ABSTRACT
Up to 50% of cancer patients and up to 90% of those in terminal stages experience pain associated with disease progression, poor quality of life, and social impact on caregivers. This study aimed to establish standards for the accreditation of oncological pain management in healthcare organizations. A mixed methods approach was used. First, a pragmatic literature review was conducted. Second, consensus between professionals and patients was reached using the Nominal Group and Delphi technique in a step that involved anesthesiologists, oncologists, family physicians, nurses, psychologists, patient representatives, and caregivers. Third, eight hospitals participated in a pilot assessment of the level of fulfillment of each standard. A total of 37 standards were extracted. The Nominal Group produced additional standards, of which 60 were included in Questionnaire 0 that was used in the Delphi Technique. Two Delphi voting rounds were performed to reach a high level of consensus, and involved 64 and 62 participants with response rates of 90% and 87%, respectively. Finally, 39 standards for the management of cancer pain were agreed upon. In the self-evaluation, the average range of compliance was between 56.4% and 100%. The consensus standards of the ACDON Project might improve the monitoring of cancer pain management. These standards satisfied the demands of professionals and patients and could be used for the accreditation of approaches in cancer pain management.
ABSTRACT
BACKGROUND: Complex regional pain syndrome (CRPS) is a multifactorial condition with complex pathogenesis characterized by spontaneous or stimulus-induced pain that is disproportionate to the inciting event. It is also commonly accompanied by a myriad of autonomic and motor disturbances in highly variable combinations. This condition has been underreported in children until recently. Consequently, the management of CRPS in the pediatric population presents an even greater challenge than in adults, partly because there is a lack of clinical data concerning the efficacy of the diverse treatment methods available, and partly because successful treatment of CRPS involves a multidisciplinary approach. There is a variety of invasive methods to the treatment of CRPS, but scarce pediatric-focused trials have been published to date. OBJECTIVE: To examine and analyze the data currently existing for the invasive management of CRPS in children. It further suggests a management algorithm based in the evidence reviewed and our team experience. STUDY DESIGN: A comprehensive review of invasive management for pediatric CRPS. SETTING: Academic hospital in Spain. METHODS: A comprehensive review of all the evidence published to date was conducted. Four databases (PubMed, Medline, Web of Science, Embase, and Cochrane databases) were searched for articles published from 1980 to 2014. The eligibility criteria were any paper published in English or Spanish where a non-conventional approach was used to manage pediatric CRPS. Two independent reviewers extracted the data. RESULTS: Many case series have reported the use of interventional management with positive results; however, there is not a single randomized control trial to date comparing the conservative and the invasive management in children. The largest series of pediatric cases showed that between 29% to 35% of children with CRPS needed interventional measures to manage this condition successfully. Sympathetic blocks and spinal drug infusion emerge as the most reported techniques; the spinal infusion of drugs together with the spinal cord stimulation being the most successfully employed. Based upon the available evidence with regard to effect and complications, we recommend an algorithm for the management of pediatric CRPS. LIMITATIONS: The limitations of this study include the paucity of literature, lack of randomized trials, and lack of quality evidence. CONCLUSIONS: Invasive techniques have been used to treat CRPS over the last few decades; however, the evidence for their use is still very weak. Invasive management should be contemplated only when high-standard conservative management has failed to work.