Pain Management Practices for Lumbar Punctures: Are We Consistent?

Pain Management Practices for Lumbar Punctures: Are We Consistent? Jacqueline A. Ellis, RN, PhD Kim Villeneuve, RN, BScN Kym Newhook, RN, BScN Jillian Ulrichsen, RN, MScN(cand)

In most pediatric oncology centers across Canada, it is now standard practice for children to be sedated for lumbar punctures (LPs). Although the use of sedation for LPs is well established in the pediatric oncology population, its use in other hospital units is not well documented. A patient record audit was completed to understand the types of pain management strategies used for LPs performed throughout a pediatric hospital. Fifty-nine patients aged between 3 days and 17 years underwent a total of 67 LPs. Pain management strategies varied among the different patient service units. Oncology patients were consistently sedated for an LP, whereas patients in the emergency department were less likely to be given any type of sedation. Recommendations are aimed at providing consistent best practice pain management for LPs throughout the hospital. © 2007 Elsevier Inc. All rights reserved.

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HE USE OF analgesia and sedation to reduce procedural pain has been well studied in pediatric oncology patients. In particular, the practice of using sedation for lumbar puncture (LP), bone marrow aspirate, bone marrow biopsy, and intrathecal chemotherapy has been described in the literature (Barnes et al., 2002; Innalfi et al., 2005; Ljungman, Gordh, Sorensen, & Kreuger, 2001; Rosenburg, Walker, Bechtel, & Altieri, 1998; Sievers, Yee, Foley, Blanding, & Berde, 1991). In most pediatric oncology centers across Canada, it is now standard practice for children to be sedated for these procedures (Ellis et al., 2003). Although the use of sedation for procedural pain and distress has been implemented consistently in the pediatric oncology population, its use in other hospital units is not well documented. A patient record audit was completed to understand the types of pain management strategies used for LPs performed throughout a pediatric hospital. BACKGROUND An LP is performed for both diagnostic and therapeutic purposes. Infectious diseases and neurologic conditions, such as meningitis, sepsis, meningoencephalitis, and subarachnoid hemor-

Journal of Pediatric Nursing, Vol 22, No 6 (December), 2007

rhage, are typically diagnosed, in part, by analyzing cerebrospinal fluid (Carlson et al., 2006). For therapeutic purposes, medications, including antineoplastic agents and anesthetic agents, can be injected into the subarachnoid space via an LP (Carlson et al., 2006). There are a number of potential complications associated with LPs, including postdural puncture headache, bleeding, dysesthesia, infection, and herniation of the brain stem (Carlson et al., 2006; Chordas, 2001; Evans, 1998). Lumbar punctures are painful and cause significant distress in children of all ages (Broome, Bates, Lillis, & McGahee, 1990; Crock et al., 2003; Holdsworth et al., 2003; Simini, 2000). In a survey of adults about procedural discomfort, pain from an LP was reported to be an average of 7.8 on a 10point scale (Singer et al., 1997).

From the Department of Nursing, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada. Address correspondence and reprint requests to Jacqueline Ellis, RN, PhD, School of Nursing, University of Ottawa, 451 Smyth Rd., Ottawa, ON, Canada K1H 8M5. E-mail: [email protected]. 0882-5963/$ - see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.04.009

