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PubMedDate not supplied

The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries.

Fentanyl has been shown to be effective for the management of intense pain of short duration. We have recently used intravenous fentanyl for burn wound procedures because of its rapid onset, high potency, and short duration. In this report, we reviewed our experience with fentanyl in a variety of procedural burn pain settings to develop specific recommendations about its effectiveness and safety for the treatment of pain in patients with burn injuries. The medical records of patients with burn injuries who received fentanyl for wound procedures over a 2-year period were retrospectively reviewed. Patient demographics, the amount of fentanyl administered, the level of analgesia achieved, and the incidence of adverse effects were analyzed. Fifty-five patients who were 9 months to 75 years old with burn wounds (range, 1%-90% of total body surface area) received 148 doses of fentanyl for the treatment of procedural pain. An average of 8.0 +/- 7.0 microg/kg of fentanyl (range, 0.7 to 38.0 microg/kg) was required for the first wound procedure with fentanyl. No correlation between dosage of fentanyl given and either age or percentage of total body surface area burned was observed. Transient respiratory depression was observed in 17 patients (31%). No patient required intubation or additional supplemental oxygen after the conclusion of the procedure. High doses of fentanyl are required to achieve adequate analgesia during some burn wound procedures. Respiratory depression associated with fentanyl use is transient but requires adequate preparation and trained personnel. Fentanyl may be effectively integrated into the pain control strategy for patients with burn injuries.

Adolescent↗
PubMed2005

Morphine does not provide adequate analgesia for acute procedural pain among preterm neonates.

BACKGROUND: Morphine alleviates prolonged pain, reduces behavioral and hormonal stress responses induced by surgery among term neonates, and improves ventilator synchrony and sedation among ventilated preterm neonates, but its analgesic effects on the acute pain caused by invasive procedures remain unclear. OBJECTIVE: To investigate the analgesic efficacy of intravenously administered morphine on heel stick-induced acute pain among preterm neonates. DESIGN: This study was nested within a prospective, randomized, double-blind, multicenter, placebo-controlled trial (the NEOPAIN Trial). SETTING: A tertiary-care NICU in a teaching hospital. PARTICIPANTS: Forty-two preterm neonates undergoing ventilation. INTERVENTIONS: Neonates were randomized to either the morphine (loading dose of 100 microg/kg, followed by infusions of 10-30 microg/kg per hour according to gestation, N = 21) or placebo (5% dextrose infusions, N = 21) group. Pain responses to 3 heel sticks were evaluated, ie, before the loading dose (T1), 2 to 3 hours after the loading dose (T2), and 20 to 28 hours after the loading dose (T3). MAIN OUTCOMES MEASURES: Pain was assessed with the Douleur Aiguë Nouveau-né (DAN) scale (behavioral pain scale) and the Premature Infant Pain Profile (PIPP) (multidimensional pain scale); plasma morphine levels were measured at T3. RESULTS: Infants in the placebo and morphine groups had similar gestational ages (mean +/- SD: 27.2 +/- 1.7 vs 27.3 +/- 1.8 weeks) and birth weights (972 +/- 270 vs 947 +/- 269 g). Mean +/- SD DAN pain scores at T1, T2, and T3 were 4.8 +/- 4.0, 4.6 +/- 2.9, and 4.7 +/- 3.6, respectively, for the placebo group and 4.5 +/- 3.8, 4.4 +/- 3.7, and 3.1 +/- 3.4 for the morphine group. The within-group factor (pain at T1, T2, and T3) was not statistically different over time. The between-group analysis (infants receiving placebo versus those receiving morphine) showed no significant differences. Mean +/- SD PIPP pain scores at T1, T2, and T3 were 11.5 +/- 4.8, 11.1 +/- 3.7, and 9.1 +/- 4.0, respectively, for the placebo group and 10.0 +/- 3.6, 8.8 +/- 4.9, and 7.8 +/- 3.6 for the morphine group. The within-group factor was statistically different over time. The between-group analysis showed no significant differences. Mean +/- SD plasma morphine levels at T3 were 0.44 +/- 1.79 ng/mL and 63.36 +/- 33.35 ng/mL for the placebo and morphine groups, respectively. There was no correlation between plasma morphine levels and pain scores at T3 (DAN, R = -0.05; PIPP, R = -0.02). CONCLUSIONS: Despite its routine use in the NICU, morphine given as a loading dose followed by continuous intravenous infusions does not appear to provide adequate analgesia for the acute pain caused by invasive procedures among ventilated preterm neonates.

