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PubMedDate not supplied

Communication and control: parent, child, and health care professional interactions during painful procedures.

Through use of a qualitative ethological approach, observations of 17 children who were undergoing 44 painful procedures during cancer diagnosis or treatment were videotaped and analyzed. The children, aged 4 to 18 years, were part of a larger study testing the effectiveness of nonpharmacologic pain management techniques. Analysis of the videotaped observations revealed that several distinct patterns of conversation between caregivers, parents, and children varied greatly among situations. Both child-centered and nonchild-centered communications were demonstrated. During periods of quiet, nonchild-centered behaviors increased. As a child's distress increased, parents actively changed behaviors to redirect verbal support back to the child and to the pain control interventions. Nurses' encouraging parents to be actively involved and physically close during painful treatments may results in less distress and discomfort for the child. In addition, health care professionals need to be aware of the various patterns of child-parent-caregiver interactions and the need to stay focused on the child during painful procedures to enhance the child's ability to cope.

Adaptation, Psychological↗

PubMed1999

The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department.

Painful and frightening injuries and illnesses are frequent reasons for children to seek care in an emergency department. Painful therapeutic procedures are often a necessary part of emergency care and are very distressful for the children, their parents, and healthcare providers. Inadequately relieved pain and distress have acute and long-term consequences, yet methods for pain and anxiety reduction during frightening minor and major procedures are often not used because of lack of detailed knowledge of techniques and fear of adverse effects. This article reviews psychologic and pharmacologic means of safe and effective reduction of anxiety and pain during emergency department procedures.

Anesthetics, Local↗

PubMed2002

Uptake pharmacokinetics of the Fentanyl Oralet in children scheduled for central venous access removal: implications for the timing of initiating painful procedures.

BACKGROUND: The Fentanyl Oralet (Abbott Laboratories, Abbott Park, IL, USA) is an oral transmucosal drug delivery system. We previously examined pharmacokinetic parameters of children who had completed consumption of the Fentanyl Oralet. The present study was designed to clarify pharmacokinetic parameters during the consumption phase to determine if there is an optimal administration time before painful procedures. METHODS: Patients, aged 3-10 years, who were scheduled for elective removal of central venous access devices under general anaesthesia, received a Fentanyl Oralet (fentanyl 10-15 microg x kg(-1)). Plasma fentanyl concentrations were measured by radioimmunoassay. Data from blood samples obtained during and after consumption of the Fentanyl Oralet from 17 patients in the present study were combined with data from our previous study to better characterize both the consumption and postconsumption concentration versus time profiles. RESULTS: Estimated fentanyl bioavailability (mean +/- SD) was low (36.1 +/- 0.4%), as were peak plasma concentrations (1.03 +/- 0.31 ng.ml-1), suggesting that many children swallowed a large fraction of the dose. This led to a relatively late and variable peak concentration time of 53 +/- 40 min. In addition, because of the apparently large degree of gastrointestinal absorption, concentration versus time curves were wide and flat. CONCLUSIONS: The wide and flat concentration versus time profile may allow flexibility in the timing of a painful procedure following Fentanyl Oralet administration. However, the variability of the time to peak concentration makes it difficult to suggest a minimum interval between Fentanyl Oralet consumption and the start of a painful procedure.

Administration, Buccal↗

PubMed1997

Ketamine-midazolam versus meperidine-midazolam for painful procedures in pediatric oncology patients.