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Pain management techniques for LPs include analgesics, anesthetics, and nonpharmacologic interventions. A meta-analysis of 28 randomized and controlled trials that examined the efficacy of cognitive and behavioral techniques for the control of pain and distress associated with needle procedures indicated support for the efficacy of distraction, combined cognitive–behavioral interventions, and hypnosis (Uman, Chambers, McGrath, & Kisely, 2006). Nonpharmacologic interventions are not a substitute for medications but have been shown to increase their effectiveness (Anghelescu & Oakes, 2002). Techniques such as distraction, touch, massage, and guided imagery reduce pain perception by diverting attention from the noxious stimulus (Anghelescu & Oakes, 2002; Broome, Lillis, McGahee, & Bates, 1992; Ellis & Spanos, 1994; Pederson, 1996; Zeltzer & LeBaron, 1982). This is accomplished by “passively redirecting the child's attention or by actively involving the child in the performance of a distracting task” (Anghelescu & Oakes, 2002, p. S56). Pederson (1996) reported that children who practiced these techniques with the help of their parents had lower levels of selfreported pain, fewer expressions of fear, and fewer requests for emotional support during an LP. EMLA (eutectic mixture of local anesthetics) is a topical anesthetic that is effective for reducing the pain of needle sticks and has been used for LPs. It is an equal mixture of 2.5% lidocaine and 2.5% prilocaine; it is applied to the skin and then covered with an occlusive dressing and left in place for at least 60 minutes (Halperin et al., 1989). Reports in the pediatric oncology literature indicate that EMLA applied to the skin at L3 and L4 can significantly reduce pain associated with an LP (Buckley & Benfield, 1993; Juarez Gimenez et al., 1996; Kapelushnik, Koren, Solh, Greenburg, & DeVeber, 1990; Kaur, Gupta, & Kumar, 2003; Koscielniak-Neilsen, Hesselbjerg, Brushoj, BrittJensen, & Stens-Pedersen, 1998; McCain, 2004; Weise & Nahata, 2005). However, time is a barrier to the use of EMLA and the 60-minute wait time required for EMLA to produce the desired effect may not always be feasible in a busy emergency department (ED). Ametop, a local anesthetic gel, works in less time as compared with EMLA (45 minutes) but only reaches the layers of the epidermis and not the dermal layer, where it is needed for an LP (Canadian Pharmaceutical Association, 2006). Procedural sedation and general anesthesia are also used to reduce the pain of LPs for infants,

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children, and adolescents (Krauss & Green, 2000). Studies on the pediatric oncology population indicate that sedation with propofol is effective for achieving comfort and amnesia while optimizing conditions for elective pediatric oncology procedures (Ellis et al., 2003; Hertzog et al., 2000; Ljungman et al., 2001). Ljungman et al. compared the effectiveness of procedural sedation with that of general anesthesia for pediatric oncology patients undergoing an LP. They reported that although procedural sedation failed at times, it was preferred to general anesthesia by physicians and patients in part because of longer fasting times and the necessity of going to the operating room for general anesthesia. Ellis et al. reported that 57% of pediatric oncology centers use procedural sedation for LPs and bone marrow aspirates most of the time or always for school-aged and adolescent patients. Procedural sedation is used consistently in the pediatric oncology population; however, its use in other patient care specialties is not as well documented. There is a scarcity of literature devoted to the study of pain management for LPs in patients outside of pediatric oncology. This is critical given that untreated pain has serious consequences that may have lasting negative ramifications for children. Unrecognized and unrelieved pain places significant burdens on children and their families. In addition, untreated pain may have consequences for later pain-related behavior, particularly untreated pain in infancy (Fitzgerald & Walker, 2003; Grunau, 2000; Howard, 2003; Taddio, Shah, Gilbert-MacLeod, & Katz, 2002). Studies on preterm infants indicate that painful experiences such as heel lance or venipuncture can actually alter brain development and affect pain perception as infants develop (Byers & Thornley, 2004; Taddio et al., 2002). One study that examined the long-term behavioral consequences of pain reported that male infants who undergo circumcision display more pain behaviors during routine immunization as compared with uncircumcised boys (Taddio, Goldbach, Ipp, Stevens, & Koren, 1995). Clinical studies on hospitalized children indicate that children in pain may experience irritability, sleep disturbances, eating problems, and general distrust of health care professionals (American Academy of Pediatrics, 2001; Carlson, Clement, & Nash, 1996; Goldschneider, 1998). In addition, families may feel inadequate and angry for being unable to prevent or alleviate pain in their child (World Health Organization & International Association for the Study of Pain, 1998).

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PROBLEM In this hospital, there was no standardized practice for LP pain management and practices were not consistent throughout the hospital. For example, routine practice for LPs in the oncology patient service units (PSUs) includes the involvement of an anesthesiologist to provide sedation during an LP. In addition, it is standard practice to use topical analgesia and lidocaine infiltration at the puncture site. In the ED, pain management practices vary widely and may include sedation, or topical analgesia, or local anesthetic at the puncture site; in addition, occasionally, no medication of any kind is used. Generally, there was a perception among pain resource nurses, who are advocates of best practice pain management in PSUs throughout the hospital, that pain and distress associated with LPs were managed inconsistently. A decision was made to do a record audit to determine practice variations in LP pain management practices used throughout the hospital. METHODS

Setting The hospital is a 150-bed pediatric teaching facility that serves patients and families from Eastern Ontario, Western Quebec, and Baffin Island. The hospital offers a full range of inpatient medical and surgical services as well as ambulatory, ED, and rehabilitation services.

