The assessment and management of pain is a high priority in the care of medical and surgical patients of all ages.1 * 2 3 3–7 4–8 2 † 8 9
The purpose of this study was to assess current national pediatric pain management practices to determine how IV opioid analgesia, specifically that delivered through a PCA delivery device, is provided to children. In addition, we sought to determine the effect that patient characteristics, demographic factors, and the recommendations of these expert bodies have had on this practice.
METHODS
After receiving institutional IRB approval, we e-mailed a web-based, cross-sectional, descriptive survey to select members of the Society for Pediatric Anesthesia (SPA) who practice in multiple types of hospital settings within the United States. The survey was distributed via Survey Monkey (www.surveymonkey.com
The survey consisted of 56 questions (Appendix). The sections of the survey included recipient and institutional demographics, pediatric pain service existence and direction, modalities of opioid pain treatment available, use of PCA, use of PCA by proxy, monitoring regimens for patients receiving IV opioids, recalled need for the antagonist naloxone to treat opioid-induced cardiopulmonary side effects, and recalled patient deaths secondary to IV opioid therapy.
Data are presented as the percent (number) of respondents who answered a given question. Data were analyzed with STATA statistical software (StataCorp. 2007, Stata Statistical Software: Release 10, StataCorp LP, College Station, TX). Noncontinuous data were analyzed with the χ2 test. A P value ≤0.05 was considered statistically significant.
RESULTS
Provider and Hospital Demographics
The overall response rate to the survey was 41% (294 of 724) of practitioners contacted and represented 63% (252 of 400) of institutions polled. Of note, 99% (292 of 294) of respondents were anesthesiologists. One respondent was excluded from the survey because he or she was retired and did not complete the survey. There were 21 institutions from which >1 individual responded. When >1 respondent replied from an institution, variation in responses occurred only 5% of the time (average variability 2.5 questions per institution). Once duplicate responses were pooled, data from 252 institutions were included in the final analysis.
Respondent demographics are presented in Table 1 . Data were obtained from institutions throughout the United States; no one region provided a major bias. Respondents were from 44 states, the District of Columbia, and Puerto Rico. Although the majority of respondents practice in a freestanding children's hospital (105 of 252) or in a children's hospital within a general hospital (68 of 252), 32% of respondents practice at least part of the time in a general hospital. More than two-thirds of respondents practice at a university-affiliated teaching hospital, and responses were received from all national pediatric anesthesia fellowship training programs. The number of pediatric patients cared for annually varied widely with the median number of pediatric beds per institution ranging between 101 and 150, and the median number of pediatric surgical procedures per institution ranging between 3001 and 5000 annually.
Table 1:
Pediatric Pain Service Availability and Characteristics
Overall, 129 of 252 institutions surveyed (51%) had a pediatric pain service. A pediatric pain service was present in 85% of freestanding children's hospitals; the service was less common in children's hospitals within general hospitals (44%) and unusual in the general hospital setting (13%) (P < 0.001). Hospitals that provided a pediatric pain service were significantly larger and performed more surgeries than those that did not (P < 0.001). Of hospitals with >150 pediatric beds, 82% offered a pediatric pain service, but only 22% of hospitals with ≤50 beds did so. Seventy percent of institutions offering a pediatric anesthesia fellowship training program had a pediatric pain service.
Across all hospital settings, pediatric pain services were most frequently under the administrative direction of the anesthesiology department (91%). Pain service coverage was delegated to both physicians and nurses. Approximately 36% of primary daytime calls were directed to an attending physician, 18% were directed to either a resident or fellow, and 44% were directed to a clinical nurse specialist or nurse practitioner. Nighttime call coverage was largely physician based, with calls directed to an attending physician at 47% of institutions and to a resident or fellow at an additional 47% of institutions. Overall, 31% of call responsibility was covered by an in-house provider.
IVPCA Availability and Management
Respondents from 96% of institutions reported that IVPCA was available to all pediatric patients who needed it and who qualified based on age and mental and physical ability. More than half (59%) of responding institutions did not have age restrictions for pediatric patients who could independently use IVPCA. For those institutions that did have age limitations, approximately two-thirds allowed for independent PCA use by children 6 years or older.
