capacity, and that the use of standardized and validated tools is the exception rather than the rule.

Analgesia administration for acute abdominal pain in the pediatric emergency department

OBJECTIVE

To document the use of analgesia for children with acute abdominal pain in the Pediatric Emergency Department (PED) and to compare between children with suspected appendicitis in a high versus low probability.

STUDY DESIGN

Patients 0-16 years recruited prospectively as part of another PED study in Toronto. History of present illness and physical examination was available, and information on analgesia administered in the PED was retrospectively collected from charts. Physicians' probability of appendicitis before any imaging was recorded. A follow-up call was made to verify final diagnosis.

RESULTS

We included 438 patients, 16% with appendicitis. Analgesics were given 154 times to 112 patients. Thirty-one percent of the cohort received analgesia before seeing the physician, mostly febrile, 37% after seeing the physician, and 17% after seeing a pediatric-surgery consultant. Fifteen percent received multiple dosages. Underdosing was recorded in 14% of medications, mostly morphine (24%). Analgesia was given significantly more often to children with high probability of appendicitis. Age was not a factor in analgesia administration.

CONCLUSION

Children with abdominal pain receive more analgesia when the physician suspects appendicitis, yet only in half of the cases, and only 15% receive opioids. Opioid underdosing happens in a quarter of times it is given.

Assessment of physician directiveness: using hypoplastic left heart syndrome as a model

OBJECTIVE

To test the hypothesis that surgeons are more directive than pediatricians in discussions with parents of critically ill children.

STUDY DESIGN

We designed a novel tool to assess physician directiveness in discussions with parents of children with hypoplastic left heart syndrome. We sent surveys containing the assessment tool as well as demographic questions to all attending physicians in Neonatology, Pediatric Critical Care, Pediatric Cardiology, and Congenital Cardiac Surgery at 14 of the largest pediatric cardiac surgery centers in the United States. Responses to the tool were used to determine a "directiveness score" for each physician. We then performed univariate and multivariable linear regression analyses to assess the association of physician specialty, race/ethnicity, religion, gender, and years in practice with the directiveness score.

RESULTS

Responses from 138 physicians were analyzed. In univariate analyses, with neonatologists as the reference group, surgeons were most directive (regression coefficient 3.02, 95% confidence interval 0.69 to 5.35, P=0.01), followed by cardiologists (regression coefficient 1.67, 95% confidence interval 0.13 to 3.20, P=0.03). No other variable was associated with physician directiveness score. These results were similar in the multivariable analysis.

CONCLUSIONS

These results suggest that physician specialty is associated with directiveness. It is unclear, however, what amount of direction parents of critically ill children prefer.