Patient Record Audit Tool A patient record audit tool was developed by the research team, piloted on five records and revised based on feedback from the team (Figure 1). A research assistant (J.U.), who is a nurse and a graduate student, performed the pilot test of the tool.

Procedure The ethics review board of the hospital-affiliated research institute approved the protocol for record review. We were interested in reviewing a minimum of 50 LPs and estimated that a 2-year time frame would provide an adequate sample size. The records of patients who underwent an LP between January 2003 and January 2005 were included in the study. Patient records were retrieved from medical records based on a unique code specific for an LP. All of the records retrieved had at least

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one episode of LP during the designated time frame. Two of the study authors conducted the record reviews (J.U. and K.V.). Both of the authors are nurses at this hospital and were familiar with the format of the patient records. The first 10 records were audited by both reviewers and then compared for consistency. Disagreements related to information retrieval and interpretation of the audit tool were discussed until agreement was reached. When both reviewers felt confident using the audit tool, they divided the remaining records and reviewed them independently. RESULTS

Sample Fifty-nine patient records were retrieved for review, and there were 67 LPs included in the review. Eight patients had more than 1 LP included in the review. Patients ranged in age from 3 days to 17 years. Their average age was 4 years (SD = 4.9), and their median age was 1.5 years. It was the first LP performed on the child in 49 of the 67 LPs (73%) reviewed. Twenty-one LPs (31%) were performed for chemotherapy administration, whereas 46 (69%) were performed for diagnostic purposes to rule out cancer, sepsis, or meningitis. Fifty-seven patients (97%) had intravascular access at the time the LP was performed. It is unknown if the other two patients (3%) had intravascular access because there was no indication in their records. Pain intensity scores were not included in the oncology protocol for LPs, and only 1 patient had a pain score documented. The pain score was 6 on a scale of 0–10, and it is not known if this score related to the pain of the procedure, postprocedural pain, or a preexisting painful condition. Postprocedural analgesia was given to a total of 20 patients (34%) as follows: 13 (22%) received acetaminophen; 3 (5%) received fentanyl; and 1 each received ibuprofen, morphine, and codeine. Table 1 describes the LPs with respect to the place where the LP was performed, the procedurist, patient age, medications, and patient reaction.

Number of Attempts There was documentation about the number of attempts for successful needle placement for 65 of the 67 LPs performed. Fifty-seven of the 65 LPs were successful on the first attempt (88%). Eight

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Figure 1. Record audit tool.

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Figure 1. (continued).

patients required more than one attempt as follows: three required two attempts, four required three attempts, and one required four attempts before successful needle placement was achieved. Six of the 8 LPs (75%) that required more than one attempt were performed in the ED. All six of these patients were unsedated, and two had topical anesthetic applied to the puncture site. A pediatric resident performed the LP in five cases, whereas a staff physician did in two; it was not documented in one case.

Adverse Events The only adverse events recorded were bleeding, which occurred in 10 patients (15%), and tachycardia, which occurred in 2 (3%). None of these patients was sedated, and all of the LPs were for diagnostic purposes in nononcology patients. One LP was recorded as unsuccessful, and this was

performed without sedation for diagnostic purposes on a 7-day-old infant.

