[Therapy recommendations in a pediatric outpatient pain clinic : Adherence and effectiveness of implementation]

BACKGROUND

Supplementary pain-related recommendations for the treatment of chronic pain in children and adolescents are an essential component of multimodal pain treatment. Studies are scarce regarding adherence to these recommendations and their effectiveness.

OBJECTIVE

The aim of this study was to evaluate patient adherence to pain-related recommendations and their effectiveness 12 months after initial presentation of children and adolescents with chronic pain to a pediatric outpatient pain clinic.

MATERIALS AND METHODS

A total of 413 patients were assessed using a structured telephone interview. The assessment included pain characteristics during the last 4 weeks as well as information regarding the implementation of the pain-related recommendations and the effectiveness. Due to different recommendations given to migraine patients this subgroup was dealt with separately.

RESULTS

Patients reported significant improvements 12 months after the initial presentation and 29.5 % of the patients were pain free. Adherence levels and estimated effectiveness regarding recommendations, such as change of lifestyle, multimodal inpatient treatment and use of medication were high. Other recommendations, such as active relaxation and outpatient psychotherapy had low adherence levels and low estimated effectiveness. Migraine patients had a significantly higher adherence rate and estimated effectiveness regarding the recommendation use of medication than non-migraine patients.

CONCLUSION

The adherence level as well as the estimated effectiveness regarding the majority of pain-related recommendations was high. Some recommendations had low adherence rates and low estimated effectiveness. These results can help to further improve the performance of outpatient clinics for children and adolescents with chronic pain.

[Pediatric general practitioners and tertiary care structures for pain therapy. A qualitative study on the need for networking]

BACKGROUND

Despite the urgency of the problem of chronic pediatric pain and the importance of early interventions, many children experience intermittent episodes of pain over a long period of time. One aim of this study was to investigate the need of structured diagnostic tools and therapies of chronic pediatric pain in pediatric general practices. Another aim was to describe the aims, services and challenges of a network between pediatric practices and a tertiary pediatric pain centre, from the perspective of general pediatric practitioners.

MATERIAL AND METHODS

A qualitative research design was selected and 20 general pediatric practitioners were interviewed using a semistructured interview guide. Interviews were analyzed by use of qualitative content analysis according to Mayring.

RESULTS

Generally, the idea of a network between pediatric practices and the German Pediatric Pain Centre was rated positively by pediatric general practitioners. From the results of the analysis three categories were identified: (i) expectations from the network (ii) desire for cooperation in the network and (iii) recommendations for improved patient care.

CONCLUSION

A network with a centre for tertiary care was preferred by the general pediatric practitioners. To optimize the care of children with chronic pain further education for general pediatric practitioners as well as structured diagnostic tools and therapies of frequent pediatric chronic pain diseases are warranted.

Difficulties in screening for peripheral neuropathies in children with diabetes

AIMS

To assess the diagnostic utility of a novel abbreviated monofilament test in comparison with the tuning fork test to detect diabetic peripheral neuropathy in children.

METHODS

A total of 88 children with Type 1 diabetes mellitus were screened for diabetic peripheral neuropathy using the monofilament test and the tuning fork. Nerve conduction studies were performed according to the 'gold standard' for neuropathy. We assessed the diagnostic utility and inter-rater agreement of the two screening methods.

RESULTS

A total of 43 (49%) children (aged 6-18 years) had at least one abnormal nerve conduction study result. Diagnostic utility and inter-rater agreement were very low for both screening methods. The monofilament test yielded a sensitivity of 18% and a specificity of 80%. The tuning fork yielded a sensitivity of 0% and a specificity of 98%.

CONCLUSION

The present study found that an abbreviated monofilament test has low diagnostic utility for the detection of early diabetic peripheral neuropathy because of its low reliability. The problem of reliability needs to be more thoroughly addressed in order to improve the screening procedures in diabetes management in childhood and adolescence.

