Postoperative analgesics for children and adolescents: Prescription and administration

VOL9 No. 2 F&may I994

esc

journal ojPain and Symptom Managemen!

X5

rest

Mary D. Tes!er, MS, DianaJ.

Wilkie, PhD, William L. Holzemer,

PhD, and

Marilyn C. Savedra, DNS Depatiments of Family Health Care Nursing (M.D. T, M. C.S.) and Mental Health, Community, and Administrative Nursing (WL.H.), School of Nursing, University of Cal@nia, San Fran&o, Culifonzia; and DepaTtmtmt of Physiok@cal Nursing (D.J. W), University of Wmhington, Seat&, WaSrrington

Pain tica^rnxasured and analgesic treatment examined in 131 children and a&&scents, 8-l 7 years of age, for 5 days after surgay. Analgesic data were converied to 10 mg intramuscu&zr morphine-equivalent doses (IMMSEQJ and were designated appropriate or inappropriate body weight. Analgesic onset, peak, and duration were calculated in. relation to administration routes and the time pain assessments were made C&!&n rt@rted moderately severe pain in many body locations. &tially, all but two children woe pzs‘=.bed and ultimately all but one received analgesics. Prescribed and administered &es were frequently less than a&s recommended for weight. Two-thirds of the children were beyond analgesti action when pain was assessed. Weak to moderately strong associations were noted between IMMSEQ doses and pain intensity scores on each of the 5 postoperative days. Unftiuaately, findings indicate that children continue to be undertreated when thq, experience postoperative pain. J Pain

for

Symptom Manage 6994;9:85-95. Key Words Children, postoperative pain, analgesic doses, presrribed, administered

For more than a quarter of a century, it has been known that children’s postoperative pain has been undertreated. In a 1968 study, Swafford and Allan’ reported that opioids were received by only two of 60 children undergoing general surgery and by 26 of 180 children in an Address rejnint requests to: Mary D. Tesler, MS, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, CA 941450606, USA.

Acc@tedforpublication: September 22, 1993. 0 U.S. Cancer Pain Relief Committee, 1994 Published by Elsevier, New York, New York

intensive care unit. In the subsequent two decades, three groups of investigators24 compared the analgesic treatment of diagnostically matched samples of adults and children and found that invariably disproportionately larger percentages of adults were prescribed analgesics than children (96% vs 4%*, 70% vs 30%“. and 100% vs 87%4). Beyer and colleagues” also found that 58% of children’s but 73% of adults’ prescriptions were for potent analgesics, and by postoperative day 5 there were analgesic orders for 96% of adults but only 46% of the children; during the first 3 days, the mean number of meperidine doses received was 8 for adults and

86

3 for children3 Schechter and colleagues4 likewise reported that adults received twice the mean number of doses as children and that analgesic a~inis~tion patterns were influenced by diagnosis, length of stay, hospital setting, and child’s age. In yet another study of 170 postoperative children, only 84% had anaIgesic orders Among tbose with opioid orders, 39% did not receive a dose. Where there was a choice between opioid or nonopioid analgesics (29%)) nonopioids were administered exclusively. Although 53% of the children reported no pain on postoperative day 1, 17% reported severe pains Findings of these studies, reported between 1968 and 1986, indicate that children were likely to have inadequate pre~riptions for postoperative pain and were even less likely to receive analgesics during their postoperative recovery. In the intervening years, suck findings have prompted massive educational efforts to improve health professionals’ knowledge about the appropriate treatment of children’s poWperative pain. It is unknown whether this education has improved pain management in clinical practice. It is now recognized that children who are 3 years and older can provide valid and reliable self-reports of pain using developmentally appropriate tools and that those who experience pain should receive potent opioids and ace~minophen, with doses initially based on body weight and then titrated to effect.” Furthermore, it is prudent practice for analgesics to be administered at time intervals consistent with the pharmacokinetics of the drug. Previous reports provide limited insight about analgesic prescription and administration practices in relation to drug pharmacokinetics and the nature of the pain reported by children. Recently, we sought to address these issues by examining the prescription and administration patterns of analgesics to children and adolescents undergoing complex surgeries in institutions noted for excellence in pediatric care. Specifically, the purposes of the study were (a) to identify the analgesics prescribed and administered to children and adolescents for postoperative pain, (b) to determine appro priateness of the analgesic dose prescribed and administered based on body weight, (G) to identify the analgesic effect of the drug; at the the a pain assessment was made, and (d) to

i%ler et al.