Nonpharmacologic Pain Management Parents were present for 5 (18%) of the unsedated LPs and for 2 (5%) of the sedated LPs. Parental presence was not documented for 40 (60%) of the LPs. There was no documentation that child life specialists were involved or if other types of comfort measures (e.g., distraction and imagery) were used to manage pain and distress for the LPs. Currently, there is no specific protocol for parental presence and practice varies widely among PSUs. DISCUSSION Results from the record audit confirmed the nurses' perception that pain management for LPs

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Table 1. Demographic data on sedated and unsedated LPs Variable

Place [n (%)] MDU ED OR Rx room Infant medicine Other a Procedurist [n (%)] Staff physician Resident Pediatric fellow RN/ACNP Unknown Age Range M SD Medication [n (%)] EMLA Yes No Not documented Lidocaine Yes No Not documented EMLA + lidocaine Propofol Propofol + fentanyl Propofol + ondansetron Propofol + sevoflurane Midazalom + fentanyl Other Patient reaction [n (%)] Tolerated well Crying Under general anesthesia Not documented

Sedated LPs (n = 39, 58%)

Unsedated LPs (n = 28, 42%)

21 (54) 1 (3) 9 (23) 5 (13) 3 (8)

– 26 (93) 1 (4) 1 (4) –

30 (77) 5 (13) 0 (0) 4 (10) 0 (0)

4 (14) 11 (39) 2 (8) 0 (0) 11 (39)

18 weeks to 17 years 6.8 years 4.8 years

3 days to 8 weeks 15.5 days 16.2 days

14 (36) 20 (51) 5 (13)

4 (14) 22 (78) 2 (8)

6 (15) 21 (54) 12 (31) 3 (8) 14 (36) 15 (38) 3 (8)

3 (11) 19 (68) 6 (21) 0 (0) – – –

2 (5) 2 (5) 3 (8)

– – –

17 (44) 1 (2) 21 (54)

8 (29) 5 (18) 1 (4)

0 (0)

14 (46)

Note: MDU indicates medical day unit (reserved for oncology patients); OR Rx room, operating treatment room (designed to accommodate procedures that require sedation); RN/ACNP, registered nurse/acute care nurse practitioner. a Critical care, oncology, and surgery.

varied according to patient service and location. Unexpectedly, the variation in pain management practices was most prominent when we compared the ED with the oncology service. Oncology patients were consistently offered sedation and analgesia, whereas patients undergoing LPs in the ED were not. The consistent use of sedation and analgesia for oncology patients is in keeping with recommendations from an early task force on procedural pain (Zeltzer, Altman, & Cohen, 1990) and recent clinical practice guidelines (Anghelescu

et al., 2005; Barnes et al., 2002). The department of anesthesiology is committed to providing sedation when needed and has addressed the scheduling and logistic issues that facilitate this collaborative practice. It has instituted a twice-weekly oncology clinic where an anesthesiologist is available to provide sedation for patients undergoing LPs and bone marrow aspirates. Evidence suggests that the involvement of an anesthesiologist leads to safer and more effective use of sedation medication (American Academy of Pediatrics, 2001; Hertzog et al., 2000; Krauss & Green, 2000). Additional evidence suggests that with proper training, nonanesthetists, including qualified emergency or intensive care physicians, and nurse anesthetists can safely deliver and monitor procedural sedation and analgesia in the ED (Lin, 1998; Pitetti, Singh, & Pierce, 2003; Shavit & Hershman, 2004). Other forms of support that have been implemented to facilitate consistent use of best practices for oncology patients include a documentation record in the form of an ink pad and rubber stamp that is imprinted in physicians' notes. A physician simply checks the appropriate boxes and fills in the blanks to indicate the use of topical anesthetic, local anesthetic infiltration, LP needle size, number of attempts to achieve successful needle placement, description of cerebral spinal fluid, and the occurrence of any adverse event. Educational resources that describe the cognitive–behavioral interventions that parents can use to help their child cope with procedural pain and distress before, during, and after a painful procedure have been developed. It was clear from the record review that procedural pain management for LPs performed in the ED was not optimal. Sedation was offered to only one patient in the ED, and topical analgesia or local infiltration of lidocaine was documented for only one quarter of the patients. There was evidence in the records that some of these patients were distressed by the LP and that the LP required more than one attempt for successful needle placement in six cases. All six patients who required more than one needle stick were unsedated, and four had no topical or local anesthetic. Baxter et al. (2006) examined LPs in an ED setting to understand the factors that predicted a successful tap. Patient age was a factor, and they reported that LPs performed on infants older than 12 weeks were three times more likely to be successful as compared with LPs performed on younger infants. In addition, LPs performed with local anesthetic were twice as likely