Responsibility for PCA order writing varied among institutions even when a pediatric pain service was present. At 45% of hospitals with a pediatric pain service, the pain service wrote >75% of the PCA orders. However, at institutions without a pediatric pain service and at 32% of institutions with a pediatric pain service, the patient's primary service was responsible for the majority of IVPCA orders. Computerized provider order entry (POE) systems were available at half of the institutions surveyed, and computerized IVPCA ordering was available at one-third of them. Handwritten IVPCA orders and calculations were used by almost half of our respondents. Handwritten orders were used despite the fact that 39% of these providers practiced at hospitals where POE systems were available.
Morphine was the most frequently available opioid for IV delivery via IVPCA. Of 212 responses, all could provide morphine via IVPCA. More than 75% of these institutions also had fentanyl and hydromorphone available via IVPCA, whereas 17% offered IV meperidine via IVPCA. The presence or absence of a pediatric pain service had no bearing on the availability of IV meperidine. Approximately half of respondents who completed the survey failed to provide information concerning IVPCA dosing and/or monitoring standards in their institutions. For those who responded, the most frequently selected hourly basal infusion doses were morphine 10 to 19 μg · kg−1 · h−1 (48%), hydromorphone 1 to 3 μg · kg−1 · h−1 (56%), and fentanyl 0.2 to 0.4 μg · kg−1 · h−1 (43%). There was somewhat more variability in bolus dose selection. More than two-thirds of responses were divided between morphine 20 to 29 μg/kg/dose (36%) and 10 to 19 μg · kg−1 · h−1 (33%), and >80% of responses were divided between hydromorphone 1 to 3 μg/kg/dose (43%) and 4 to 6 μg/kg/dose (40%); almost 90% chose fentanyl 0.2 to 0.4 μg/kg/dose (58%) and fentanyl 0.5 to 1.0 μg/kg/dose (29%). Fifty percent of hospitals used hourly dose limits for pediatric patients receiving IVPCA, whereas 10% had no time-dependent dose limits. In general, dosing of non-IVPCA continuous opioid infusions was reported to be similar to dosing of the PCA basal infusion, but “traditional” IV as-needed opioid doses were at least twice as large as (and significantly less frequent than) PCA bolus doses.
Twenty-nine percent of institutions routinely used basal or continuous infusions when administering IVPCA, 63% provided it on a case-by-case basis, and 8% never used a continuous infusion. Institutional ordering practices differed significantly based on the involvement of a pediatric pain service. Those hospitals that had a pediatric pain service were >3 times more likely to routinely use a basal infusion (41% vs 12%), whereas those without a pediatric pain service were >8 times more likely to never use a basal infusion (17% vs 2%, P < 0.001).
Nursing instruction regarding PCA pump programming was reported to occur at 90% of institutions, and 98% provided instruction regarding pain assessment, 90% regarding treatment of opioid side effects, and 60% regarding administration of surrogate or proxy doses. Nurses were able to administer supplemental opioids to treat breakthrough pain in patients who received either IVPCA or non-PCA opioids at 78% of institutions (150 of 193), but only 26% allowed nurses to independently increase or decrease the PCA pump settings within predefined, physician-approved dosing limits. Educational material concerning IVPCA was provided to patients or their families by 40% of institutions (93 of 234). The presence of a pediatric pain service did not change this percentage significantly because respondents from more than half of those institutions reported that they did not provide instructional material to families.
PCA by Proxy
Approximately 38% of respondents (95 of 252) worked in institutions at which some children were treated with “authorized” IVPCA by proxy, i.e., demand or bolus dosing of the IVPCA pump initiated by an authorized person other than the patient.9
Patient characteristics played a role in an institution's decision regarding the availability of PCA by proxy to a patient. At 98% of institutions, nurses were allowed to trigger the IVPCA demand dose button for patients who qualified for PCA use on the basis of age but who could not independently self-administer PCA because of mental or physical disability. Only 45% allowed parents to do the same. Age also played a role. At 27% of institutions, nurses were allowed to administer proxy doses once the patient was older than 1 year; at 28%, parents were allowed to do the same. Five institutions (2 children's hospitals, 2 children's centers, and 1 general hospital) allowed neonatal patients to receive nurse and/or parent-administered doses.