VW. 9 No. 2 Fkbruaty 1994

estimate the equianalgesic dose administers prior to the pain assessment as well as the association between equianalgesic dose and pain ~ntensi~.

Further analysis of data from two tool development studies’s was undertaken to examine analgesic prescription and administration for postoperative pain in children and adolescents. This descriptive research was ap proved by the Committee on Human Research at the U~ive~i~ of California, San Francisco, and all participating hospitals.

Combining subjects from the two studies resulted in a convenience sample of 131 children and adolescents (6’7 boys and 64 girls) who underwent surgery. The children were 8-17 years old (mean = 12.6 and SD = 2.9) and were expected to be hospitalized for at least 5 days after surge+ They understood and could read English, and had no developmental delays; 66% were Caucasian, 14% African-American, 8% Hisp~ic-~e~can, and 12% were from other ethnic groups. The 131 surgical procedures included orthopedic 26%, thoracic 19%, abdominal 17%, urologic 15%, neurologic 12%, and 11% miscellaneous operations. Many of these were complex cases and high levels of pain were expected. The smallest child weighed 20 kg and the largest adolescent weighed 110 kg (mean = 45.7 kg and SD = 16.8 kg). Age and weight of the children were strongly correlated (r= 0.60).

The Adolescent Pediatric Pain Tool (APPT)7*s was used to collect data on the location, intensity, and quality of postsurgical pain from chiidren 8-1’7 years of age. The APPT, modeled on the McGill Pain Questionnaire,” has been reported to produce valid and reliable pain reports in 8 to f7-yearold children.‘sJO-*s The one-page tool shows the front and back of a body outline on side 1, and a IO-cm word-graphic rating scale and a pain descriptor list on side 2. APPT pain descriptors are grouped into sensory, affective, and evaluative categories. Space is provided for additional words that the child is free to supply. Similar

Vol 9i’h. 2 Februay 1994

Postoperative Analgesics fur Children

versions of e APPT were use e two studies: one version had 43 words boxed by category’ and the other version bad 53 unboxed words8 Documented on two add~~o~~ forms were demographics (age, gender, ethnicity, weight, surgical procedure, and hospital), analgesic prescriptions (drug, route, and dose}, and administered analgesics (drug, route, dose, and time).

Procedure Data were collected by nurses trained in the study protocol. Patients were recruited from day of admission to postoperative day 3. Written parental consents and child assents were obtained. The patients were interviewed for demo~phic data on the first day of participation and asked to complete the APPT between 3:30 p.m. and t?:OO p.m. on postopetative days I-5 using a standardized protocol. Parents may or may not have been present when the APPT was completed, however, patients completed the tool by themselves without parental assistance. Medical records were audited independently by three data collectors to obtain the patients’ weight and the information about analgesics prescribed and administered before completion of the APPT. Acceptable reliability for the chart audit was defined as total agreement in data provided by two of three data collectors.

Data Analysis On the APPT, the number of body segments marked as painful by the child was tabulated for each day. Pain intensity was measured in tenths of a millimeterfrom the left of the word-graphic rating scale to the line marked by the child the higher the score, the greater was the pain intensity.The quality of the pain was measured by counting the words the child selected. Because of the difference in the number of wordsin the twoversions,four percentage scores were tabulated for the (a) number of words selected, aml the number of (b) sensory, (c) affective, and (d) evaluativewords selected for each version of the APPT. Scores from the two versions did not significantly diier by t tests; quality data daerefore were combined. None of the pain scores differed significantlyby ethnicity, surgery, or ho,spitalsetting. Analgesic data for each day were converted into (a) dose inappropriate for weight (yes/

