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Responses to the JACHO Reccomendation |
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The safety and efficacy of parent-/nurse-controlled analgesia in
patients less than six years of age.
Monitto CL, Greenberg RS, Kost-Byerly S, Wetzel R, Billett C, Lebet RM,
Yaster M.
Departments of Anesthesiology and Critical Care Medicine and Pediatrics,
The Johns Hopkins Hospital, Baltimore, MD 21287, USA. cmonitto@welchlink.welch.jhu.edu
Over the past 5 yr, we have treated nonsurgical and postoperative pain
in children <6 yr of age by using a patient-controlled analgesia pump to
deliver small-dose continuous IV opioid infusions supplemented by
parent- and nurse-controlled opioid bolus dosing. We call this technique
parent-/nurse-controlled analgesia (PNCA). Because the safety and
efficacy of PNCA have not been previously evaluated, we have undertaken
a prospective, 1-yr observational study to determine patient
demographics, effectiveness of analgesia, and the incidence of
complications (pruritus, vomiting, and respiratory depression) in
patients receiving PNCA. Data were collected on 212 children (98 female)
who were treated on 240 occasions with PNCA for episodes of pain.
Patients averaged 2.3 +/- 1.7 yr of age and 11 +/- 5 kg, and received a
median of 4 (range 2-54) days of PNCA therapy. Maximum daily pain scores
were < or =3/10 (objective pain scale) or < or =2/5 (objective or
self-report pain scale) in more than 80% of all occasions of PNCA use.
PNCA usage was associated with an 8% incidence of pruritus and a 15%
incidence of vomiting on the first day of treatment. Nine children
studied received naloxone, four (1.7%) for treatment of PNCA-related
apnea or desaturation. All had improvement in their symptoms after
naloxone administration. IMPLICATIONS: Parent-/nurse-controlled
analgesia provided effective pain relief in most children <6 yr of age
experiencing nonsurgical or postoperative pain. The observed incidence
of vomiting and pruritis was similar to that seen in older patients
treated with patient-controlled analgesia. However, significant
respiratory depression, although uncommon, did occur, thus reinforcing
the need for close patient monitoring.
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| "the point of the alert and the current patient
safety movement is that systematic safeguards should be in place when
dangerous drugs/procedures intersect with real people. "Systematic
safeguards" in this case include patient selection, parent
screening/selection, parent education, frequent clinician assessment and
monitoring, careful dose selection and parameters for pump settings,
nurse education, and so forth." |
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