Acute Disease↗
PubMed2006

Consigning "brutacaine" to history: a survey of pharmacological techniques to facilitate painful procedures in children in emergency departments in the UK.

OBJECTIVE: To determine the proportion of emergency departments in the UK that use modern pharmacological methods of pain and anxiety control in children, such as analgesia with intranasal diamorphine, procedural sedation using ketamine or midazolam, and adrenaline-cocaine gel, TAC or LAT for anaesthetising wounds in children. METHODS: A survey UK Emergency Departments conducted by email, post and telephone. RESULTS: Of the 183 (70%) of UK Emergency Departments responding, sedation is achieved using ketamine in 27% and using midazolam in 54%. In 55% of emergency departments intranasal diamorphine is used for analgesia and 41% use at least one of the topical local-anaesthetic mixtures to anaesthetise wounds before suturing. CONCLUSIONS: About half of UK emergency departments use modern pharmacological methods of procedural pain control in children. There is still considerable potential to improve the management of pain in children.

Administration, Intranasal↗
PubMed2001

[Prevention and treatment of procedural pain in pediatric wards: collected guidelines].

Present knowledge and available pharmacological agents allow for adequate prevention and treatment of pain in children. We present guidelines we prepared for the prevention and treatment of procedural pain in children in our general pediatric ward. This followed extensive review of the literature, participation in scientific meetings, discussions with experts and consultation with interested clinicians. Successful implementation of the guidelines requires increased appreciation of the importance of pain prevention, participation of the nursing, as well as medical staff, and ability to evaluate pain in children of various ages.

Analgesics↗
PubMed2006

A conceptual model of factors influencing children's responses to a painful procedure when parents are distraction coaches.

The purpose of this article is to present a model of factors that may influence a child's response to a painful procedure when parents are distraction coaches during the procedure. Nonpharmacological interventions, in particular, distraction, and parents as coaches for their children during procedures are discussed. A conceptual model is presented that illustrates the multiple factors and their possible relationships. A selected review of studies is provided that supports the inclusion of these factors in the model. The model and literature review focus on three major areas: characteristics of the child, characteristics of the parent, and procedural variables. The model presented is currently being tested in a large multisite study on the use of distraction during intravenous line insertion.

Attention↗
PubMed2000

Rapid induction analgesia for the alleviation of procedural pain during burn care.

Burn patients must often endure intense pain during their regular dressing changes. The aim of the present study was to investigate the therapeutic effect of rapid induction analgesia (RIA) on resting and procedural pain, anticipatory anxiety, relaxation levels and medication consumption in 30 hospitalized burn patients. Patients rated levels of pain and relaxation for four burn care sessions. RIA was conducted twice on 15 patients, whereas dressing changes proceeded as usual in 15 control patients. When asked to recall pain during the dressing changes, patients remembered an experience which was worse in its entirety than the average of spot ratings taken during the burn care procedure. However, self-reported ratings of the sensory and affective components of pain decreased significantly during and after RIA, particularly in patients who became readily absorbed, and relaxation increased during burn care. Anticipatory anxiety decreased before dressing changes in the RIA group, and analgesic intake decreased between treatment sessions. The promising outcome of this study confirms RIA as a viable adjunct to narcotic treatment for pain control during burn care.

Adolescent↗
PubMed2006

Psychological interventions for needle-related procedural pain and distress in children and adolescents.