PURPOSE: To compare the efficacy, characteristics of onset/recovery, and safety of ketamine/atropine/midazolam with meperidine/midazolam used as premedication for painful procedures in children with cancer. METHODS: A randomized, double-blind crossover trial for two successive painful procedures (bone marrow aspiration or biopsy, lumbar puncture, or combined procedures) was performed at a referral-based pediatric hematology-oncology clinic and associated inpatient service of a university teaching hospital. Twenty-two children, aged 24 to 178 months, were enrolled and 18 (81.8%) completed the double-blind, crossover trial. Each child received intravenous premedication with either meperidine 2 mg/kg and midazolam 0.1 mg/kg (MM) or atropine 0.01 mg/kg, midazolam 0.05 mg/kg, and ketamine 1.5 mg/kg (KM) on one occasion followed by the alternative regimen on a second occasion. The initial premedication regimen was chosen by random assignment. RESULTS: Efficacy was assessed by a trained observer using the Observational Scale of Behavioral Distress-Revised (OSBD-R). Operator, nurse, parent, and patient opinions of efficacy were recorded on a visual analog scale (VAS). Side effects were monitored by pulse oximetry, nasal end-tidal capnography, and serial blood pressure measurements. Use of KM resulted in significantly less procedural distress than MM (1.37 +/- 2.20 v 7.04 +/- 8.06 OSBD-R units; P < .05). Both operators and nurses rated KM more effective than MM. KM use was associated with earlier readiness for the procedure (19.2 v 24.0 minutes) and more rapid recovery (39.3 v 74.6 minutes for removal of monitoring devices and 58.5 v 87.1 minutes for discharge). Procedures undertaken after ketamine sedation were associated with fewer side effects than observed with MM sedation (hypoxia, 17.7% v 82.4%; hypotension, 16.6% v 55.6%; reduced respiratory rate, 0% v 38.9%). The incidence of emergence reactions or behavioral abnormalities within 24 hours postprocedure was similar in both treatment groups. At 7 days postprocedure, no child had persistent behavioral abnormalities and all children had amnesia for the procedure. Parents and children expressed a preference for KM over MM in 12 of 18 cases (P < .05). CONCLUSION: A premedication regimen of KM produced superior sedation with a faster onset and recovery and fewer side effects than a MM combination.

Anesthetics↗

PubMedDate not supplied

Intravenous anesthesia with propofol for painful procedures in children with cancer.

OBJECTIVE: To study the safety and efficacy of propofol-based intravenous anesthesia in children with cancer undergoing painful procedures. METHODS: This study is a retrospective analysis of data collected from 52 consecutive children who underwent 335 procedures using propofol anesthesia. These data were routinely collected in all patients: time to induction, duration of the procedure, time to recover, and the doses of the drugs used. Monitoring with electrocardiography and pulse oximetry was continuous during the procedure; blood pressures were recorded before and after the procedure and every 5 to 10 minutes during the procedure. The patients received one of these four propofol-based intravenous regimens according to the anesthesiologist's preference: propofol only; propofol plus fentanyl; propofol plus midazolam; or propofol, fentanyl, and midazolam. The efficacy of sedation was rated by this scoring system: 3 = no movement during procedure; 2 = minimal movement that did not interfere with the procedure; 1 = moderate movement requiring physical restraint to complete the procedure. RESULTS: There were six episodes of mild hypoxia (oxygen saturation 85%-94%) and one episode of laryngospasm. None required intubation. Two patients had agitation and one patient had emesis during the postrecovery phase. There was no difference in the efficacy of sedation between the four regimens. Patients receiving the combination of propofol, fentanyl, and midazolam received the least amount of propofol and required the least time to recover. There were no life-threatening complications. CONCLUSIONS: Propofol-based anesthesia, when administered by an anesthesiologist in a controlled setting, is safe and effective for performing painful procedures in children with cancer.

Ambulatory Care↗

PubMed1992

Ketamine. A solution to procedural pain in burned children.

Our experience has shown ketamine to be a safe and effective method of providing pain relief during specific procedures in burned children. It renders high doses of narcotics unnecessary and offers children the benefit of general anesthesia without the requirement of endotracheal intubation and a trip to the operating room. The response of parents and staff to the use of ketamine has been positive. Parents often experience feelings of guilt following injury to a child and are eager to employ methods that reduce their child's pain. So far, no parent has refused the administration of ketamine; some have even asked that it be used during subsequent procedures on their child. With adequate pre-procedure teaching, parents are prepared for the possible occurrence of emergent reactions and can assist in reorienting the child during recovery. Staff have found that the stress of doing painful procedures on children is reduced when ketamine is used. The procedures tend to be quicker and the predicament of working on a screaming, agitated child is eliminated. At the same time, nursing staff have had to get used to the nystagmic gaze of the children and accept that these patients are truly anesthetized even though they might move and talk. Despite the success we and others have had with ketamine, several questions about its use in burn patients remain unanswered. The literature does not answer such questions as: Which nursing measures reduce the incidence of emergent reactions? How many ketamine anesthetics can safely be administered to one individual? How does the frequency of administration relate to tolerance in a burn patient? Are there detrimental effects of frequent or long-term use? Clearly, an understanding of these questions is necessary to determine the safe boundaries of ketamine use in burn patients. Ketamine is not a panacea for the problem of pain in burned children. But it is one means of managing procedural pain, which is, after all, a significant clinical factor in treatment and recovery.