Most institutions that offered PCA by proxy (84%) were children's hospitals or children's hospitals within general hospitals, and 78% had a pediatric pain service. This was not always the case, however, because 5 respondents who worked at small general hospitals reported that they provided this service, and 3 of those institutions did not provide a pediatric pain service. Sixty-three percent of respondents reported that their institution treated fewer than 100 pediatric patients annually with PCA by proxy but 8% treated >500 children per year (Fig. 1 ). Only 26% (25 of 95) of institutions that offered PCA by proxy provided instructional material to parents regarding its use.
Figure 1.:
Number of patients treated annually with IV patient-controlled analgesia (IVPCA) at children's hospitals/children's centers (n = 131) and general hospitals (n = 47) as compared with the number of patients treated annually with IVPCA by proxy at children's hospitals/children's centers (n = 77) and general hospitals (n = 15).
In 2004, the JCAHO issued a sentinel event alert concerning PCA by proxy.†
Monitoring Standards for Pediatric Patients Receiving IV Opioids
Pediatric patients who received IV opioids, either PCA or non-PCA, could be admitted to any bed in the hospital at most responding institutions and were routinely monitored with pulse oximetry, usually for the duration of opioid administration. Use of other patient monitoring modalities generally occurred in tandem with pulse oximetry, but less frequently (Fig. 2 ). At 78% of responding institutions, routine monitoring was provided to all patients receiving IV opioids regardless of age, and 67% reported that monitoring was not changed if opioid dosing was increased.
Figure 2.:
Type of patient monitoring used when opioids are administered to pediatric patients. (Total number of respondents who answered question, 149; total number of respondents who provided IV patient-controlled analgesia [IVPCA] by proxy, 95.) Ninety percent of respondents reported using pulse oximetry monitoring when patients were administered PCA. Electrocardiographic monitoring and capnography were always used in conjunction with pulse oximetry, whereas respiratory inductive plethysmography (Respitrace) was almost always provided in conjunction with pulse oximetry (>90%) but was occasionally used as the sole type of monitoring.
At >90% of responding institutions, preprinted protocols were available for treating opioid-induced side effects, such as respiratory depression, nausea and vomiting, and pruritus. In addition, 89% had protocols for oxygen desaturation, 44% for urinary retention, and 30% for constipation. Respondents also reported having protocols for hypotension, bradycardia, fever, seizures, oversedation, lack of pain relief, and altered mental status.
Polypharmacy
At most responding institutions, coadministration of IV opioids and sedatives and/or anxiolytics was common. The practice was allowed at 69% of institutions in conjunction with bolus-only IVPCA, 62% in conjunction with IVPCA with a continuous infusion, 46% in conjunction with IVPCA by proxy, 53% in conjunction with non-IVPCA continuous infusions, and 74% in conjunction with non-IVPCA intermittent or bolus dosing of opioids.
Serious and Life-Threatening Complications
Forty-two respondents recalled patients having received naloxone to counteract the cardiopulmonary side effects of opioids during the year before receipt of the survey. Naloxone use was reported to occur in patients receiving IVPCA either with or without a continuous infusion, IVPCA by parent or nurse proxy, and non-IVPCA continuous opioid infusions. In addition, 8 respondents recalled patient deaths having occurred over the past 5 years in patients receiving IVPCA, non-PCA continuous infusions, and PCA by proxy. Approximately 75% of respondents who reported serious complications worked in institutions in which coadministration of sedative/ anxiolytics in conjunction with IV opioids was at times permitted.