87

no), (b) intramuscular (I hine equianalgesic (IMMSEQL)dose, and (c) analgesic effect based on drug onset, peak, and du~tion, A dose inappropriate for weight was calculated as the analgesic dose prescribed or administered compared with the recommended dose for the child’s weight. The recommended dose was the range between the low and high recommended doses for each drug based on weight (kg) (Table 1). t4,r8A dose equal to or within the range of the low and the high recommended doses was considered appropriate for the weight and was coded as “inappropriate dose-no.” A dose not given within 24 hr of APPT completion was also coded as “inappropriate-no,” because insuffIcient data were avaifableto score it otherwise.A dose not equal to or not within the range recommended for t.he child’s weight was coded as “inappropriate-yes.” Inappropriate doses were determined for all prescribed analgesics and for the dose administered prior to completion of the APPT on each day. The IMMSEQdose was a continuous variable computed for each day by converting the prescribed and administered dose to equlanalgesic doses based on conversion factors listed in Table 1 (Peter Koo, PharmD, personal communication, April 1990).‘4J” A dose not administered within 24 hr was coded as “0 mg IM~SEQ.” The analgesic effect at the time the APPT was administered became a categorical variable (effect) based on the time the drug was admi~~tered and the cycle info~ation listed in Table 1. The four levels of effect were (a) administration of the drug to onset of effect, (b) onset of effect to peak effect, (c) peak effect to duration of effect, and (d) postdumtion of effect (Figure I). Descriptive statisticsand Pearson correlation coefficients were computed using CRUNCH.~~ Statistical significance was set at P < 0.05.

The children reported moderate to severe levels of pain in many body locations (Table 2). Two children on postoperative days 1 and 2, four on day 3, five on day 4, and three on day 5

‘kr0.t 9 No. 2 February1994

i%!m et al.

88

T&k f Reammended Dosages for weight Used to Determine ~pp~P~~~~ of the Dose Prescribd and Administeredfor Posto~rathe Pain and lXqMg&c Dose to 10 mg IntramuscularMorphine aad Effectiveness _ Drug

Route

Recommended

dosage

0.1-0.13 mg/kg every 3-4 hr

Morphine

0.05-0.10 mg/kg every 2 hr Meperidine

IM

l-l.3 mg/kg every 3-4 hr 0.5-0.7 mg/kg every 2 hr

Hydromorphone

IM SC

0.02-0.026 mg/kg every 3-4 hr 0.01&0.025 mg/kg every 3-4 hr 0.01-0.015 mg/kg every 2 hr 0.05 mg/kg every 4 hr

Codeine

IM PO

1 mg/kg every 3-4 hr 1 mg/kg every 3-4 hr

Acetaminophen with codeine

PO

Aspirin

Effectiveness onset

10 10 5 60

20 min 30 min 5 min l-l.5 hr

40min 40min 30 min 2hr

3-4 hr 3-4 hr i-2 hr 4-6hr

75 50 300

15-20 min 5 min l-l.5 hr

1 hr 5-15 min 2 hr

2 hr 1-2 hr 3-4 hr

20 min 20 min 5 min 1.5-2 hr

30 min 45-60 min 15min 2 hr

3 hr 3-4 hr 2hr 3-4 hr

20 min l-l.5 hr

40-60 min 2hr

3 hr 3-4 hr

1.5 1.5 1 7.5 60 200

PO

10-15 mg/kg ever)r4 hr

Rectal

IO-15 mg/kg every 4 hr

PO

65 mg/kg/24

hr in 4-6 doses

Rectal

65 mg/kg/24

hr in 4-6 doses

2 tabs 1 tab 0.5 tab 2 tabs ltab= 0.5 tab 2 tabs ltab= 0.5 tabs 2 tabs ltab= 0.5 tab

Cycle peak

Duration

l-l.5 hr

2 hr

3-4 hr

2 hr

2-2.5 hr

3-4 hr

= = = =

3 1.5 0.75 3 1.5 = 0.75

l-l.5 hr

2 hr

3-1 hr

1.5-2 hr

2-2.5 hr

3-4 hr

= 3 1.5 = 0.75 = 3 1.5 = 0.75

l-l.5 hr

2 hr

3-4 hr

l-2 hr

2-2.5 hr

3-4 hr

2 tabs = 1 tab = 0.5 tab = 2 tabs = 1 tab = 0.5tab=

Rectal

~e~minophen

Equianalgesic dose (mg)

6 3 1.5 6 3 1.5

Source:Grdd,1988”;Ck&.u~i~, 1987’“;ibu, pcrwnd correspw~dcnce.APrill990.1M,int1~nruscular;SC, subcutaneous; IV,inuwwous; and PO, orally.

reported a score of zero {no pain). The mean number of body segments marked, the mean pain intensity scores, and the mean quality scores decreased over the 5 days. Children were experiencing clinically significant pain, however, as reflected in the mean intensity scores and in the range of the individual pain scores over the 5 days (Table 2).

