The Effectiveness of Distraction as Procedural Pain Management Technique in Pediatric Oncology Patients: A Meta-analysis and Systematic Review.

CONTEXT: Diagnostic tests and treatment regimens for pediatric cancers involve invasive and painful procedures. Effective management of such pain has been shown to be suboptimal in many parts of the world, often because of the cost and limited availability of appropriate medications. Current evidence suggests that distraction (a relatively low-cost technique) is a promising intervention for procedural pain management. There is, however, limited evidence demonstrating its effectiveness in pediatric oncology patients. OBJECTIVES: A systematic review was conducted to ascertain the effectiveness of distraction as a procedural pain management technique in pediatric oncology patients. METHODS: Using a comprehensive search strategy, MEDLINE, PsycINFO, Cochrane Library, AMED, CINAHL, Web of Science, and EMBASE electronic databases were searched for studies comparing distraction techniques to standard care/any intervention. Using the selected studies, a systematic review and meta-analysis of randomized controlled trials was conducted. RESULTS: Two hundred ninety-nine studies were identified, with seven randomized control trials identified as eligible for inclusion. Pain was assessed using self-report, observer-report, and physiological measures. A meta-analysis of four studies showed distraction as effective in reducing procedural pain, based on self-reported pain. A meta-analysis of three studies, based on pulse rates, demonstrated similar results. For observer-reported pain, limited evidence supported the effectiveness of distraction. CONCLUSION: This systematic review demonstrates that distraction is a promising intervention for procedural pain. Future research should assess effectiveness of distraction in varied populations, to explore evidence of cultural influences on pain expression, measurement, and management approaches.

Is intranasal midazolam an effective rescue medication in adolescents and adults with severe epilepsy?

The aim of this study was to determine whether intranasal midazolam is a safe and effective rescue medication in adolescent and adult patients with severe epilepsy. This field trial was designed to test the feasibility of the use of intranasal midazolam as an alternative to rectal diazepam in a cohort of patients with severe epilepsy who require rescue medication as part of their treatment. A dose of intranasal midazolam (5 mg if the patient weighed less than 50 kg and 10 mg if the patient weighed over 50 kilograms) was prescribed for those who had previously responded to other rescue medication. Midazolam was prescribed buccally if excessive head movement accompanied seizures. The protocol reverted to the usual rescue medication if there was no response to midazolam within 10 minutes. Vital signs were monitored for half an hour following the administration of the treatment. Twenty-two patients received 84 treatment episodes and 79 of these were considered clinically effective. Five treatment failures were recorded, three due to poor technique in delivering the midazolam. Two patients were successfully retried on midazolam and a third is awaiting a retrial of this drug. The two other treatment failures received the drug buccally. In the first patient the clinical opinion was that this was possibly a psychogenic non-epileptic seizure. The other patient responded initially, but within an hour had another seizure requiring further rescue treatment. No significant adverse effects were reported. Our study shows that intranasal midazolam, when used appropriately, is an effective treatment in those who require rescue treatment. There are clear advantages in the use of midazolam over diazepam in the treatment of acute seizures. These include the favourable pharmacokinetic and pharmacodynamic properties of midazolam as well as the potential of a more acceptable and dignified administration route.