DISCUSSION
This cross-sectional, descriptive survey provides a general overview of how IV opioid analgesia, particularly IVPCA, is provided to pediatric patients nationally. As with adult patients, we found that PCA was generally available to all pediatric patients capable of independently using it. However, IVPCA by proxy was a treatment option for the young and/or children with developmental or physical disability at one-third of institutions surveyed. Some prescribing practices, such as use of a basal opioid infusion, use of PCA by proxy, and supervision of pediatric pain management were influenced by patient characteristics, type and size of institution, and published guidelines by expert bodies, such as the ASA and JCAHO. The presence of a pediatric pain service was largely influenced by type of institution, but in most cases, this service was provided under the auspices of an anesthesiology department. Other factors such as standard monitoring, drug choice, patient and family education, and order writing were less influenced by patient and institutional demographics. Although complications were uncommon, serious and life-threatening events were recalled at all types of institutions surveyed.
Our findings suggest that the provision of pediatric pain management is generally consistent with the practice guidelines for acute pain management proposed by the ASA.3 2
Even when a pediatric pain service was absent, the availability of IVPCA for pediatric perioperative pain management was widespread, consistent with the concept of superiority of PCA when compared with other more painful modes of therapy, such as IM injections.2,10 3 3
Forty-two respondents recalled patients having received naloxone to counteract the cardiopulmonary side effects of opioids during the year before receipt of the survey, whereas 8 respondents recalled patient deaths having occurred over the previous 5 years. Thus, our results suggest that adverse events including cardiopulmonary complications and deaths may occur in children receiving IV opioid analgesia delivered by PCA, PCA by proxy, or non-IVPCA continuous opioid infusions. In general, we found that reported complications seemed to correlate most closely with how often a modality was used rather than the modality itself. However, because our data are recalled, it is impossible for us to determine with any degree of certainty the true incidence of adverse events, whether 1 mode of therapy was associated with more adverse outcomes than others, whether other medications were coadministered with opioids, or whether the use of opioid analgesia was causative or simply associated with the adverse outcomes recalled by our respondents.
Previous studies have demonstrated that adverse PCA-related events at times involve patient comorbidities,4,7 4,6,7 11 8 11
Computerized POE systems have been shown to decrease medication prescription errors,12 13 14 15
In 2004, when the JCAHO issued a sentinel event alert regarding the use of PCA by proxy,† 16
Finally, the JCAHO has recommended “careful” patient monitoring for patients receiving IVPCA. Consistent with this recommendation, we found that pulse oximetry is the standard of care at many institutions during the entire time that a pediatric patient is receiving IVPCA. However, capnography, which may promote even earlier detection of respiratory depression,17
Our study has several limitations. Because this is a survey of practice, we are unable to assess the accuracy of the responses. To get a broad national response, many participants were chosen because they were pediatric anesthesiologists, not specifically pediatric pain specialists, and hence some may not have been fully aware of specific dosing or management regimens used by the pediatric pain service in their institution. Likewise, for those institutions without a pediatric pain service, most IVPCA management was supervised by the primary service and not by members of the anesthesiology department, and data were not collected from these providers.
Another important limitation to our study is that our data concerning complications were gathered strictly by respondent recall. Thus, our complication data may have been artificially decreased by providers not recalling and/or being unaware of adverse events. For example, rescue naloxone use may be known only by a limited group of providers at many institutions, and we may not always have queried the appropriate person. In addition, given that providers may be more prone to recall significant events such as a patient death, it is also possible that some respondents may have incorrectly included events that occurred >5 years ago. It is noteworthy that although we cannot provide a true incidence of life-threatening events with any degree of accuracy based on our data, no deaths have been reported in previously published small studies,4–7
In conclusion, although pain may be universal, pediatric acute pain management is unique in certain ways. At many hospitals, especially children's hospitals, it is frequently provided by a dedicated pain service under the direction of the anesthesiology department. Although IV opioid analgesia can be provided in a number of different ways, PCA seems to be a widely available modality, and PCA by proxy, although significantly less common, is still being used. There are life-threatening risks associated with all modalities of opioid infusion therapy, but their incidence is presently impossible to track with any degree of accuracy. Interventions that may diminish the incidence of adverse events include improved staff, patient, and family education and systems to minimize human error involved in the prescribing and dispensing of IVPCA opioids. Presently, these interventions are underused. This study highlights the need for a more rigorous approach to collection of data regarding adverse events to accurately identify rare but serious problems and improve the safety of patient analgesic delivery systems in children. Such an approach is already underway in the United Kingdom, and we believe it should be instituted in the United States as well.