Physicians prescribed an average of 3.1 (SD = 1.6) analgesics per child during the 5 postoperative days; initially only two children had no orders for an analgesic. There were 227 analgesic orders on the day of surgery. Morphine (120 orders, 53%) was the most

frequently prescribed analgesic on the day of surgery, followed by ace~minophen with codeine (49 orders, 22%), acetaminophen (40 orders, 18%), meperidine (14 orders, 6%), and codeine (4 orders, 2%). The intravenous (IV) route (103 orders, 45%) was most frequently prescribed on the day of surgery. Physicians were less likely to prescribe the intramuscular (IM) route (28 orders, 12%). Other analgesics, such as hydromo~hone, hydrocodone with acetaminophen, and aspirin were also prescribed during the postoperative period. The prescribed doses were frequently under or over the recommended doses based on the child’s body weight. Table 3 illustrates inappropriateness of the pre-

A&5&l-

istration

d I-~----.

Onset

-

Peak

DlW~tiO~

The

2

4

3

I l4

Fig. 1. Analgesic e~yect [example for Iv morphine): recommended dose, 0.05-Q.10 mg/kg q 2 hr; and

equiaual~esic dose, 5 mp; (which is equivalent to IO mg IM mo~hine}; I, adrni~is~ti~n to onset effect; 2, onset to peak activity 3, peak Q duration of effect; aad 4, after duration of effect. scribed doses for intravenous (IV) morphine and Table 4 shows thi: orders for acetamino-

phen with codeine, the two analgesics most frequency prescribed.

Ana@Gcs Ad-?-~ini?Etered The analgesics administered before the child completed the APFT are listed in Table 5. One child, who received no analgesic during the postoperative period, reported no pain on days 1 and 2 and did not provide intensity data on days 3, 4, and 5. The most frequently administered analgesic was IV morphine on days 1 and 2, acetaminophen with codeine on days 3 and 4, and ace~~nophen with codeine or acetaminophen on day 5. Meperidine, codeine, hydrocodone with acetaminophen, and hydromorphone were infrequently administered analgesics. The doses administered averaged 4.4 mg I~~SEQ on day 1 and ~min~hed to 3 mg IM~§~Qon day 5 (Table 2). At each pain measurement with the APP?; most children were beyond the analgesic effect of their drugs (Table 6), and the doses were generally inappropriate for weight. Averaged over the 5 days, the APFT wa!s completed when the analgesic dose was recently given for 1l%, between onset and peak effect of the drug for 8%, between the peak and duration of effect for 16%, and postduration of effect for 66% of the children. Communing this problem, the analgesic dose administered was inappropriate for the child’s weight on day 1 for 43% of the children, day 2 for 51%, day 3 for 42%, day 4 for 45%, and day 5 for 41%. The inapprop~ate administered doses were under and over the recommended doses based on the child’s weight (Tables 7 and 8).

Weak to moderately strong associations were noted between IMMSEQdoses and pain intensity scores on each of the 5 postoperative days. Correlations were weakest on postoperative days 1 (r= 0.22 and P< 0.052 and 2 (T=0.24 and P c 0.02), were stronger on postope~tive days 3 (r= 0.49 and P< 0.0001) and 4 (r= 0.48 and P < O.OOOl), and were less strong on day 5 (r= 0.37 and Pc 0.01).

Our findings are partially congruent with the recently published guidelines for management of children’s postoperative pain.6 That all but two (1.5%) children had analgesic orders is a major achievement when compared with earlier reports,2-‘l in which 12%-16% of the children were not prescribed analgesics postoperatively. Furthermore, morphine was the drug most frequently prescribed, and meperidine (a drug noted for neurotoxic effects} was infrequendy prescribed. ~dition~ly, the IV route was more frequently prescribed than the IM route. This finding represents progress in utilization of pediatric pain research, which has highlighted the importance of developmentally appropriate medication adminis~~on methods. It is now generally known that children and adolescents detest IM injections and fear needles.t7*tHClearly prescriptions for IV analgesics reflect practice consistent with recently released federal guidelines.” Our findings also indicate that current analgesic administration practice in institu-

Postoperative day Equianaigesic

1

Dose (mg) Mean SD Range

ii:;: O-10

2

3

4.1

3.6

&2:

4

5

O-1;

2.8 2.5 O-14

3.0 3.0 O-14

Intensity (mm) Mean SD Range

52.0 23.0 o-102.2

44.9 24.9 cL100.7

36.3 23.3 O-92.5

29.1 21.9 O-79.3

32.5 24.5 O-90.5

bcation (no.) Mean SD Range

:: O-18’

