Low-Dose Versus High-Dose Postoperative Naloxone Infusion Combined With Patient-Controlled Analgesia for Adolescent Idiopathic Scoliosis Surgery: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: The aim of this prospective randomized clinical trial was to compare low (0.5 µg/kg/h) and high (2.5 µg/kg/h) dose naloxone infusion on the time to tolerate liquids and meals after surgery, patient-controlled analgesia (PCA) opioid requirements, nausea and pruritus ratings, and hospital length of stay. SUMMARY OF BACKGROUND DATA: Adolescents undergoing posterior spinal fusion often receive PCA after surgery and may experience common opioid-associated side effects, including nausea and pruritus. Low-dose naloxone infusion has been shown to reduce the incidence of pruritus and nausea while preserving analgesia, although an ideal dose has not been determined. Less is known about the potential for naloxone to improve bowel function after surgery. METHODS: Eighty-four patients (age 10-21 years) were randomly allocated to receive low- or high-dose naloxone infusion postoperatively. Surgical anesthetic consisted of propofol and opioid infusion with intrathecal morphine (10-15 µg/kg) at the conclusion of surgery. A visual analog scale (VAS) was used to rate nausea and pruritus. RESULTS: The groups had similar time to oral liquid intake after surgery and transition from PCA to oral pain medication. The VAS scores for pruritus and nausea were also similar, as was the need to treat these side effects. Morphine equivalents were similar between groups on postoperative day (POD) 0 and 1. On POD 2, the high-dose infusion group had significantly greater PCA bolus use (1.41±0.9 vs. 1.04±0.6; p<.05), although pain scores did not differ significantly. Hospital length of stay was similar for the two groups. CONCLUSION: High-dose naloxone infusion was associated with similar rates of opioid side effects as low-dose. Increased PCA use noted on POD 2 may represent partial reversal of opioid analgesia in the high-dose naloxone group. LEVEL OF EVIDENCE: Level 1.

Increasing ED Use of Jet Injection of Lidocaine for IV-Related Pain Management.

BACKGROUND AND OBJECTIVE: Venipuncture is a leading cause of procedural pain for children. Jet injection of lidocaine (JIL; J-Tip) has been demonstrated to be effective in controlling intravenous (IV) placement-related pain and, due to its rapid onset, is particularly suited to emergency department (ED) use. Our objective was to increase JIL use with IV placements in our ED from 11% at baseline to 50% within 12 months. METHODS: We initiated the project at our urban, tertiary pediatric ED in July 2014. We surveyed medical and nursing teams to identify barriers to JIL use. We initiated changes at monthly intervals: (1) order set changes, (2) online education, (3) hands-on workshops, (4) improved accessibility, (5) standing order policy revision, and (6) reminders. We collected biweekly data on IV placements for all ED patients, except level 1 (critical) triage patients. We used standard quality improvement methodology and statistical process control for statistical analysis. RESULTS: JIL use with IV placement increased to 54% over 7 months and has remained >50% for >12 months. For all eligible IV placements (n = 12 791), 76.4% of those where JIL was used were successful on the first attempt compared with 75.8% without JIL (χ21degrees of freedom = 0.33, P = .56), with no significant difference in the success at IV placement. CONCLUSIONS: We sustainably increased JIL use with IV placement. The use of JIL was not associated with a difference in first-attempt IV placement success rates. We are expanding the project to other parts of the institution.

Using quality improvement methods to increase use of pain prevention strategies for childhood vaccination.