BACKGROUND: Needle-related procedures are a common source of pain and distress for children. Several psychological (cognitive-behavioral) interventions to help manage or reduce pain and distress are available; however, a previous comprehensive systematic review of the efficacy of these interventions has not been conducted. OBJECTIVES: To assess the efficacy of cognitive-behavioral psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4, 2005), MEDLINE (1966 to 2005), PsycINFO (1887 to 2005), EMBASE (1974 to 2005), the Cumulative Index to Nursing and Allied Health Literature (1982 to 2005), Web of Science (1980 to 2005), and Dissertation-Abstracts International (1980 to 2005). We also searched citation lists and contacted researchers via various electronic list-servers and via email requests. SELECTION CRITERIA: Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only randomized controlled trials (RCTs) with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality. Included studies were coded for quality using the Oxford Quality Scale devised by Jadad and colleagues. Standardized mean differences with 95% confidence intervals were computed for all analyses using RevMan 4.0 software. MAIN RESULTS: Twenty eight trials with 1951 participants were included. Together, these studies included 1039 participants in treatment conditions and 951 in control conditions. The most commonly studied needle-procedures were immunizations and injections. The largest effect sizes for treatment improvement over control conditions exist for distraction (on self-reported pain, SMD -0.24 (95% CI -0.45 to -0.04), combined cognitive-behavioral interventions--reduced other-reported distress (SMD -0.88, 95% CI -1.65 to -0.12; and behavioral measures of distress (SMD -0.67, 95% CI -0.95 to -0.38) with hypnosis being the most promising--self-reported pain (SMD -1.47, 95% CI -2.67 to -0.27), with promising but limited evidence for the efficacy of numerous other psychological interventions, such as information/preparation, nurse coaching plus distraction, parent positioning plus distraction, and distraction plus suggestion. AUTHORS' CONCLUSIONS: Overall, there is preliminary evidence that a variety of cognitive-behavioral interventions can be used with children and adolescents to successfully manage or reduce pain and distress associated with needle-related procedures. However, many of the included studies received lower quality scores because they failed to describe the randomization procedure and participant withdrawals or drop-outs from the study. Further RCTs need to be conducted, particularly for the many interventions for which we could not locate any trials.

Adolescent↗
PubMedDate not supplied

Describing and predicting the nature of procedural pain after thermal injuries: implications for research.

A prerequisite for studying and treating burn-related pain is the establishment of a good understanding of the nature of burn-related pain. However, in most investigations of pain, researchers have failed to examine pain over time or to create summary scores that capture differences in the nature of the pain experiences of individual patients. For 10 consecutive days, 47 patients treated for burn injuries reported on three aspects of procedural pain: worst pain, sensory pain, and affective pain. Three summary pain scores were constructed for each pain dimension: average pain, variability in pain, and linear change in pain. The authors found considerable variability in pain reports from the same patient and from different patients. Analyses indicated that pain reports decreased over time and that patients who had more trait anxiety reported more pain. Patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low pain reports that differed from patients with less severe burn injuries. These findings suggest that adequate assessment of burn pain must occur frequently over the course of a single day, as well as for the duration of each patient's care.

Adult↗
PubMed2002

Painful procedures in pediatric cancer. A comparison of interventions.

Different interventions (i.e., cognitive-behavioral, pharmacological) and their combination were examined and compared to assist pediatric patients with cancer to manage distress during painful procedures. Findings revealed that cognitive protocols are effective in relieving procedural distress for a significant number of children. Pharmacological therapies were found to be relatively safe and effective when carefully administered and monitored by medical personnel. Data from combined cognitive therapies and pharmacological interventions, particularly those more recent pharmacological interventions, reveal generally mixed results, with both types of interventions yielding distinct benefits and disadvantages. Recommendations are made for future studies that match interventions to specific characteristics of the children for whom they are intended, as well as additional studies that combine pharmacological approaches together with cognitive techniques.

Adolescent↗
PubMed1992

The use of distraction and imagery with children during painful procedures.

The effectiveness of a pediatric pain management program was examined using a multiple case study design. This study examined both the children's pain experience during cancer treatment, as well as their parents' anxiety and behavioral stress. Fourteen children were videotaped while receiving lumbar punctures during an 8-12 month period. Baseline data were obtained at the first of three visits prior to the introduction of relaxation, imagery, and distraction exercises. Self-ratings of child fear and parent anxiety, videotaped observations of child and parent behavior, and child pain ratings were obtained at all three visits. The children's behavioral responses to the procedure varied considerably, but their fear scores were stable and their reports of pain decreased over time. Parents reported high-trait, low-state anxiety scores that were stable over time. They were observed to be very supportive during the procedures. Implications for further research in this area and recommendations for practice are presented.

Adolescent↗
PubMed2006

Pediatric procedural pain.

This article reviews the various settings in which infants, children, and adolescents experience pain during acute medical procedures and issues related to referral of children to pain management teams. In addition, self-report, reports by others, physiological monitoring, and direct observation methods of assessment of pain and related constructs are discussed and recommendations are provided. Pharmacological, other medical approaches, and empirically supported cognitive behavioral interventions are reviewed. Salient features of the interventions are discussed, and recommendations are made for necessary components of effective treatment interventions.

