Increasing staff nurse awareness of postoperative pain management in the NICU.

Infants must have effective pain management in the postoperative period. A Level III NICU evaluated its current practice and identified barriers to effective pain management. Action was then taken to eliminate the identified barriers. This included developing a pain management team, testing and implementing an objective postoperative pain tool, employing a new flow sheet that incorporates the pain tool, offering multidisciplinary educational activities, and involving nurses in research. These actions have broken down the barrier to effective postoperative pain management and provided direction for a new standard of care.

Intrathecal morphine for postoperative analgesia in an infant with bronchopulmonary dysplasia following upper abdominal surgery.

We present a case of severe bronchopulmonary dysplasia in which intrathecal morphine was successfully used for analgesia after a Nissen fundoplication and gastrostomy. Various options for anaesthesia are discussed with the knowledge that two previous procedures had been complicated by congestive cardiac failure and increased respiratory failure.

CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability.

We have developed a neonatal pain assessment tool CRIES. The tool is a ten point scale similar to the APGAR score (Apgar 1953). It is an acronym of five physiological and behavioural variables previously shown to be associated with neonatal pain. C--Crying; R--Requires increased oxygen administration; I--Increased vital signs; E--Expression; S--Sleeplessness. We have tested CRIES for validity and reliability. This report is the result of that testing. We have found CRIES to be valid, reliable and well accepted by neonatal nurses.

Intrathecal morphine (ITM) for postoperative pain control in children: a comparison with nalbuphine patient controlled analgesia (PCA).

This is a retrospective study covering the ten-year period 1984-1993. Single shot spinal morphine (ITM) is compared with PCA nalbuphine for postoperative pain relief in children having abdominal or thoracic procedures. The records of 52 patients meeting selection criteria were examined. Nursing and physician notations were reviewed for hourly pain assessments, evidence of associated complications, respiratory depression, nausea and or vomiting, pruritus, and urinary retention. ITM provided significantly better pain relief (2.2 h in pain) during the first 24 h postoperatively than PCA nalbuphine (9.2 h in pain). With the exception of urinary retention which was significantly more frequent following ITM (58.6%) compared to PCA nalbuphine (8.7%), narcotic related complications were not different between the two groups. No difference in duration of hospital stay or ICU stay could be demonstrated. We conclude that ITM provides better pain relief, without more serious complications, than PCA nalbuphine. We recommend it as a safe, effective technique to treat postoperative pain in children following thoracic or upper abdominal procedures.

Anesthesia in 'stone man': myositis ossificans progressiva.

Myositis ossificans progressiva is a rare disease leading to complete ossification of the muscular system. Very little information about this rare disease and its anesthetic implications has appeared in anesthetic literature. This disease is felt to have an autosomal dominant pattern of inheritance and is usually associated with anomalies of the hands and feet. Afflicted patients are frequently misdiagnosed in childhood as having a rheumatologic disorder. Later in life (as true bone is formed in striated muscle, ligaments, and fascia), the correct diagnosis becomes obvious. Although muscles of the heart, diaphragm, larynx, and sphincters are spared, those of the chest wall are not, and pulmonary function progressively deteriorates. Death frequently occurs as a result of a pulmonary infection. Specific anesthetic considerations include positioning to avoid injury, potential need for fiberoptic intubation or tracheostomy, decreased thoracic compliance with the need for increased ventilating pressures, and the ultimate in disuse atrophy contraindicating the use of succinylcholine. Myositis ossificans progressiva can present the anesthesiologist with interesting challenges. Anesthetic management will need to be individualized according to the severity of the disease.

Naloxone: report of a beneficial side effect.

We report two cases. The first was an unexpected, complete resolution of an acute unilateral neurologic deficit associated with anesthesia when naloxone was administered to reverse residual narcotic effect. The second was a complete resolution of postoperative unilateral electroencephalographic evidence of ischemia after naloxone administration in a patient following a carotid endarterectomy. A literature search suggests that naloxone may be useful in the treatment of acute and hyperacute stroke due to ischemia.