Physician consultation in young children with recurrent pain-a population-based study

Background. Recurrent pain is a common experience in childhood, but only few children with recurrent pain attend a physician. Previous studies yielded conflicting findings with regard to predictors of health care utilization in children with recurrent pain. Methods. The present study analyzes data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study comprising n = 2,149 children (3-10 years old) with recurrent pain to find robust predictors. We used multiple logistic regressions to investigate age, gender, socio-economic status (SES), migration background, pain intensity, pain frequency, pain-related disability, mental health problems, and health-related quality of life (HRQL) as predictors for visiting a doctor due to pain. Results. Overall, young girls with high pain-related disability, intensity, frequency, and migration background were more likely to attend a physician. Pain-related disability had the largest impact. Socioeconomic status, health-related quality of life and mental health problems were not systematically related to health care utilization. An analysis of the variability of these results indicated that several hundred participants are needed until the results stabilize. Conclusions. Our findings highlight the importance of pain-related disability and frequency in assessing the severity of recurrent pain. Generic predictors and demographic variables are of lesser relevance to children with recurrent pain. On a methodological level, our results show that large-scale studies are need to reliably identify predictors of health care utilization.

Childhood diabetic neuropathy: functional impairment and non-invasive screening assessment

AIM

Sensory diabetic neuropathy, determined by nerve conduction studies, is common in children with Type 1 diabetes. Diabetic neuropathy diagnoses are rarely made in paediatric daily care because they are asymptomatic, vibration detection is mostly normal and nerve-conduction testing is impractical. The present study aims to: (1) describe somatosensory dysfunction in children with diabetes, (2) test whether diabetes duration and HbA(1c) are related to somatosensory dysfunction and (3) identify the best screening test for large-fibre dysfunction, as indicated by nerve conduction studies.

METHODS

Forty-five children (age 13.2 ± 2.5 years) with Type 1 diabetes for 6.7 ± 2.5 years and matched control subjects were assessed by neurological examinations, nerve conduction tests and quantitative sensory testing on the feet using the protocol of the German Research Network on Neuropathic Pain. Abnormal nerve conduction was used as gold standard to define neuropathies.

RESULTS

We found a high prevalence of mechanical (38%) and thermal (24%) hypoesthesia often associated with hyperalgesia (47%). Tactile hypoesthesia (33%) was more frequent than pallhypaesthesia (11%). Only cold detection and mechanical pain thresholds were related to HbA(1c). Tactile hypoesthesia had the highest sensitivity (75%), specificity (89%) and positive (75%) and negative (89%) predictive values for neuropathies defined by nerve conduction tests (31% abnormal).

CONCLUSIONS

Almost half of the children with diabetes have subclinical large- and small-fibre neuropathies. Tactile detection was better than vibration for neuropathy assessment. Quantitative sensory testing is a valuable tool for assessment of neuropathy as well as a target of interventional studies in children with diabetes.

[Pain perception of adolescents with chronic functional pain : adaptation and psychometric validation of the Pain Perception Scale (SES) by Geissner]

BACKGROUND

Pain perception is a central aspect of the multidimensional model of chronic pain. Up to now, validated measurement tools are lacking in the German language for measuring pain perception in adolescents. The aim of this study was to examine and adapt the well-established Pain Perception Scale for Adults by Geissner (SES) for use in adolescents with chronic pain to provide a measure for clinical diagnosis and evaluation of treatment effects.

MATERIAL AND METHODS

Principal component, reliability and item analyses were conducted on a sample with 139 adolescents. To test validity, age and sex effects, correlations with pain-related constructs, differences between treatment groups (inpatients vs outpatients) and concordance between adolescents and their parents were analysed.

RESULTS

Findings support a two-factor solution with one affective and one sensory factor; three additional sensory items were included in the final version. The scales show good internal consistency. Consistent with hypotheses, we found significant correlations with pain characteristics, emotional and cognitive variables as well as pain-related disability. Inpatients and outpatients show a significant difference in affective pain perception. Concordance between parents and adolescents was high.

CONCLUSION

With this questionnaire there is now a validated German assessment tool to measure pain perception in adolescents with chronic pain (Pain Perception Scale for Adolescents, SES-J). Due to its practicability it is suitable for clinical application.

