The Participant will be able to: All Better!: Pediatric Adenotonsillectomy Pain Management

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1 All Better!: Pediatric Adenotonsillectomy Pain Management Deborah Scalford, RN, MSN The Children s Hospital of Philadelphia Objectives The Participant will be able to: Identify reasons why pain is unrelieved. Discuss highlights from the 2011 Practice guidelines. Describe current pain management practices provided to children 5-10 years old undergoing Adenotonsillectomy at The Children s Hospital of Philadelphia (CHOP). What we Know? I have no disclosures or conflicts of interest related to this presentation The undertreatment of pediatric pain has been widely researched and continues to be a concern for healthcare professionals. Adenotonsillectomy is a common pediatric surgery associated with a moderate to high level of pain postoperatively. As large numbers of children undergo this procedure, collecting institutional data on this population will provide valuable information regarding pain management practices at CHOP. Unrelieved Pain Continues: Why? Translating standards into practice is challenging Education alone is necessary, but not sufficient Attitudes and beliefs create barriers Fear about the use of pain medications, especially opioids Pain is subjective The question is not, can they reason? Nor, can they talk? But, can they suffer? Jeremy Bentham, philosopher,

2 Effects of Unrelieved Pediatric Pain May have persistent changes in nocioceptive processing Neonates with prolonged heel sticks may develop increased sensitization Greater medical fears for children who have experienced many invasive procedures while in ICU (Rennick, et, al, 2002) Changes in quality of life (e.g., sleeplessness, fear) Pain Management Commitment To provide effective pain assessment and treatment for patients in pain and to include the patient and caregiver as an active participant in the process. Work with the patient and family to establish goals of pain relief. Pain management is a complex interdisciplinary process and needs to be managed as such. Barriers to Adequate Pain Management Organizational Is there a commitment to pain treatmenthospital wide? What is the specific unit culture? Adequate education and knowledge of staff regarding pain management. Different practices depending on the clinical unit, health care provider, culture, priorities Do staff, families, and patients have similar goals for pain management? Methods to Overcome Barriers Explore the beliefs and attitudes of staff and families about pain management Myths and misconceptions Prior experiences Ongoing Continuing Education Develop clinically expert pain management nurses as unit based resources Painful? Literature Review Literature Review Utilizing children having adenotonsillectomy is a useful model for the study of postoperative pain because of the large numbers of children that undergo that On a yearly basis, approximately 800 children have this surgery in our pediatric tertiary care center. In addition to being a common surgery, adenotonsillectomy is a procedure associated with moderate to high complaints of pain postoperatively and for the first few days following the procedure(chimona et al, 2008; Wilson & Helgadottir, 2006). 2

3 Literature Review An extensive review of the literature on pediatric pain management following adenotonsillectomy provided evidence to compare against the care currently provided at CHOP. Reasons cited for inadequate pain management in children Child s age and difficulty with self report Nurses clinical judgment (can be influenced by their beliefs and attitudes) Pain assessment, rather than total amount of analgesic, should be the outcome of choice to evaluate pain management Myths and misconceptions regarding pediatric pain management (e.g., fear of addiction). Wilson & Helgadottir (2006). Patterns of pain and analgesic use in 3-7 year old children after tonsillectomy. Pop, Manworren, Guzetta & Hynan. (2007). Perianesthesia nurses pain management after tonsillectomy and adenoidectomy: pediatric patient outcomes. Wiggins & Foster (2007). Pain after tonsillectomy and adenoidectomy: ouch it did hurt bad Idvall, Holm & Runeson (2005).Pain experiences and non-pharmacological strategies for pain management after tonsillectomy: a qualitative study of children and parents Pediatric PACU Pain Management Challenges Heightened anxiety and potentially altered sensorium making it difficult for self report of pain An unfamiliar environment that can appear very frightening (e.g., face masks). Fortier, DelRosario & Martin (2010). Perioperative anxiety in children Pop, Manworren, Guzetta & Hynan. (2007). Perianesthesia nurses pain management after tonsillectomy and adenoidectomy: pediatric patient outcomes. Adenotonsillectomy Pain Management Partnership between parents and health care providers Developmentally appropriate preparation for the surgery is key. Introduce the pain assessment tool to the child and make sure the child can understand how to use it before surgery. Education and discussion with child and parent about what to expect. Parent able to stay with child for induction and at bedside upon wakening. Highlights from 2011 Practice Guidelines Convincing evidence to no longer use acetaminophen with codeine for post operative pain management: Codeine is ineffective due to a genetic variation in the enzyme CYP2D6 that blocks codeine metabolism; this variation is thought to occur in 10-20% of the population Ultra rapid metabolism of codeine may put some children at risk with the use of codeine Substantial side effects of codeine such as postoperative nausea, vomiting, and constipation 3

4 Highlights from 2011 Practice Guidelines NSAIDS are effective for mild to moderate pain and assist with decreasing inflammation post operatively. Evidence from a Cochrane Review of nearly 1000 children in 13 randomized controlled trials found that NSAIDs did not significantly alter postoperative bleeding compared with placebo or other analgesics (odds ratio, 1.46; 95% CI, ). Inconclusive evidence for the use of IV ketorolac intraoperatively or immediately postoperative. Research Study Purpose The purpose of the study was to understand current pain management of children (ages 5-10 years) in the PACU post-adenotonsillectomy. Exploring relationships between demographic and surgical variables and the child's pain outcomes was the main focus of the study. Additionally identifying areas for improving pain management was important. Does T & A surgery hurt? How did we do it? Design: descriptive, exploratory Retrospective chart review assessing 100 charts of patients between the ages of 5 and 10 years old who underwent outpatient adenotonsillectomy. This study was approved by The Children s Hospital of Philadelphia institutional review board. How did we do it? This study was conducted in a post anesthesia care unit located in a tertiary care children s hospital at an academic medical center. Approximately 1500 adenostonsillectomies are done per year at our main hospital. Patients receive Phase I and Phase II care in the same space without transfer. Patients are discharged home after completing recovery from this unit. Parental visitation in the PACU is the norm. 4

