Validation of the Individualized Numeric Rating Scale (INRS): a pain assessment tool for nonverbal children with intellectual disability.

Clinical observations suggest that nonverbal children with severe intellectual disability exhibit pain in a wide variety yet uniquely individual ways. Here, we investigate the feasibility and describe the initial psychometrics properties of the Individualized Numeric Rating Scale (INRS), a personalized pain assessment tool for nonverbal children with intellectual disability based on the parent's knowledge of the child. Parents of 50 nonverbal children with severe intellectual disability scheduled for surgery were able to complete the task of describing then rank ordering their child's usual and pain indicators. The parent, bedside nurse and research assistant (RA) triad then simultaneously yet independently scored the patient's post-operative pain using the INRS for a maximum of two sets of pre/post paired observations. A total of 170 triad assessments were completed before (n=85) and after (n=85) an intervention to manage the child's pain. INRS inter-rater agreement between the parents and research nurse was high (ICC 0.82-0.87) across all ratings. Parent and bedside nurse agreement (ICC 0.65-0.74) and bedside nurse and research nurse agreement (ICC 0.74-0.80) also suggest good reliability. A moderate to strong correlation (0.63-0.73) between INRS ratings and NCCPC-PV total scores provides evidence of convergent validity. These results provide preliminary data that the INRS is a valid and reliable tool for assessing pain in nonverbal children with severe intellectual disability in an acute care setting.

Percutaneous sclerotherapy for lymphatic malformations: a retrospective analysis of patient-evaluated improvement.

PURPOSE: To evaluate the midterm outcomes of percutaneous sclerotherapy of lymphatic malformations (LMs) as judged by patients. MATERIALS AND METHODS: A 13-item survey questionnaire was sent to 74 patients who had undergone at least one sclerotherapy procedure in our hospital from January 1997 through January 2003. Information regarding the anatomic location, specific symptoms reported, history, treatment satisfaction, postprocedural complications, and number of treatment sessions was elicited. Four sclerosing agents (as single agents or in combination with other agents) were used: ethanol, sodium tetradecyl sulfate 3% (STS), OK-432, and doxycycline. RESULTS: Fifty-five patients or their caregivers completed the survey. The patients' ages ranged from 6 months to 48 years at the time of the first procedure (mean, 12 y; median, 4 y). A majority of LMs were located in the cervicofacial region. The size and location of the lesion, recurrent infection, and pain were the most frequent indications for treatment. Fifty-one percent of these patients received sclerotherapy alone or in conjunction with surgery as primary treatment. Ethanol was the most common sclerosing agent used, followed by doxycycline, STS, and OK-432. Response varied with the type of LM, with 100%, 86%, and 43% of the patients reporting good to complete response for macrocystic, microcystic, and combined-type LMs, respectively. Skin blistering and ulcers were the most common complications. Permanent complications were uncommon and were largely related to ethanol use. CONCLUSIONS: Percutaneous sclerotherapy provides effective midterm primary treatment for LMs. Treatment outcomes appear to vary according to the morphology of the malformation.

Infant sedation for MR imaging and CT: oral versus intravenous pentobarbital.

PURPOSE: To compare the effectiveness and safety of oral (PO) versus intravenous (IV) pentobarbital sedation for magnetic resonance (MR) imaging and computed tomography (CT) in infants younger than 12 months. MATERIALS AND METHODS: The institutional review board approved the review of medical records and determined informed consent to be unnecessary. All parents gave informed consent for patient sedation. Prior to MR imaging or CT, infants younger than 12 months were sedated with PO pentobarbital (4-8 mg per kilogram body weight) or IV pentobarbital (2-6 mg/kg), depending on the presence of an IV catheter or need for IV contrast medium. A computer database used to record sedation data was reviewed for data from January 1997 to September 2003. PO and IV sedation groups were compared for mean age, weight, dose, time to sedation, time to discharge, and duration of sedation with a two-sample Student t test. Multivariate analysis of covariance was used to determine whether differences in sedation time, time to discharge, and duration of sedation between groups were independent of age, weight, sex, American Society of Anesthesiologists physical status classification, dose, and type of procedure. Sedation effectiveness (outcome) was determined as the percentage of sedation failures in each group. Safety was determined separately for other adverse events as a total and for respiratory adverse events. RESULTS: A total of 2164 infants received 2419 (1264 PO, 1155 IV) doses of pentobarbital for sedation. Weight and sex were comparable between groups. Time to sedation was significantly longer with PO than with IV pentobarbital (18 minutes +/- 11 vs 7 minutes +/- 7; P < .01), but time to discharge was similar, at approximately 108 minutes +/- 35. Total adverse events rate during sedation was not significantly different (0.8% [PO] vs 1.3% [IV]), but incidence of abnormal oxygen saturation (5% decrease from baseline, >1 minute duration) differed significantly (0.2% [PO] vs 0.9% [IV]; P = .02). Sedation effectiveness was comparable (failure rate, 0.5% [PO] vs 0.3% [IV]; P = .76). CONCLUSION: PO pentobarbital has comparable effectiveness and a lower rate of respiratory complications compared with IV pentobarbital in infants younger than 12 months; its use should be considered, regardless of presence of an IV catheter.

