The State of Pediatric Acute Pain Management
The delivery of optimal pain management in the acute setting has been an area of interest of mine for many years. Along the way I have collected articles that have helped identify some of the missed opportunities from the past and suggestions for how to rectify these shortcomings for our new trainees and practicing providers.
In this article by Kozlowski et al, the researchers interviewed and performed treatment review of 200 pediatric patients admitted to the hospital from October 2007 through November 2008. I will highlight some of the salient points of this article; the information is so important I have referred to this article many times over the past several years. I hope you find these points applicable in your daily practice.
Although this article is from 2014, we continue to struggle with similar issues today. Will it be another 15 years before we have made any progress in this regard?
- Patient population enrolled consisted of both surgical patients as well as those with medical conditions
- orthopedic, general, and urologic surgery
- 86% revealed a source of pain at enrollment, however...
- only 48% had a documented pain score of >1 in the medical record
- highest mean pain scores were reported on study day 1 in both surgical and medical patients
- 40% of patients rated their pain as moderate or severe during some point in their hospitalization
- < 5% of physicians documented pain scores
- children who had received analgesics prior to hospitalization reported significantly higher pain scores on study day 1
- 45% had PRN order for acetaminophen; only 5% had an around-the-clock (ATC) order
What does this all mean?
- we, especially physicians, need to do a better job documenting pain scores for our patients
- I record the previous 24 hours' worth of pain scores including a current pain score I
ascertain from the patient; this allows me to understand the trends of pain
- side effects with opioids, especially pruritus and nausea / vomiting, are common
- if opioids are to be considered, anticipate side effects and write PRN orders for
your choice of anti-pruritics / antiemetics (and don't forget the stool softeners!)
- the PRN method of pain medication delivery may be inadequate, especially regarding the prescription of first-line agents such as acetaminophen and NSAIDs.
- if a patient has a surgical procedure or medical condition associated with
moderate-severe pain or has opioids prescribed, I make sure acetaminophen and
NSAIDs are scheduled around-the-clock (ATC) unless there are contraindications
- My own observation:
- non-pharmacologic strategies are often not prescribed from the beginning and
are not emphasized as part of the 'pain management plan'
Here are some suggestions you can make to your patients to improve their comfort
through distraction and other modalities
- focused provider education may lead to improved pain assessment and potentially better management
- so if you're reading this post and striving to improve your
skills, you're taking a step in the right direction!
- despite what we know about pain management, getting those recommendations out into general practice continues to be difficult. My answer to that...
The development of a clinical decision tool to make providers
aware of the options available for pain and symptom management with a
multimodal treatment plan
Sign up to learn more about beta-testing the PreEmpt Pain app; become a member today to start the process.
Your opinion matters!
Have comments about this post or other topics in general? Reach out and share your thoughts.
Read the full text of the journal article here and opportunity to download the pdf for your files.