5.7 3.0 O-17

3.2 2.6 O-13

K O-16

3.4 3.6 O-18

15 12 O-68

14 12 O-51

13 11 o-51

11 11 O-46

10 12 O-51

Mean SD RWF

11 14 O-73

09 13 CL64

08 13 O-64

:: O-34

04 14 O-100

Evaluative Mean SD Range

22 20 o-86

18

:: O-l

15 19 O-88

15 17 O-76

15 13 O-71

14 12 Q-59

10 10 O-40

09 11 O-59

@ality (%Iof words selected) Sensory Mean SD

Range Affective

Total Mean SD Range

O-1: 13 11 O-59

SD. standard dcvinion.

tions reputed for excellence in pediatrics has improved somewhat in the past 25 years. Except for one child, who reported no pain on the APm, all children received analgesics during their postoperative recovery. This rep resents a major shift in practice since Swafford and Allant found that only 3% of children received an analgesic after general surgery. Our findings, however, are similar to those reported by Schechter and colleagues9 (1986), when 82% of children received an analgesic postoperatively. Together, findings suggest that today few children can be expected to be deprived of postoperative analgesics. This progress notwithstanding, the most significant overall finding of this study was the confirmation that children’s postoperative pain is still tindertreated despite improved

knowledge about pain and its treatment. Unrelieved pain is a major ethical issue that is fraught with physiologic and p~chologicai consequences for the child and can adversely influence a child’s response toward medical care immediately and for years.ts,20 Prescription practices were less than optimal when dose was considered in relation to the child’s weight. Few of the children (2%) had prescribed doses that exactly reflected the recommendation of 0.0!5-0.1 mg morphine/ kg14 [the Agency for Health Care Policy and Research (AHCPR) guidehne recommends 0.1 mg/kg every 34 hr]. For 77% of the children, the prescribed dosages fell somewhere within the recommended morphine range. Unfortunately, 16% of the children had prescribed dosages below the recommended morphine

Postoperative Analgesicsfor Chilclren

Vol. 9 No. 2 February I994

Table3 PresCPibii tterns ChW?r 5 Posto~~~e for IV Morphine Sulfate (N = 93)

Percent ofN

Range of recommended for body weight” Pattern

Below

Within

dose Above

IV,intravenous;and PRN, as necdcd. “Based on a recoumended doze of 0.05-0.10 u&kg; a 45-kg child would be expecled LOhave a prescribed dose raugiug between 2.25 mg and 4.5 mg of IV nlorphinc. A prcscriptiou of l-3 rng every 2 hr would be represenled by pac~ern IS.

range and 4% had prescribed dfjsages above the recommended morphine range (Table 3). Similar prescribing patterns were found for acetaminophen with codeine (Table 4). Our in placfindings repre zct some improvement tice since 1983 when Beyer and colleagues” reported that 35% of children’s prescriptions were within the recommended range, 19% were below, and 17% were above the recommended range. Foster and Heste$’ also found that prescribed morphine doses ranged from 7% to 200% (means = 47%-99%) of those recommended and that prescribed azetaminophen with codeine doses ranged from 31% to 224% (means = 64%-114%) of those recommended. Morphine and acetaminophen with codeine were the most frequent analgesics administered, but other opioids (meperidine, codeine, and hydromorphone) were also administered-admittedly sporadically-throughout the hospital stay. The use of the nonopioid or acetaminophen, inanalgesics, aspirin creased after the first 2 days. This administration pattern, early predominance of opioids then shifting to nonopioid analgesics has been reported previously. s5 This pattern, however, does not reflect current knowledge about the synergistic analgesic effects that can be ob rained when nonopioids are combined with opioids to relieve pain via peripheral and central mechanisms.‘”

91

also fotmd less than optimal practice regarding adminiseration dose and interval between doses. Nurses administered IV morphine to less an half of the children (46 of 104) who bad orders for Iv morphine on postoperative day 1 and to less than 25% on day 3 (Table 7). Of the doses administered over the 3 days, at the most 68% were within the recommended dose range, 43% were below, and 9% were above the recommended dose range for intravenous morphine. In contrast, none of the children were administered an excessive dose of acetaminophen. Foster and Wester*l also noted variability in the doses of morphine administered to children. In their study, morphine doses ranged from 38% to 131% (mean = 68%) of the recommended dose and administered acetaminophen doses ranged from 41% to 180% (mean = 92%) of the recommended dose. Fortunately, in our study, professionals appeared to understand the potential toxicity of acetaminophen. That over 60% of the children were in the postduration stage of the last administered analgesic on each of the 5 days when pain was assessed was particularly disturbing. Considering the range of concurrent pain scores (O-102.2), this indicates prolonged time intervals between analgesic doses, some longer than Table 4