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to be successful as compared with LPs performed without local anesthetic. Although the age of patients presenting to our ED who require an LP cannot be controlled, the pain medication practices are modifiable and should be improved. A number of factors may have contributed to the suboptimal pain management practices in the ED, including patient age, patient acuity, and lack of organizational support. All of the ED patients were infants, and their average age was only 15 days. Although there is no contraindication to the use of procedural sedation and analgesia in full-term infants, ED staff may not be as comfortable with medicating and monitoring this age group as compared with older children. Doyle (2002) reviewed pediatric sedation procedures in EDs in the United Kingdom and suggested that neonates and infants younger than 6 months should not receive sedation unless an anesthesiologist is present during the procedure. This age group is at risk for rapid hypoxia from airway obstruction as a result of relatively high oxygen consumption and a low alveolar volume (Benumof, Dagg, & Benumof, 1997). In addition, the airway obstructs more easily because the tongue is large relative to the size of the oropharynx and the head is more difficult to position because of the large occiput (Bauman & McManus, 2005). There is a perception among nurses that time pressures in the ED are a barrier to using topical analgesia such as EMLA. When a septic workup, which includes an LP, is ordered, the time frame to complete the LP is unpredictable. Physicians and nurses have suggested that waiting for the topical analgesia to work may delay the diagnosis. Although there is a medical directive pertaining to investigation of febrile infants (0–60 days) in the ED, which includes the application of EMLA to the lower lumbar spine, it is often omitted. The barriers and supports for using topical analgesia on infants who require an LP need further examination. A retrospective record review can be an efficient mechanism to identify problems, but it will not provide all of the details related to supports and barriers.

Recommendations A procedural pain committee specifically for the ED has been formed to propose a unified plan to address the needs of patients undergoing all types of painful procedures. The management of LPs in the ED should be in accordance with best practices, including analgesia and sedation, topical

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analgesia, and nonpharmacologic measures consistently applied in a standardized way. For the short term, a number of supports that are already in place in the institution could be used for patients undergoing LPs in the ED. For example, sucrose analgesia is effective for pain reduction in term and preterm infants for needle stick and heel lance procedures (Gibbins et al., 2002; Stevens, Yamada, & Ohlsson, 2006). A sucrose analgesia protocol that will enable nurses throughout the hospital to use this form of analgesia for infants younger than 30 days is currently being implemented. All of the patients in the ED included in the present study were young enough to benefit from sucrose (Barr et al., 1995). Although sucrose analgesia is not sufficient as the only form of analgesia for an LP, it could serve as an adjunct to topical and local anesthetics. The use of buffered lidocaine is currently being implemented in the ED as the anesthetic of choice for local infiltration. A number of studies have indicated that buffered lidocaine is less painful and equally effective as unbuffered lidocaine (Bartfield, Gennis, Barbera, Breuer, & Gallagher, 1990; Eccarius, Gordon, & Parelman, 1990; Ong, Lim, & Koay, 2000). Davies (2003) reviewed 63 studies on buffering lidocaine before injecting it and concluded that it was simple, safe, inexpensive, and effective. Sucrose and buffered lidocaine are now part of the pharmacy ward stock in the ED and other PSUs throughout the hospital. The documentation records that have been developed for the oncology service could be easily adapted to the context of the ED. The rubber stamp format is simple to use and provides a standardized template for documentation. In addition, the nursing documentation record for oncology patients, albeit somewhat lengthy, could be used to design an abbreviated version for the ED. Consultation with the department of anesthesia around facilitating effective collaboration for procedural sedation would be a positive step toward providing improved pain management for LPs performed in the ED. Finally, we encourage other pediatric and general hospitals to examine pain management practices for LPs on a hospital-wide basis to determine the consistency and adequacy of practice. Our finding that infants in the ED undergoing an LP did not have their pain managed consistently is possibly true in many acute care settings in which patient age and time pressures may be factors influencing care. In addition, the process of conceptualizing and implementing this quality

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assurance project informed by nurses' perception of a problem was an effective and empowering way to improve practice. The record audit provided evidence that pain was not being adequately

managed for LPs in the ED. The process of improving practice through critical reflection was useful for understanding pain management for LPs and could be applied to other practice issues.

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