Paroxysmal Hemicrania in Children—Symptoms, Diagnostic Criteria, Therapy and Outcome

Whereas paroxysmal hemicrania (PH) is studied extensively in adults, even case reports of PH in children are rare. We present the first prospective follow-up study on PH in children. Our aim was to investigate whether differences exist between paediatric and adult patients. We assessed all children with chronic headache who were referred to our paediatric out-patient pain clinic within 3 years based on interviews and validated questionnaires. Among 628 patients we found five children with PH (0.8%) and three with probable PH (0.5%), in total 1.3%. Pain characteristics, autonomic symptoms and treatment response to indomethacin were similar to adult PH patients. Our results demonstrate that the International Headache Society classification of PH is also applicable to children. We suspect that PH has been underdiagnosed in children and therefore suboptimally treated thus far.

[IMPaCCT: standards of paediatric palliative care]

The needs of children and families living with life-limiting and life-threatening illness are similar across all European countries. Meeting these needs requires a comprehensive and integrative approach, with the input of a skilled multidisciplinary paediatric team. It is essential that the core standards for paediatric palliative care recommended in this document of the European Association for Palliative Care (EAPC) now be implemented across Europe.

[Ambulatory pain management for children in the family practice]

Effective pain management is possible for children just as for adults and is especially demanded by all experts. Nevertheless, many children still receive inadequate pain management care, whether it is after operations, for infections or for chronic painful conditions. There are clear therapeutic concepts for the treatment of children even in the family practice which include the use of short-acting opioids depending on the intensity of the pain and symptoms.

[Three-week multimodal inpatient treatment of children with chronic pain. First results of the long-term follow-up]

OBJECTIVE

In children and adolescents we investigated the impact of a 3-week inpatient multimodal pain therapy on subjective burden of life, pain intensity, and number of days off from school 3, 6, or 12 months later.

METHODS

At the beginning of therapy (inpatient setting) and 3, 6, and 12 months thereafter (outpatient setting) we collected the respective data using standardized questionnaires. For statistical analysis we used Wilcoxon's signed rank test. A p <0.05 was regarded as statistically significant.

RESULTS

A total of 72 patients aged 7.5-18.2 years suffering daily pain entered the study, most of them being diagnosed with somatoform pain disease. After 3, 6, and 12 months, 65, 27, and 30 patients could be reevaluated. Mean pain intensity of the week before data acquisition was significantly less than at the beginning (2.9, 2.3, and 2.9 vs 6.3) as was the mean number of days off from school due to pain during the 4-week period before each day of data acquisition (1.8, 1.5, and 1.4 vs 9.2). Mean subjective burden of life was significantly less than at the beginning (24.5, 22.0, and 25.8 vs 37.8).

CONCLUSION

Outpatient multimodal pain therapy has a sustained impact on children and adolescents suffering from chronic pain.

[Practical pain control in pediatric oncology. Recommendations of the German Society of Pediatric Oncology and Hematology, the German Association for the Study of Pain, the German Society of Palliative Care, and the Vodafone Institute of Children's Pain Therapy and Palliative Care]

In pediatric oncology, optimal pain control is still a challenge. A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in the prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented toward the WHO multistep therapeutic schedule. On no account should the pediatric patient have to climb up the "analgesic ladder" - strong pain requires the primary use of strong opioids. Give opioids preferably by the oral route and by the clock - short-acting opioids should be used to treat breakthrough pain. Alternatives are i.v. infusion, patient-controlled analgesia, and transdermal applications. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of pediatric nurses is of the utmost importance in pediatric pain control. Nurses deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses' task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our guideline we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.

Buprenorphineinsatz bei Kindern

There is a paucity of relevant pediatric data on buprenorphine, especially with respect to the long-term application in children suffering chronic pain or to pediatric pharmacokinetic as well as pharmacodynamic data after repeated sublingual or long-term transdermal administration. Compared to adults, after single-dose buprenorphine, children seem to exhibit a larger clearance related to body weight and a longer duration of action. If combined with other opioids or sedatives or if the metabolite norbuprenorphine cumulates, it is difficult to estimate the risk of respiratory depression. Clear-cut evidence is missing that in children there is a ceiling of buprenorphine-induced respiratory depression. Due to its various application routes, long duration of action, and metabolism largely independent of renal function buprenorphine is of special clinical interest in pediatrics, especially for postoperative pain and cancer pain control. There is no reason to expect effects fundamentally different from those in adults.