Prescribing Patterns Over 5 Postoperative Days for

PEW Acetamimophen with Codeine (N = 75)

Percent ofN

Range of recommended dose for body weight” Pattern

Below

Within

Above

<-> acetan~inopheu. c-----> codeine. PRN. as needed. “Based on recomu~er.ded dose of IO-15 ~ug/kg ofacctaudn~ phen by mouth and 1 mg/kgofcodcinc by ~noutb. a 45-kgchild would be expected 10 have a prescription for 450-675 nag OT acctaminophcn and 45 mg of codeine. A prescription lor 650 mg of acetamninophcn and 30 mg of codeine would be reprcsenvd by yauern C.

VoL 9No. 2 F&q

T&r et aL

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1994

Table 5 ‘Qpe aad Number of Doses and Route of Amdgesirs Administemd Friar to Aulolesceat Pediatic Pain Tool (APPT) Assessments on Postoperative Days 1-5 Postoperative day Drug/route

1 (&80) S(%,~

2 (X87) ;:%J’o,

3 (S80) pcs,

Morphine Intravenous Other

46 (58) 3 141

37 (43) 4 (51

22 (28)

Meperidine Xntravenous Orally

4 1

(5) (1)

Hydromorphone Intramuscular Codeine Orally

2

Acetaminophen/codeine Orally

1

(1)

23 (26) 2

(21

13 (15) -

11 (14) 2 (21

4

-

(5)

f(W) 7 (16) 1 (21 1

1721 -

(31

3

18 (23) -

(2)

(2) -

22 (34)

(3)

-

1

-

27 (34) 2

5 (S45)

17 (27) 2 (3)

(6)

-

2

-

-

~e~minophen/~pirin Orally Suppository

(71 (l!

(31

11 (14)

Hydrocodone/acetaminophen Orally

6 1

5

4 (S64) I-(%)

16 (36)

(5)

2

18 (28) 1 (-2;

(41

17 (38) -

N, ~oti nun~bcrof children receiving doses on each day; andl, nwnbcr of children receiving specific drug. *Pcrccnt of analgesic doses administered way 110~bc equal 10 1OOYodue w rounding.

24 hr. Other investi~torss~~ also have reported this problem. For example, Mather and Ma&es found that 77 of 170 children received only a single analgesic dose in 24 hr. Rauen and HolmarP report that, while analgesics were administered every 3-6 hr to most children, at one period there were time intervals greater than til/z hr between doses for 54% of the children. Furthermore, pain measures between these doses demu:lstrated that 17 of the 50 children reported pain scores greater than 3 on a O- to *point scale. ~ditio~ally, these investi-

gatorP noted that fewer analgesics were administered on the night shift. Bush and coileague@ found that the child’s body size correlated with the amount of analgesic administered, but that the decision to medicate was based more on assessed seriousness rather than the assessed painfulness of the surgery. Orders for “as needed” medication more frequently led to poor management rather than individualized therapy. We also found an increasing linear association between equianalgesic dose administered

Table 6 Analgesic Effect at the The Adolescent Pediatric Pain Tool (APPT) Was mitered

on Postoperative Days l-5=

Postoperative day N:%)

i-$%1

Administration to onset of analgesic effect

5

(6)

11 (12)

Onset of drug to peak analgesic effect

7

(9)

Peak analgesic effect to

$96, 10 (11)

(3)

10 (11)

20 (24)

18 (19)

13 (14)

50 (61)

64 (67)

61 (65)

3

analgesic duration Postanalgesic duration

“Number ofsubjccls varies because all children did not provide *Mean % of subjects at each analgesic sls~~cfor Ihe 5 days.

ZJSXSSII~CI~L data OIL

4 N(%> 7

(9)

10 (12)

Q (11) 56 (68) each of Ihe 5 days.

