Evaluating comfort measures for commonly performed painful procedures in pediatric patients.

Introduction: Management of pediatric pain from medical procedures is of great importance for improving both patient care and experience. In this study, we investigated methods of managing acute pain in infants and children by studying the correlation between the number of attempts to complete painful procedures, given different comfort measures. Methods: The study is a retrospective review of 74,276 procedures performed at two pediatric hospitals in an integrated academic children\u27s health system between 2013 and 2016. We compared three comfort measures most frequently offered: positions of comfort (POC), distraction (DIST), and pharmacological (PHARM). These methods were compared in the setting of four procedures: peripheral intravenous (PIV) catheter insertion, gastrointestinal tube placement, incision procedures, and bladder catheterization. We used the number of attempts needed to complete a procedure as a measure of efficacy minimizing distressing experience in an acutely painful setting (single attempt vs repeat attempts). Results: Among younger children, DIST appears superior to the other two methods; it performs significantly better for three of the four procedures (PIV catheterization, incision wound, and urinary catheterization) among infants agedchildren, POC tends to perform slightly better than the other two methods, although it is significantly better only for PIV catheterization among adolescents aged 13-21 years and urinary catheterization among children aged 9-12 years. Conclusion: Results from this study may be used to determine appropriate comfort measures for painful procedures in pediatric setting

Hypnosis for acute procedural pain: a critical review

Clinical evidence for the effectiveness of hypnosis in the treatment of acute procedural pain was critically evaluated based on reports from randomized controlled clinical trials (RCTs). Results from the 29 RCTs meeting inclusion criteria suggest that hypnosis decreases pain compared to standard care and attention control groups and that it is at least as effective as comparable adjunct psychological or behavioral therapies. In addition, applying hypnosis in multiple sessions prior to the day of the procedure produced the highest percentage of significant results. Hypnosis was most effective in minor surgical procedures. However, interpretations are limited by considerable risk of bias. Further studies using minimally effective control conditions and systematic control of intervention dose and timing are required to strengthen conclusions

Structured sedation programs in the emergency department, hospital and other acute settings: protocol for systematic review of effects and events.

BACKGROUND: The use of procedural sedation outside the operating theatre has increased in hospital settings and has gained popularity among non-anesthesiologists. Sedative agents used for procedural pain, although effective, also pose significant risks to the patient if used incorrectly. There is currently no universally accepted program of education for practitioners using or introducing procedural sedation into their practice. There is emerging literature identifying structured procedural sedation programs (PSPs) as a method of ensuring a standardized level of competency among staff and reducing risks to the patient. We hypothesize that programs of education for healthcare professionals using procedural sedation outside the operating theatre are beneficial in improving patient care, safety, practitioner competence and reducing adverse event rates. METHODS: Electronic databases will be systematically searched for studies (randomized and non-randomized) examining the effectiveness of structured PSPs from 1966 to present. Database searches will be supplemented by contact with experts, reference and citation checking, and a grey literature search. No language restriction will be imposed. Screening of titles and abstracts, and data extraction will be performed by two independent reviewers. All disagreements will be resolved by discussion with an independent third party. Data analysis will be completed adhering to procedures outlined in the Cochrane Handbook of Systematic Reviews of Interventions. If the data allows, a meta-analysis will be performed. DISCUSSION: This review will cohere evidence on the effectiveness of structured PSPs on sedation events and patient outcomes within the hospital and other acute care settings. In addition, it will examine key components identified within a PSP associated with patient safety and improved patient outcomes.Trial registration: PROSPERO registration number: CRD42013003851

Management of paediatric procedure-related cancer pain

Paediatric malignancy is not always painful in its own right; however, young patients with cancer undergo numerous painful procedures for diagnosis, therapy and supportive care, including lumbar puncture, bone marrow aspiration and biopsy. Children with cancer consider painful procedures to be the most difficult part of their illness and the frequent repetition of procedures does not desensitize them to the distress. This review provides a brief overview of the state of the art with regard to procedure-related pain in children, and presents some methods and strategies for assessing it and managing it effectively. The first section briefly identifies the dimensions of procedure-related pain and describes the most commonly used methods for its assessment. This followed by an examination of the pharmacological strategies for pain management, including local anaesthesia, conscious sedation and general anaesthesia. In the next section, psychological interventions for the management of procedure-related pain, such as preparation, cognitive–behavioural therapy and hypnosis, are reviewed. The review concludes with recommendations for clinical practice

Hypnotherapy for procedural pain, itch, and state anxiety in children with acute burns: A feasibility and acceptability study protocol

Background: Burns and related procedures are painful and distressing for children, exposing them to acute and chronic sequelae that can negatively afect their physiological, psychological, and social functions. Non-pharmacological interventions such as distraction techniques are benefcial adjuncts to pharmacological agents for procedural pain, state anxiety, and itch in children with burns but have limitations (e.g. lack of research on burn-related itch, tailoring, and consensus on optimal treatment). Hypnotherapy is a non-pharmacological intervention that can be tailored for varied settings and populations with evidence of beneft for itch and superior efectiveness in comparison to other non-pharmacological interventions for children’s procedural pain and state anxiety. Thus, children with burns can beneft from hypnotherapy as an adjunct to pharmacological agents. Yet, in paediatric burns, rigorous studies of efectiveness are limited and no studies have been identifed that screen for hypnotic suggestibility, an important predictor of hypnotherapy outcomes. Considering potential barriers to the delivery of hypnotherapy in paediatric burns, the proposed study will examine the feasibility and acceptability of hypnotic suggestibility screening followed by hypnotherapy for procedural pain, state anxiety, and itch in children with acute burns. Methods: An observational mixed-methods feasibility and acceptability study will be conducted over 15 weeks. Eligible children (N = 30) aged 4 to 16 years presenting to a paediatric burns outpatient centre in a metropolitan children’s hospital in Australia with acute burns requiring dressing changes will be included. Eligible parents of children (N = up to 30) and clinicians who perform dressing changes (N = up to 20) will also be included. Child participants screened as having medium to high suggestibility as assessed by behavioural measures will receive hypnotherapy during dressing changes. A process evaluation will target feasibility and acceptability as primary outcomes and implementation (i.e. fdelity in delivery), reach, potential efectiveness, and adoption of evaluation procedures and intervention as secondary outcomes. Discussion: Ethical approval was obtained from the Queensland Children’s Hospital and Health Service ethics committee. Results will be published in peer-reviewed publications and conference proceedings. The fndings will guide the design of future trials on the efectiveness of hypnotherapy and inform the development of child-centred hypnotic interventions in children with burns. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN1262000098895

The Effects of Virtual Reality on Procedural Pain and Anxiety in Pediatrics

Distraction and procedural preparation techniques are frequently used to manage pain and anxiety in children undergoing medical procedures. An increasing number of studies have indicated that Virtual Reality (VR) can be used to deliver these interventions, but treatment effects vary greatly. The present study is a systematic review and meta-analysis of studies that have used VR to reduce procedural pain and anxiety in children. It is the first meta-analytic assessment of the potential influence of technical specifications (immersion) and degree of user-system interactivity on treatment effects. 65 studies were identified, of which 42 reported pain outcomes and 35 reported anxiety outcomes. Results indicate large effect sizes in favor of VR for both outcomes. Larger effects were observed in dental studies and studies that used non-interactive VR. No relationship was found between the degree of immersion or participant age and treatment effects. Most studies were found to have a high risk of bias and there are strong indications of publication bias. The results and their implications are discussed in context of these limitations, and modified effect sizes are suggested. Finally, recommendations for future investigations are provided