by Sandra Merkel, BSN, MSN, Clinical Nurse Specialist, and Shobha Malviya, MB, BS, Director Pediatric Sedation
Despite advances in pediatric pain research, pain in children continues to be undertreated. Difficulties with pain assessment in preverbal children and concerns regarding opioid side effects and dependence contribute to the reluctance to treat pain in children. Since the inception of the pediatric pain service at C. S. Mott Children’s Hospital in 1990, the number of patients has increased from 125 in the first year to more than 870 patients in 1995. This included more than 137 children who received epidural analgesia. The focus of the pain service has been on improving pain management through clinical care, consultation and staff education.
The pediatric pain service is staffed by a clinical nurse specialist, a resident and a faculty or fellow who make rounds on all patients on a daily basis. The resident assigned to the pain service is also on call that night, thereby providing additional follow-up when necessary. The faculty or fellow is assigned to the pain service for an entire week to provide for continuity of care. They are also available on nights and weekends by pager to provide additional support and consultation. The nurse rounds on the pain service throughout the year and provides additional continuity as well as a valuable resource for education and implementation of policies. The nurse also coordinates and organizes pain related research in children.
Clinical service consists of PCA (patient controlled analgesia), epidural analgesia and consultation regarding pain management and sedation. PCA is generally used in children who are at least nine-years-old. Younger children often need frequent review and reinforcement about how to use the PCA dosing around ambulation and other painful activities. A continuous infusion plus small bolus doses is often used following extensive abdominal, orthopedic and cardiac surgical procedures. This combination allows the child to sleep for longer periods and decreases the doses required for turning and coughing. Young children, or cognitively impaired children who cannot operate the pump, are treated with NCA (nurse controlled analgesia). This works especially well for children who may need continuous opioid infusions and small bolus doses for procedures such as suctioning, turning and dressing changes. Thoracic and lumbar epidural analgesia are used when necessary to provide postoperative pain relief in children undergoing abdominal and cardiac surgery. These patients are monitored daily by the pain service staff and by the nursing staff in accordance with protocols developed by the pain service.
New treatment modalities and protocols appropriate for children are frequently developed and evaluated by the anesthesiology staff. EMLA (eutectic mixture of
local anesthetics) has been used to relieve the pain associated with starting preoperative lines and the children have found it to be very effective. The mixture needs to be applied at least one hour prior to venipuncture to get the maximum effect. Transcutaneous electrical nerve stimulation (TENS) has been used in selected patients who are undergoing painful dressing changes or who require additional analgesia but need to limit opioids if possible. The management of pain associated with mucositis following bone marrow transplantation has provided the pain service with numerous challenges. These children experience a rapid escalation in the intensity of their pain and require frequent and large increases in their opioid infusions.
In addition to pain management in children, the section of Pediatric Anesthesiology has developed practice guidelines for analgesia and sedation of children in intensive care units as well as diagnostic areas outside the operating room. During this past year, Shobha Malviya, MD has been actively involved in developing and implementing guidelines for the sedation of children undergoing diagnostic and minor procedures. These guidelines and a pocket reference for drugs and patient monitoring have been very helpful to primary care physicians and nurses as they prescribe and administer sedative drugs. The pediatric pain service also provided to the patient care units copies of a publication issued by the Agency for Health Care Policy and Research, ‘Acute Pain Management in Infants, Children, and Adolescents: Operative and Medical Procedures’. This quick reference and a larger guideline is available free to clinicians by contacting the Center for Research Dissemination and Liaison, AHCPR Publication Clearinghouse, PO Box 8547, Silver Spring, MD 20907, (800) 358-9295. The pediatric pain service at the University of Michigan may be reached by paging the clinical nurse specialist, Sandra Merkel, RN or by calling the Pediatric Anesthesiology office and asking for the faculty in charge of the pain service.