*;%I

Q (15)

Meanb (%I 11

(5)

8

6 (10)

16

3

41 (69)

66

!SampIe Day postsurgery @9 46 37 22

1 2 3

ostope~~ve pain ~~agern~~t for c &en and ad5les~eo~. Id~~~~~g factors that influence the underreagent of chiIdren’s pain is an ongoing and complex process with some pr~bI~ms nearer solution than others. In contrast to previously reported studies, there now are valid and reliably self-report tools to assess pain inte~si~ in ~biId~en over 3 yr of age. The best known are the Poker Chip,‘L4 the Oucher,ss the WongBaker FACES scakzG and the APIT*7 Yet most pediatric units have not adopted a validated tool with which to assess their patients’ pain. Burokas”” and Stern Radish and colleague@ found that cures most frequendy used vital signs, expected pain severity, nonverbal behaviors, and type or seriousness of surgery as criteria for me~~dng the chikd. These nons~d~diz~ assessments pose barriers to the development of consensus about pain severity or to identification of data that can be used to negotiate for more medication. When these nonstandardized assessments are coupled with misinterpretation of children’s coping behaviors as absence of pain they can pose major hurdles to the appropriate management of children’s pain. In contrast, Power@ found s~~stic~ly sign~cant positive correlations between nurses’ and children’s pain intensity assessments when nurses and children used the same tool to assess pain. With the advent of d~g~du~tion programs and the escalation of the “war on drugs,” the

of N for whom

dose administered was below, within, or above range of recommended dose for body weight. Percentage

Beiow

Within

Abcce

26% 43% 27%

65% 49% 68%

9% 8% 5%

IV,infravcnous. and pain intensity over the first 4 postoperative days. Correlations were weakest on days when average pain intensity was high (33-52 mm) and stronger when average pain inte~si~ was less (29-S mm). Unfortunately, the magnitude of the correlations was never strong (r = O.~I~.S~) or very strong (r= ~.$I-~.~).l~ The findings from this study and previously published studies suggest noticeable progress in some aspects of children’s postoperative pain management and clear lack of improvement in others. It seems that educational efforts in the past have helped physiciau,!: and nurses understand which drugs should bc cased for management of children’s pain and by which route these drugs should he given. However, educational efforts have done little to improve prescription and administration of weight-appropriate doses and administration of doses at intervals consistent with drug pharmacodynamics and pharmacokinetics. Ed-

Thfile8 Administered Acetannnophen with Codeine for 5 Days After Surgery

Day postsurgery

Analgesic

Sample (N)

Percentage of Nfor when dose administered was below, withii, or above resommended dose for weight Below

Within

Above

1

Acetaminophen Cademe

10 10

60 70

40 -

30

2

Acetaminophen Codeine

23 23

69 65

30 -

34

3

Acetaminophen Codeine

26 26

69 69

31 -

31

4

Aeetaminophen Codeine

21 21

;:

29 -

29

5

~e~m~nophen Codeine

16 16

50 50

50 6

44

94

Tesle et al.

administrttuon of opioids has become a more complex issue for health professionals, fami&es, and children. investigators have reported patient and family reluctance to use patientcontrolled analgesia (PCA) for fear of addiction.31This compounds the problems for both physicians and nurses, whose own education about these drugs emphasized dangerous side effects and gover~ent control, and underemphasized their analgesic actions and mechanisms. The medical, as opposed to the recreational, use of these drugs needs to be clarified for ah concerned. New modalities for drug delivery, such as PC& are positi~ly altering the analgesic dehvcry pattern for a select group of children. The findings of this study, however, are still very significant for the large population of children for whom PCA is not appropriate and who, because of age, development, or financial reasons require analgesics administered by professionals. Financial concerns associated with PCA are important when one considers that PCA machines cost thousands of dollars and that a S-day course of therapy may cost more than $400 per day {Savedra ?t al., unpublished obse~tions). Such a ch;Jrge is troublesome as cost containment becomes more of an institutional focus throughout the nation. Some hospitals currently don’t have this equipment available. The ending of our study are critical to lessen the remainingvariations in practice. Our findings reafllrm the undertreatment of children’s pain that has apparently changed only slightly in 25 years. Previous studies raised concerns about undertreatment of children’s postoperative pain, but provided little detailed information about the trajectory of the pain over time and the characteristics of prescribed and administered analgesics, especially dosages and timing of analgesics in relation to subject.ive pain report It is obvious that current pIXtke still is not optimal or in accord with federal practice guidelines.”

Ackmwedgnent This study was supported by the Nations Institutes of Health, National Center for Nursing Research (1 ROl NU 01045). and the American Cancer Society, Northern California Division.

Vol. 9 No. 2 FeZmay 1994

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