Burn Units↗

PubMed2004

Propofol or propofol--alfentanil anesthesia for painful procedures in the pediatric oncology ward.

BACKGROUND: For children with cancer receiving curative treatment, the pain of diagnostic and therapeutic procedures is often worse than that of the disease itself. In order to evaluate if light propofol anesthesia in the pediatric oncology ward (POW) could improve the management of procedure pain and anxiety, a questionnaire was developed. METHODS: After prolonged EMLA application, 65 propofol anesthetics were performed successfully in 28 children during lumbar puncture and/or bone marrow aspiration in the POW, with short recovery time and without major adverse events. The questionnaire was mailed to the parents of the 28 children who were included in the survey. RESULTS: The return of questionnaire compliance was 89% (25 of 28), 12 females and 13 males, mean age was 7 years (range 2-16). Among those who replied, the diagnoses were acute lymphatic leukemia in 21, lymphoma in two and tumor in the other two. In the questionnaire, all parents/patients reported advantages with anesthesia in the POW compared with the operating room. In the list of stated advantages, 88% marked 'familiar nurses and doctors', 84% 'familiar environment', 80% 'closer to own room', 68% 'the child more calm', 72% 'shorter waiting-time', 60% 'faster recovery', 44% 'shorter fasting-time' and 44% 'parents more calm', as benefits. For future procedures requiring anesthesia to reduce pain, discomfort and/or anxiety, 92% of the parents/patients preferred anesthesia in the POW. CONCLUSIONS: If anesthesia is chosen for invasive procedures, this study suggest that propofol anesthesia in the POW is preferred by parents and children.

Adolescent↗

PubMed2003

Chemoembolization for hepatocellular carcinoma: effect of intraarterial lidocaine in peri- and post-procedural pain and hospitalization.

PURPOSE: To assess the efficacy of intraarterial lidocaine on peri- and post-procedural pain and on length of hospital stay in hepatocellular carcinoma (HCC) patients undergoing chemoembolization. MATERIALS AND METHODS: Twenty-eight patients (19M, 9F, age range 49-76) who underwent hepatic chemoembolization at our Institution between March 2000 and February 2002 were included in the study. Group A consisted of 14 patients who received intraarterial lidocaine immediately before and during chemoembolization, while in the 14 patients of group B lidocaine was substituted with saline solution. The doses of centrally acting narcotics (tramadol) administered periprocedurally and in the three days following the procedure were compared, as were the hospitalization times. Subjective pain was measured using the visual analogue scale. Chemoembolizations were performed with an emulsion of lipiodol, cisplatin and epirubicin followed by embolizing material (gelfoam of Contour particles) in order to achieve complete blood flow stop in the proper hepatic artery. RESULTS: No side effects were noted that could be due to systemic administration of lidocaine. All patients experienced some degree of post-embolization syndrome. Periprocedural, day 1 and day 2 post chemoembolization dosages of tramadol were significantly lower in group A with respect to group B patients. No group A patient required analgesia on day 3. No statistical difference was observed in time persistence of nausea and vomiting, fever and hospitalization time between the two patient groups. CONCLUSIONS: Intraarterial administration of lidocaine before and during chemoembolization is a safe and effective method for preventing or reducing peri- and post-procedural pain and dosage of narcotic analgesics in patients with HCC. Hospitalization times did not differ significantly between the two groups, probably because of the other components of post-embolization syndrome, such as fever, nausea and vomiting.

Abdominal Pain↗

PubMed2004

Neonatal procedural pain and preterm infant cortisol response to novelty at 8 months.