Superiority of pentobarbital versus chloral hydrate for sedation in infants during imaging.

PURPOSE: To compare the effectiveness and safety of oral pentobarbital and oral chloral hydrate for sedation in infants younger than 1 year during magnetic resonance (MR) imaging and computed tomography (CT). MATERIALS AND METHODS: A computerized database was used to collect information about all cases in which sedation was used. Outcomes of all infants who received oral pentobarbital or oral chloral hydrate for sedation between 1997 and 2002 were reviewed. Two study groups were compared for sedation and discharge times by using Student t test and for adverse events by using Fisher exact test and multiple logistic regression analysis. RESULTS: Infants (n = 1,316) received an oral medication for sedation. Mean doses were 50 mg/kg chloral hydrate and 4 mg/kg pentobarbital. Student t test demonstrated no difference in mean time to sedation and in time to discharge between groups. Overall adverse event rate during sedation was lower with pentobarbital (0.5%) than with chloral hydrate (2.7%) (P <.001). There were fewer episodes of oxygen desaturation with pentobarbital (0.2%) than with chloral hydrate (1.6%) (P <.01). Both medications were equally effective in providing successful sedation. CONCLUSION: Although oral pentobarbital and oral chloral hydrate are equally effective, the incidence of adverse events with pentobarbital was significantly reduced.

Evolution of a protocol for ketamine-induced sedation as an alternative to general anesthesia for interventional radiologic procedures in pediatric patients.

PURPOSE: To establish a protocol for credentialed pediatric radiology nurses, with radiologist supervision, to administer ketamine to induce sedation and analgesia during interventional radiologic procedures. MATERIALS AND METHODS: This study was conducted in two phases. The goal of the first phase was to develop a sedation protocol to replace that of using general anesthesia for specified pediatric interventional procedures. Ketamine was administered intravenously (with intermittent bolus or continuous infusion) or intramuscularly. Sedation induction times, adverse events, doses, and sedation and recovery durations were recorded. In phase 2, the results of phase 1 were reviewed and a formal ketamine protocol was developed. RESULTS: Neither sedation failures nor substantial adverse events occurred in phase 1. Mean duration of all sedations was 52 minutes, and median recovery room time was 0 minutes. In phase 2, the results of phase 1 were reviewed and a sedation protocol was proposed to a hierarchy of hospital committees before final approval from the medical staff executive committee. Subsequently, standard order forms for radiology nurse administration of ketamine with radiologist supervision were prepared for exclusive use by the pediatric interventional radiology department. CONCLUSION: Ketamine-induced sedation may be a safe and effective alternative to general anesthesia for some interventional radiologic procedures in pediatric patients. Collaboration between anesthesia and radiology departments is important for development of a safe and successful ketamine sedation program. To the authors' knowledge, this is the first report describing the intravenous infusion of ketamine for sedation in pediatric patients and the only report describing the establishment of a protocol for ketamine administration by credentialed radiology nurses with radiologist supervision.

The development of a pediatric radiology sedation program.

BACKGROUND: An increase in the number of patients undergoing sedation for imaging procedures has led to many changes in practice over the past 10 years. OBJECTIVE: The purpose of this study was to compare and evaluate sedation practice changes in a pediatric radiology department during the last 5 years. MATERIALS AND METHODS: The radiology computer database and corresponding minutes of the Radiology Sedation Committee were reviewed to identify changes in sedation policy. Data from three blocks of time were analyzed to determine time to sedation, time to discharge, drug frequency, rates of adverse events, sedation failure, and paradoxical reaction. RESULTS: Specific practice changes undertaken over the 5-year period include: (1) increased speed of administration of IV pentobarbital, (2) alternating pentobarbital and fentanyl, (3) presedation with midazolam, and (4) administering oral pentobarbital to children under and (5) over 12 months of age. Based on data analysis, changes 1 and 4 were incorporated into the sedation policy, while changes 2, 3, and 5 were abandoned. Comparison of data from the three time segments revealed improvement in the time to sedation, sedation failure, adverse event, and paradoxical reaction rates. CONCLUSION: There is improvement in all aspects of patient outcomes with sedation, as a result of several changes in sedation practice.