5 Sample: How did we do it? One investigator screened approximately 400 charts to yield 100 charts that met study criteria. From August, 2007 through July, 2008, we cared for 881 children ages 5-10 years who had this procedure performed, making the chart review of 100 children reasonable. Charts of patients who underwent adenotonsillectomy between January 2009 and July 2009 were included in the analysis. Sample Included: day surgery pts. ASA I or II Excluded: chronic pain, developmental delay, anesthesia/post-anesthesia complications Developed data collection tool for chart review Retrospective reviews of 100 charts of children who had undergone outpatient adenotonsillectomy surgery at CHOP over a six month period Focused on influence of pain medications administered on pain scores and total time spent in PACU Sample Demographics 52% male Mean age: 7.2 years (±17 months) Race: 46% White, 37% Black/AA, 2% Asian 82 % surgery naïve 68% had no history of previous hospitalizations 66% used the FLACC pain scale in the PACU Parents arrived at bedside on avg. of 18 mins, range 0-48 mins Surgical technique: cautery n=91; coblation n=6; other n=3 Subject's Body Mass Index by Percentile and Gender (n=98) Male (n=51) Female (n=47) Total < 3%tile 2 1 3% 3-10% 0 6 6% 10-90% (Normal) % 90-97th %tile % > 97%tile % Pain Medications Intraoperative Phase I Recovery Medications 5

6 Phase II Recovery Medications Opioids Used to treat moderate to severe pain Bind to µ-opiate receptors in the CNS Potency determined by affinity for receptors Interpatient variability, failure of one failure to all Allergies: important to know reaction, majority are not true allergies Safety issue with transfer to floor Opioid Comparison Chart Opioid Onset T 1/2 Analgesia Dosage Form Oxycodone min Morphine IV PO 5-10min ~30min PO PO, IV Fentanyl 1-2 min IV, Top Total Time in PACU by Early vs Later Arrival of Parent at Bedside Mean*/ Median (SD) Early Arrival 18.3 mins * / (27.2) Later Arrival > 18.3 mins */ (36.6) Range mins mins. 25% tile 94 mins. 105 mins. 50%tile mins. 132 mins. 75%tile 128 mins. 162 mins. * p=.02 Children whose parents arrived to the bedside within 18 mins of their admission to PACU had a significantly shorter length of stay than those whose parents came after 18 mins. What does this all mean? Patients who received combination opioid analgesic medications either intraoperatively or during Phase I had significantly lower pain scores in Phase II than those who received mono therapy in either setting. Overall, PACU length of stay was not significantly different by either type or combination of analgesic medications received. 6

7 Next Steps Considering the time spent in the PACU setting, it would be important to explore the role of nonpharmacological pain management techniques such as distraction, guided imagery, music and the use of ice collars. Priority Actions to Improve Pain Management: Organizational Adopt policies and standards for pain prevention and relief Provide distraction supplies (e.g., toys, books) in all areas where children undergo painful procedures Create opportunities for interdisciplinary collaboration in pain management Make evidence based pain assessment and treatment protocols accessible to everyone Provide education to parents and children about pain management (Finely, Franck, Grunau & vonbaeyer, 2005) Priority Actions to Improve Pain Management: Individual Minimize needle procedures (e.g., combine blood samples) Provide training to parents to show them how to best support their child s pain relief Ensure a quick response to reports of pain. Consistently provide behavioral, cognitive, and physical interventions to help children cope with procedural pain Commit to use of pain free routes for medication administration (Finely, Franck, Grunau & vonbaeyer, 2005) Evidence Base (What we know) Pediatric patients receive inadequate pain management Unit and organizational culture are important to improving pain management as are beliefs and attitudes of health care providers Unrelieved pain has potentially dire consequences for our patients Satisfaction with pain management increases with attention even without complete relief Pain sources for children include fear (e.g., What will happen next? What is that machine and how will it hurt me?) There are a myriad of effective treatments for pediatric pain and using medications with nonpharmacologic treatments is always preferable! Implications The combination of drug therapy and parental presence may be helpful in decreasing pain and PACU length of stay. Exploration of the role of non pharmacologic pain management techniques such as distraction, guided imagery, music and the use of ice collars in conjunction with analgesic therapy is needed. 7

8 Implications. Future research directions could include identification of patient characteristics and interventions which lead to effectively managed or under-managed pain. This data will also guide staff in pilot testing different pain management nursing interventions. Implications Future research directions could include identification of patient characteristics and interventions which lead to effectively managed or under-managed pain. This data will also guide staff in pilot testing different pain management nursing interventions. Thank You! Questions?? Special thanks to all of the members of the team who are contributing to this project: Regina Roth RN, MSN, CPAN; Dekeisha Howard RN, MSN; Eileen Phillips RN, BSN; Eileen Ryan MSN,CRNP; Katherine Finn Davis PhD, RN; and Beth Ely, PhD, RN. Contact information: Deborah Scalford, RN, MSN, CN IV, Children s Hospital of Philadelphia, Perianesthesia Care Unit. 34 th Street and Civic Center Blvd. Phila. PA scalford@ .chop.edu 8