OBJECTIVES: Stress systems may be altered in the long term in preterm infants for multiple reasons, including early exposure to procedural pain in neonatal intensive care. This question has received little attention beyond hospital discharge. Stress responses (cortisol) to visual novelty in preterm infants who were born at extremely low gestational age (ELGA; < or =28 weeks), very low gestational age (VLGA; 29-32 weeks), and term were compared at 8 months of age corrected for prematurity (corrected chronological age [CCA]). In addition, among the preterm infants, we evaluated whether cortisol levels at 8 months were related to neonatal exposure to procedural pain and morphine in the neonatal intensive care unit. METHODS: Seventy-six infants, 54 preterm (< or =32 weeks' GA at birth) and 22 term-born infants who were seen at 8 months CCA composed the study sample, after excluding those with major sensory, motor, or cognitive impairment. Salivary cortisol was measured before (basal) and 20 minutes after introduction of novel toys (post 1) and after developmental assessment (post 2). RESULTS: Salivary cortisol was significantly higher in ELGA infants at 8 months, compared with the VLGA and term groups before and after introduction of visual novelty. Term-born and VLGA infants showed a slight decrease in cortisol when playing with novel toys, whereas the ELGA group showed higher basal and sustained levels of cortisol. After controlling for early illness severity and duration of supplemental oxygen, higher basal cortisol levels in preterm infants at 8 months' CCA were associated with higher number of neonatal skin-breaking procedures. In contrast, cortisol responses to novelty were predicted equally well by neonatal pain or GA at birth. No relationship between morphine dosing and cortisol response was demonstrated in these infants. CONCLUSIONS: ELGA preterm infants show a different pattern of cortisol levels before and after positive stimulation of visual novelty than more maturely born, VLGA preterm and term-born infants. Exposure to high numbers of skin-breaking procedures may contribute to "resetting" basal arousal systems in preterm infants.

Analgesics, Opioid↗

PubMed2005

Neonatal procedural pain exposure predicts lower cortisol and behavioral reactivity in preterm infants in the NICU.

Data from animal models indicate that neonatal stress or pain can permanently alter subsequent behavioral and/or physiological reactivity to stressors. However, cumulative effects of pain related to acute procedures in the neonatal intensive care unit (NICU) on later stress and/or pain reactivity has received limited attention. The objective of this study is to examine relationships between prior neonatal pain exposure (number of skin breaking procedures), and subsequent stress and pain reactivity in preterm infants in the NICU. Eighty-seven preterm infants were studied at 32 (+/-1 week) postconceptional age (PCA). Infants who received analgesia or sedation in the 72 h prior to each study, or any postnatal dexamethasone, were excluded. Outcomes were infant responses to two different stressors studied on separate days in a repeated measures randomized crossover design: (1) plasma cortisol to stress of a fixed series of nursing procedures; (2) behavioral (Neonatal Facial Coding System; NFCS) and cardiac reactivity to pain of blood collection. Among infants born <or=28 weeks gestational age (GA), but not 29-32 weeks GA, higher cumulative neonatal procedural pain exposure was related to lower cortisol response to stress and to lower facial (but not autonomic) reactivity to pain, at 32 weeks PCA, independent of early illness severity and morphine exposure since birth. Repeated neonatal procedural pain exposure among neurodevelopmentally immature preterm infants was associated with down-regulation of the hypothalamic-pituitary-adrenal axis, which was not counteracted with morphine. Differential effects of early pain on development of behavioral, physiologic and hormonal systems warrant further investigation.

Blood Pressure↗

PubMed2004

Physicians' perceptions of procedural pain and discomfort.