Adaptation, Psychological↗
PubMedDate not supplied

Cold therapy and its effect on procedural pain in children.

A quasi-experimental design was used to determine if cold therapy decreased the perceived pain associated with intramuscular injections in children. A convenience sample of 40 children aged 10 to 18 years was randomly assigned to the control or experimental group. The experimental group had an ice pack placed on the injection site for 15 min prior to injection, whereas the control group received injections according to hospital protocol. Ice was not shown to be significant in reducing procedural pain; however, distraction and parental support were effective.

Adolescent↗
PubMed1995

The use of oral transmucosal fentanyl citrate for painful procedures in children.

OBJECTIVE: To investigate the efficacy and safety of oral transmucosal fentanyl (OTFC) in providing analgesia and sedation for painful diagnostic procedures in children. DESIGN: Randomized, placebo-controlled clinical trial. METHOD: Forty-eight children referred to the University Connecticut Division of Pediatric Hematology/Oncology for bone marrow aspiration or lumbar puncture were randomized to receive either OTFC (15 to 20 micrograms/kg) or a placebo lollipop. Thirty minutes after administration, the procedure was begun. An anesthesiologist monitored the child's heart rate, blood pressure, and oxygen saturation every 10 minutes. At the conclusion of the procedure, the nurse, the child's parent, and all children over 8 years of age were asked to rate the pain associated with the procedure using a 1 to 10 visual analogue scale. Young children (less than 8) used a modified scale, the Oucher, yielding a 0 to 5 score. RESULTS: Significant differences in pain ratings between the OTFC and placebo groups were noted on the pain scores of the parents (P = .005), nurses (P = .001), younger children (P = .006), and older children (P = .013), and median pain scores in the OTFC group were reduced to tolerable levels. Vomiting (P = .003) and itching (P = .001) were more common in the OTFC group, but no clinically significant vital sign deviations occurred. CONCLUSION: OTFC is safe and effective for use in relieving the pain of pediatric procedures, but frequency of vomiting may restrict its clinical usefulness.

Administration, Buccal↗
PubMed1992

Clinicians' quick reference guide to acute pain management in infants, children, and adolescents: operative and medical procedures. Pain Management Guideline Panel. Agency for Health Care Policy and Research, US Department of Health and Human Services.

The management of pain is an important part of a health professional's role. The challenge for clinicians is to balance pain control with concern for patient safety and side effects of pain treatments. This is the second of two articles presenting the clinical highlights of the Agency for Health Care Policy and Research's Panel to develop clinical practice guidelines for pain management. This article presents the clinical highlights related to the assessment and management of pain in infants and children.

Acute Disease↗
PubMed2006

Inhaled nitrous oxide during painful procedures: a satisfaction survey.

Children with cystic fibrosis (CF) undergo repeated invasive medical procedures. This article summarises a survey of the use of nitrous oxide to minimise the psychological trauma and pain that was undertaken within the paediatric unit of a district general hospital (Williams et al 2004). Pain levels pre and post procedure, whether the treatment was effective, any adverse effects and comments by children and carers were recorded. Nitrous oxide was safe and effective in reducing pain, trauma and 'needle phobia'. It is now being offered to other children in the management of procedural pain.

Adolescent↗
PubMedDate not supplied

Ketamine: a safe and effective agent for painful procedures in the pediatric burn patient.

Ketamine is an effective agent when used for sedation during painful bedside procedures. We developed a ketamine administration protocol for nonanesthesiologists for the purpose of establishing safe monitoring and documentation during ketamine sedation procedures. From June 1, 2002, through June 30, 2003, a total of 522 sedation events using ketamine were performed; 347 of these events were analyzed. Seventeen (4.9%) events contained potentially adverse outcome indicators, 10 (2.9%) of which required intervention. Eight events were airway related and responded to repositioning, supplemental oxygen, or bag-valve-mask ventilation. Two patients had a decrease in blood pressure, which responded to fluid administration. Total doses of ketamine administered were between 6 and 800 mg, for procedures ranging from 1 to 105 minutes, in patients weighing between 3 and 111 kg. The development of a strict protocol ensures the safe administration of ketamine for the pediatric burn patient.

Adolescent↗