AIM: To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology. METHODS: Specific intervention strategies (i.e., comfort positioning, nonnutritive sucking and sucrose analgesia, distraction) were identified, selected and introduced in three waves, using a Plan-Do-Study-Act framework. System-wide change was measured from baseline to post-intervention by: (1) percent of vaccination visits during which an evidence-based pain prevention strategy was reported as being used; and (2) caregiver satisfaction ratings following the visit. Additionally, self-reported staff and caregiver attitudes and beliefs about pain prevention were measured at baseline and 1-year post-intervention to assess for possible long-term cultural shifts. RESULTS: Significant improvements were noted post-intervention. Use of at least one pain prevention strategy was documented at 99% of patient visits and 94% of caregivers were satisfied or very satisfied with the pain prevention care received. Parents/caregivers reported greater satisfaction with the specific pain prevention strategy used [t(143) = 2.50, P ≤ 0.05], as well as greater agreement that the pain prevention strategies used helped their children's pain [t(180) = 2.17, P ≤ 0.05] and that they would be willing to use the same strategy again in the future [t(179) = 3.26, P ≤ 0.001] as compared to baseline. Staff and caregivers also demonstrated a shift in attitudes from baseline to 1-year post-intervention. Specifically, staff reported greater agreement that the pain felt from vaccinations can result in harmful effects [2.47 vs 3.10; t(70) = -2.11, P ≤ 0.05], less agreement that pain from vaccinations is "just part of the process" [3.94 vs 3.23; t(70) = 2.61, P ≤ 0.05], and less agreement that parents expect their children to experience pain during vaccinations [4.81 vs 4.38; t(69) = 2.24, P ≤ 0.05]. Parents/caregivers reported more favorable attitudes about pain prevention strategies for vaccinations across a variety of areas, including safety, cost, time, and effectiveness, as well as less concern about the pain their children experience with vaccination [4.08 vs 3.26; t(557) = 6.38, P ≤ 0.001], less need for additional pain prevention strategies [3.33 vs 2.81; t(476) = 4.51, P ≤ 0.001], and greater agreement that their doctors' office currently offers pain prevention for vaccinations [3.40 vs 3.75; t(433) = -2.39, P ≤ 0.05]. CONCLUSION: Quality improvement methodology can be used to help close the gap in implementing pain prevention strategies during routine vaccination procedures for children.

Predictors of postoperative pain trajectories in adolescent idiopathic scoliosis.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To determine the typical trajectory of pain during the first 6 months after spinal fusion surgery for adolescent idiopathic scoliosis (AIS) and the extent to which certain demographic, medical, and psychological variables modify this trajectory. SUMMARY OF BACKGROUND DATA: Pain after spinal fusion surgery for AIS may not improve predictably with elapsed healing time, and limited data exist on predictors of the course of pain during the initial months after surgery. METHODS: Fifty patients ages 11 to 17 (mean = 14.5, standard deviation = 1.9) with AIS and undergoing posterior spinal fusion surgery comprised the study sample. Pain outcomes were assessed at 4 time points after surgery (2-week, 6-week, 3-month, and 6-month postsurgery). Preoperative predictor variables comprising demographics, baseline Cobb angle, body mass index, baseline pain, and psychological variables (anxiety, negative mood, and confidence in ability to control pain) were assessed 2 weeks before surgery. Perioperative predictor variables comprising pain, pain coping efficacy, negative mood, surgery length, length and lowest level of fusion, and analgesic use were assessed by self-report or record review. Multilevel growth models were used to evaluate hypotheses pertaining to predictors of pain trajectories. RESULTS: Pain level on average declined predictably with days since surgery (b = -0.14 to -0.19, P < 0.01). For 22% of adolescents, pain was at or above baseline levels through 6 months after surgery. Greater baseline pain and anxiety predicted slower improvement in pain, whereas greater confidence in ability to control pain predicted more rapid declines in pain. None of the demographic or medical variables reliably modified postsurgical pain trajectories. CONCLUSION: Although pain typically declines predictably with healing time from spinal fusion surgery for AIS, higher preoperative levels of pain and anxiety may be risk factors for chronic postsurgical pain whereas greater pain coping efficacy may help optimize postsurgical pain outcomes. LEVEL OF EVIDENCE: 3.

Implications of evidence-based venipuncture practice in a pediatric health care Magnet facility.

Venipunctures are very distressing for children. Nurses who routinely perform venipuncture procedures report an interest in becoming proficient in this skill. This procedure includes monitoring for potential adverse outcomes and providing age-appropriate coping strategies. These interventions make this necessary experience more positive. This study evaluated whether the completion of an evidence-based online tutorial program improved knowledge, attitudes, and self-reported venipuncture practices. Pre- and postintervention self-assessment data were obtained from 426 nurses who provide direct patient care in medical-surgical units and clinics at a pediatric Magnet hospital. Analyses of these data determined that nurses improved their ability to grade intravenous infiltrates (t = 155.78, df = 1, p = .000) and phlebitis (t = 172.14, df = 1, p = .000). These results showed that an online training program increases knowledge and practices regarding venipuncture.