BACKGROUND: Previous studies have demonstrated that patients with end-stage dementia receive a high rate of painful and uncomfortable procedures. This study was undertaken to determine whether this finding might be related to physicians' misperceptions about the burden of common hospital experiences and procedures. METHODS: Physicians were administered a survey asking them to rank on a five-point scale the pain and discomfort they perceived to be associated with 16 common hospital procedures. These ratings were compared to those previously obtained using the same instrument with cognitively intact patients who had actually undergone these procedures. RESULTS: One hundred twenty-three of 123 resident physicians (100%) and 40 of 50 attending physicians (80%) to whom the questionnaire was administered responded. Overall, physicians more often rated both pain and discomfort associated with these procedures/experiences higher than did patients, and residents typically rated pain and discomfort higher than attending physicians. Resident physicians rated 7 procedures/experiences as significantly more painful and 13 as more uncomfortable than did patients. Attending physicians rated 5 procedures/experiences as significantly more painful and 8 more uncomfortable than did patients. Having a nasogastric tube inserted was the only procedure rated more painful by patients as compared to resident or attending physicians. CONCLUSIONS: Physicians have an accurate perception of pain and discomfort associated with common hospital procedures. Further investigation should scrutinize in greater detail the ubiquity and depth of physician knowledge about the issue of procedural burden and should focus on methods and interventions that would allow physicians to consciously weigh the benefits and burdens of routine interventions in the care of persons with serious and life-threatening illness.

Adult↗

PubMedDate not supplied

Music versus distraction for procedural pain and anxiety in patients with cancer.

PURPOSE/OBJECTIVES: To test the hypotheses that the effects of a music intervention are greater than those of simple distraction and that either intervention is better at controlling procedural pain and anxiety than treatment as usual. DESIGN: Randomized, controlled experiment. SETTING: A midwestern comprehensive cancer center. SAMPLE: 60 people with cancer having noxious medical procedures such as tissue biopsy or port placement or removal; 58 provided usable data. METHODS: Participants completed measures of pain and anxiety before and after their medical procedures and provided a rating of perceived control over pain and anxiety after the procedure. MAIN RESEARCH VARIABLES: Procedural pain, state anxiety, and perceived control over pain and anxiety. FINDINGS: Contrary to hypotheses, outcomes achieved with music did not differ from those achieved with simple distraction. Moreover, outcomes achieved under treatment as usual were not significantly different from those obtained with music or distraction interventions. Some patients found that the interventions were bothersome and reported that they wanted to attend to the activities of the surgeon and the medical procedure itself. CONCLUSIONS: The effects of music, distraction, and treatment as usual are equivocal. In addition, patients have individual preferences for use of distraction during painful or anxiety-provoking procedures. IMPLICATIONS FOR NURSING: Patients having noxious medical procedures should be asked about their desire to be distracted before and during the procedure and offered a strategy that is consistent with their preferences.

Anxiety↗

PubMed2005

The risk of bleeding complications after pain procedures in anticoagulated patients.

Minimally invasive pain treatment procedures are common and generally low-risk. Complications from bleeding after these procedures are relatively uncommon, but the neurologic sequelae can be severe, particularly in the case of spinal hematomas. Changes in coagulative, fibrinolytic, and thrombolytic mechanisms escalate these risks. Consensus guidelines developed by the American Society of Regional Anesthesia summarize the risks of spinal hematoma associated with the use of different anticoagulant medications. In addition, these guidelines provide recommendations for neuroaxial procedures on patients treated with oral and intravenous anticoagulant medications. Recommendations for the neuroaxial procedures also apply to the peripheral blocks.

Analgesia↗

PubMed1993

TENS for children's procedural pain.

A 3 x 6 factorial design with a double blind and placebo control was employed to investigate the effect of TENS treatment on pain produced by venipuncture. The three treatment groups consisted of TENS, placebo-TENS and control. Subjects were blocked into six 2-year age groups (ages: 5-17 years). During the period of the study, 896 children attending the outpatient laboratory of a general hospital were screened and 514 children completed the study. The data which were collected before venipuncture included expected pain and state anxiety. Following venipuncture, pain intensity was measured with a vertical visual analogue scale (VAS) and pain affect was assessed with McGrath's faces scale. Significant main effects for treatment and age groups were obtained. Pain intensity and affect were lowest for the TENS group and highest for the control group. The pain scores were greatest for lower age groups and lowest for higher age groups. The results of this study support the use of TENS for children's pain and the need for interventions for children's procedural pain.

Adolescent↗

PubMed2005

Fluoroscopy radiation safety for spine interventional pain procedures in university teaching hospitals.