Individuelle Kinder — individuelle Kopfschmerzen

In the industrialized nations headache prevalence is increasing in children and adolescents. The nosologic classification determines the therapeutic strategy to follow. Three case reports illustrate the optimal cooperation of both a pediatric outpatient pain clinic and a pediatric psychosomatic pain clinic. We report on (1) a girl aged 2 years and 7 months with a 4-month history of headache episodes lasting about 15 min each with concomitant symptoms; (2) an 11-year-old boy with Schimmelpenning-Feuerstein-Mims syndrome, symptomatic focal epilepsy, psychomotor retardation, mild postinfectious internal hydrocephalus, and repeated heat-triggered episodes of right-sided headache beginning suddenly with a duration of 5-30 min and concomitant flush of his hemiface; and (3) a 12-year-old boy who for about 2 years has suffered from "migraine" 3 times a week, significantly impairing his quality of life. We discuss the patients' courses, diagnostic pitfalls, and therapeutic options. For the optimal treatment of children with headache not easily fitting into one of the categories, with significant comorbidity present, or if there is no adequate response to therapy conforming with guidelines, the help of an interdisciplinary pediatric pain clinic is invaluable.

Opioidtherapie chronischer Schmerzen bei Kindern

Based on 4 case reports we focus on the peculiarities of long-term pediatric opioid based pain control. Case report #1, emphasizing the importance of adequate opioid dosing with reference to body weight, illustrates that with adequate management oral sustained-release opioid therapy is safe even in infants less than one year old. Case report #2 is the first report on the usage of buccal fentanyl citrate for pediatric break-through pain control. Case report #3 focuses on the adverse effects of opioid pain control in an infant with neurological impairment. Case report #4 reports on the successful tumor pain control using transdermal buprenorphine. We conclude that proven therapeutic strategies for opioid pain control as applied in adults may be adopted for the usage on children in pediatrics. However, it is mandatory to take into account both the pharmacokinetic and pharmacodynamic peculiarities of childhood.

[Pain control in German pediatric oncology. An inventory]

As part of a nationwide quality improvement programme, our aim is the assessment of the quality of pain control in German paediatric oncology to tailor the intervention to specific needs. Here we report on the results of a questionnaire-based nationwide survey which addressed the head of the department, one supervising physician, one ward physician, one nurse, and one psychologist/social worker in each of the 76 german paediatric oncology departments. 210/380 health care professionals of 60/76 departments responded to the survey. According to 17% of the physicians (41% of the nurses, p = 0.004) there still exists '(very) often' pain despite pain therapy. Procedures are seen as the main causes of pain. According to 58% of the heads of the department and supervising physician (35% of the nurses and ward physicians, p = 0.005), faces scales are regularly used to score pain intensity. In 80% of the departments a written therapy protocol addressing procedure-related, or postoperative pain is lacking. When larger and smaller departments are compared, in former ones the significantly preferred routes for opioid administration are i. v., or oral for slow release preparations (p = 0.01). The i. m. route is exclusively used in smaller departments. In the treatment of neuropathic pain, only 5% of the physicians regard morphine, but 25% of them regard antidepressants and antiepileptics as ineffective. Only 72% of the physicians (39% of the nurses, p = 0.001) are convinced that during opioid-based pain therapy addiction 'seldom/never' developes. Nurses are less satisfied with pain therapy than are physicians, and they feel more frequently that pain therapy '(very) often' starts too late (p <0.005). The questionnaire revealed obvious deficits in both physicians' and nurses' knowledge regarding pain therapy. Deficits were also addressed by the health care professionals themselves.

Long-acting morphine for pain control in paediatric oncology

BACKGROUND

Guidelines for treatment of paediatric cancer pain recommend the usage of long-acting morphine. However, published paediatric experience with this drug is restricted to 147 children not systematically evaluated, and thus insufficient. We aimed to systematically analyse the age-dependent effects and adverse effects of long-acting morphine in paediatric cancer patients.