REFERENCES
1.Campbell J. Pain: the fifth vital sign. Presidential address. Los Angeles: American Pain Society, 1995
2.American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004;100:1573–81
3.Krane EJ. Patient-controlled analgesia: proxy-controlled analgesia? Anesth Analg 2008;107:15–7
4.Monitto CM, Greenberg RS, Kost-Byerly S, Wetzel R, Billett C, Lebet RM, Yaster M. The safety and efficacy of parent/nurse-controlled analgesia in patients less than six years of age. Anesth Analg 2000;91:573–9
5.Anghelescu DL, Burgoyne LL, Oakes LL, Wallace DA. The safety of patient-controlled analgesia by proxy in pediatric oncology patients. Anesth Analg 2005;101:1623–7
6.Czarnecki ML, Ferrise AS, Jastrowski Mano KE, Garwood MM, Sharp M, Davies H, Weisman SJ. Parent/nurse-controlled analgesia for children with developmental delay. Clin J Pain 2008;24:817–24
7.Voepel-Lewis T, Marinkovic A, Kostrzewa A, Tait AR, Malviya S. The prevalence of and risk factors for adverse events in children receiving patient-controlled analgesia by proxy or patient-controlled analgesia after surgery. Anesth Analg 2008;107:70–5
8.Hicks RW, Sikirica V, Nelson W, Schein JR, Cousins DD. Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm 2008;65:429–40
9.Wuhrman E, Cooney M, Dunwoody CJ, Eksterowicz N, Merkel S, Oakes LL; American Society for Pain Management Nursing. Authorized and unauthorized (“PCA by Proxy”) dosing of analgesic infusion pumps: position statement with clinical practice recommendations. Pain Manag Nurs 2007;8:4–11
10.Berde CB, Lehn BM, Yee JD, Sethna NF, Russo D. Patient-controlled analgesia in children and adolescents: a randomized, prospective comparison with intramuscular administration of morphine for postoperative analgesia. J Pediatr 1991;118:460–6
11.Seifert CF, Kennedy S. Meperidine is alive and well in the new millennium: evaluation of meperidine usage patterns and frequency of adverse drug reactions. Pharmacotherapy 2004;24:776–83
12.van Rosse F, Maat B, Rademaker CMA, van Vught AJ, Egberts ACG, Bollen CW. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics 2009;123:1184–90
13.Kohn LT, Corrigan JM, Donaldson M. Institute of Medicine (IOM) report: to err is human: building a safer health system. Washington, DC: National Academy of Sciences, 1999
14.Poole RL, Benitz WE. Medication errors in children. JAMA 2001;286:915
15.Lee BH, Lehmann CU, Jackson EV, Kost-Byerly S, Rothman S, Kozlowski L, Miller MR, Pronovost PJ, Yaster M. Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home. J Pain 2009;10:160–6
16.Greenberg RS, Billett C, Zahurak M, Yaster M. Videotape increases parental knowledge about pediatric pain management. Anesth Analg 1999;89:899–903
17.Lightdale JR, Goldmann DA, Feldman HA, Newburg AR, DiNardo JA, Fox VL. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006;117:1170–8
*The Assessment and Management of Acute Pain in Infants, Children, and Adolescents: A Position Statement from the American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, and the American Pain Society Task Force on Pain in Infants, Children, and Adolescents. Available at: http://www.ampainsoc.org/advocacy/pediatric2.htm Cited Here
†The Joint Commission on Accreditation of Healthcare Organizations. Patient controlled analgesia by proxy. Sentinel Event Alert, Issue 33, December 20, 2004. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm Cited Here