BACKGROUND: Fluoroscopic guidance is frequently utilized in performing various types of interventional techniques. The major purpose of fluoroscopy is accurate needle placement to ensure target specificity and accurate delivery of the injected drug. However, radiation exposure may be associated with risks to physician, patient, and personnel. Multiple studies have evaluated the risk of radiation exposure and techniques to reduce the risk in private practice settings. However, the literature is scant in evaluating the risk of radiation exposure in teaching hospitals in university settings. OBJECTIVE: To evaluate safety and duration of radiation exposure for fluoroscopy guided interventional pain procedures in university pain clinics. STUDY DESIGN: Retrospective, case study. METHODS: The data was reviewed from the fluoroscopy machines from March 2004 to April 2004 at two university pain clinics. Mean fluoroscopy time (FT), mean radiation dose per procedure, and utilization of pulsed fluoroscopy were analyzed. RESULTS: Data of a total of 165 cases of spine injection procedures were collected. The mean fluoroscopy time for lumbar epidural steroid injection, facet joint block, sympathetic nerve block, sacroiliac joint injection, and discography were 46.6 +/- 4.2; 81.5 +/- 12.8; 64.4 +/- 11; 50.6 +/- 41.9 and 146.8 + 25.1 seconds respectively. There were significant differences in fluoroscopy exposure times and radiation dosage for epidural steroid injection among different teaching physicians. Pulsed fluoroscopy was used in less than 10% of cases. CONCLUSION: The results of this study show that the fluoroscopy exposure time for various interventional procedures performed in the university settings are significantly higher than the radiation exposure periods in private practice settings. This study also showed significant differences among physicians in the same university setting.

Journal Article↗

PubMed2004

Taking the 'ouch' out - effect of buffering commercial xylocaine on infiltration and procedure pain - a prospective, randomised, double-blind, controlled trial.

AIMS: To compare the effect of buffered commercial 1% xylocaine (with 1:200,000 adrenaline) and the unbuffered commercial 1% xylocaine (with 1:200,000 adrenaline) preparation on pain during infiltration and procedure. PATIENTS AND METHODS: A randomised, double blind controlled trial involving 85 patients who underwent bilateral vasectomy under local infiltration anaesthesia. RESULTS: Each patient served as his own control by receiving the buffered commercial preparation on one side and unbuffered commercial preparation on the other. Linear analogue pain scores during infiltration and procedure were recorded and analysed. The study demonstrated that pain perceived by the patient both during infiltration and the procedure was significantly lower when buffered commercial xylocaine was used as compared to the pain perceived with the use of unbuffered commercial xylocaine. CONCLUSIONS: Use of buffered xylocaine is a simple, inexpensive and significantly effective way of reducing pain during infiltration and in surgical procedures performed under local anaesthesia.

Adult↗

PubMed2001

Management of surgical and procedural pain in a critical care setting.

Critical care nurses can serve as pain management advocates so that those patients who undergo surgery and other procedures do not suffer needless pain. Research findings indicate that surgical and procedural pain can contribute to pathologic pain states related to nerve injury, tissue inflammation, and prolonged peripheral nociceptive input. Animal research findings support clinical practices that avoid the development of these conditions by effectively interrupting ongoing nociceptive input from the injured site. Knowledge of analgesic interventions, including pharmacologic and nonpharmacologic techniques, is essential to the professional practice of nursing the critically ill. The critical care nurse plays a pivotal role in preventing suffering, discomfort, and long-term negative consequences related to surgical and procedural pain.

Analgesics↗

PubMed1996

The silent ones: a review of sampling issues and biases pertinent to the area of pediatric oncology procedural pain.

Pain related to procedures for pediatric oncology patients is a salient topic. Although these procedures can cause much distress, this area has been neglected in research. Previous research has suffered from serious sampling problems, such as using small, nonrepresentative, biased samples. In addition, little is known about the influence of sociocultural factors on the phenomena of pain in children. This article presents the results of a review of the past 10 years of pertinent literature, argues that sociocultural influences on pain need to be studied, and offers suggestions for improving sampling designs.

Child↗