PROCEDURE

Ninety-five children aged 1 to 19 years were enrolled in a collaborative retrospective study conducted over seven-and-a-half years. Pain was scored according to a numeric rating scale (NRS, range 0 to 5), and the corresponding medication was recorded.

RESULTS

In 83 children documentation period started during morphine treatment (71, oral long-acting; 1, rectal; 11, IV). Mean oral/equivalent morphine starting dose was 1.3 mg/kgbw/d (SD 0.9). Mean end dose was 2.8 mg/kgbw/d (SD 2.7). Infants aged < 7 years received the highest average dose (2.6 mg/kgbw/d, SD 2.8), while patients > 12 years received the lowest dose (1.4 mg/kgbw/d, SD 1.1). Median pain intensity decreased from score 1.0 (mean 1.2) NRS at the beginning to 0 (mean 0.6) NRS at the end. The proportion of patients scoring > 2 NRS (severe or most severe pain) under morphine treatment decreased from 26 to 12% (P = 0.08). In children > 12 years pruritus was frequently observed (23% of patients). In all age groups, there were no severe adverse effects during the study period.

CONCLUSIONS

In paediatric haematology/oncology, pain control by oral long-acting morphine proved to be safe and effective even in the very young patients. The pharmacological properties of long-acting morphine are ideally suited for paediatric use, combining efficacy and compatibility.

[Musculoskeletal pain]

BACKGROUND

In paediatrics, numerous diseases present with the leading symptom of muscular, articular, or bone-related pain. The pain as such is seldom diagnostic with regard to pain etiology. Regularly, the significance of inflammatory as well as non-inflammatory pain is underestimated.

CLASSIFICATION OF MUSCULOSKELETAL DISEASES

We present 4 case reports, illustrating the classification of musculoskeletal diseases into 4 main groups, being the basis for the modelling of disease, and pain treatment.

THERAPY

Pain therapy is either symptomatic or based on specific pathophysiology. Pain therapy consists of the moduls analgesics, antiphlogistics, physiotherapy, psychosocial support, and complementary therapies. We give advice on differential therapy. A transparent team-oriented concept comprising physicians, physiotherapists, ergotherapists, psychologists, and social workers is the basis for any successful long-term therapy. Regular outpatient visits in consent with the family doctor are mandatory as are education and treatment periods on ward. We encourage our patients to join formal self-supportive patient groups.

[Pain therapy in acute pediatric diseases and vaccination]

PHENOMENON PAIN: While pain is one of the main reasons for an unscheduled visit to the paediatrician, pain due to painful procedures is of major importance in scheduled visits. Actual pain therapy is illustrated in the treatment of burns. Incomplete analgesia may have an unfavourable impact on morbidity and mortality. The pain score does not correlate with the extent of the burned area, and is regularly underestimated. General anaesthesia or analgo-sedation are warranted during the care of the burned patient. INSUFFICIENT ANALGESIA: Consequence of insufficient analgesia during primary care is an increased need of analgesics, and an increased pain treatment failure rate during subsequent procedures. Pain is interfering with anxiety, sleep disturbances and post-traumatic psychologic alterations. All those symptoms must be treated adequately. ACUTE ILLNESS AND INJECTIONS: This article covers pain from otitis media, pharyngitis, Guillain-Barré syndrome, purpura fulminans, Toxic Epidermal Nekrolysis, as well as the usage of local anaesthesia during injections, not to forget the application of non-pharmacologic methods for pain therapy and prophylaxis.

Use of an artificial neural network (ANN) for classifying nursing care needed, using incomplete input data

BACKGROUND

In German nursing insurance, the act of classifying the client into four categories of disability is based on legally defined distinct criteria. When classifying deceased persons it is often impossible to collect all the required information.

PRIMARY OBJECTIVE

We aimed to determine the ability of an artificial neural network (ANN) to calculate the category of disability, to investigate the response of the ANN to input items of different nature, quantity and data quality, and to estimate the minimum number of training data required.

RESEARCH DESIGN

The investigation was conducted as a retrospective observational study.

METHODS AND PROCEDURES

The analysis was based on routine records of 14000 adult clients of the nursing insurance. Several ANNs were trained, varying nature, number and quality of the input items as well as the size of the training data set. Each ANN's classification competence was tested on independent validation data, judging the ANN's conformance to the result of the individual expert assessment, using kappa statistics.

MAIN RESULTS

Fed with all 30 input items available, the net classified 80% of cases correctly (weighted kappa = 0.78). Using three input items, weighted kappa was 0.63. Severe misclassification (deviation by more than one category in either direction) ranged between 0.2% (all 30 input items) and 3.7% (3/30 items). The less complete the individual input items were, the less accurate was the net's estimate. A 20% rate of missing values was well tolerated. A training set comprising 500 cases was adequate.

CONCLUSIONS

The input item set inherits redundancy. The ANN's ability to correctly respond to subsets of input items makes it a powerful tool in quality control. In the categorization of deceased persons when only an incomplete input item set is available, the ANN can achieve satisfactory results.

Accidental iatrogenic intoxications by cytotoxic drugs: error analysis and practical preventive strategies

OBJECTIVES

Drug errors are quite common. Many of them become harmful only if they remain undetected, ultimately resulting in injury to the patient. Errors with cytotoxic drugs are especially dangerous because of the highly toxic potential of the drugs involved. For medico-legal reasons, only 1 case of accidental iatrogenic intoxication by cytotoxic drugs tends to be investigated at a time, because the focus is placed on individual responsibility rather than on system errors. The aim of our study was to investigate whether accidental iatrogenic intoxications by cytotoxic drugs are faults of either the individual or the system. The statistical analysis of distribution and quality of such errors, and the in-depth analysis of contributing factors delivered a rational basis for the development of practical preventive strategies.

METHODS

A total of 134 cases of accidental iatrogenic intoxication by a cytotoxic drug (from literature reports since 1966 identified by an electronic literature survey, as well as our own unpublished cases) underwent a systematic error analysis based on a 2-dimensional model of error generation. Incidents were classified by error characteristics and point in time of occurrence, and their distribution was statistically evaluated. The theories of error research, informatics, sensory physiology, cognitive psychology, occupational medicine and management have helped to classify and depict potential sources of error as well as reveal clues for error prevention.

RESULTS

Monocausal errors were the exception. In the majority of cases, a confluence of unfavourable circumstances either brought about the error, or prevented its timely interception. Most cases with a fatal outcome involved erroneous drug administration. Object-inherent factors were the predominant causes. A lack of expert as well as general knowledge was a contributing element. In error detection and prevention of error sequelae, supervision and back-checking are essential. Improvement of both the individual training and work environment, enhanced object identification by manufacturers and hospitals, increased redundancy, proper usage of technical aids, and restructuring of systems are the hallmarks for error prevention.

CONCLUSIONS

Errors follow general patterns even in oncology. Complex interdependencies of contributing factors are the rule. Thus, system changes of the working environment are most promising with regard to error prevention. Effective error control involves adapting a set of basic principles to the specific work environment. The work environment should allow for rectification of errors without penalty. Regular and ongoing intra-organisational error analysis needs to be an integral part of any error prevention strategy. However, it seems impossible to totally eliminate errors. Instead, if the environment guarantees timely error interception, most sequelae are avoided, and errors transform into a system-wide learning tool.

[Practice of pain control in paediatric oncology--recommendations of the quality-monitoring group of the German Society for Paediatric Oncology and Haematology (GPOH)]

In paediatric oncology, optimal pain control is still a challenge.A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented on the WHO analgesic ladder. On no account the paediatric patient should have to climb up the 'analgesic ladder'- strong pain requires the primary use of strong drugs. Opioids should be given by the oral route and by the clock - short acting opioids should be used to treat break-through pain. Alternatives are IV infusion and patient-controlled analgesia. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of paediatric nurses is of utmost importance in paediatric pain control. Nurses' deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our paper we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.