St. Loius, MO -
Children and adolescents account for more than 31 million visits to emergency departments annually, according to Emergency Medical Services for Children. Forty-three percent of these pediatric visits are for treatment of injuries where management can cause pain or anxiety for young patients.
At St. Louis Children's Hospital, two pediatric emergency medicine specialists have helped foster a treatment culture in which reduction of pain and anxiety is an essential aspect of a growing number of common procedures such as fracture reduction, suturing and IV starts.
"It became clear to me that the care we provided was causing a lot of kids to cry and become upset, whether we were reducing fractures, debriding burns, drawing blood or starting IVs," says Robert "Bo" Kennedy, MD, pediatric emergency medicine physician at St. Louis Children's Hospital and associate professor of pediatrics at Washington University School of Medicine (WUSM). "The decibel level was the telling measure of the department's activity level."
Dr. Kennedy and colleague Jan Luhmann, MD, emergency medicine physician and WUSM assistant professor of pediatrics, have helped advance the increased use of pharmacologic and non-pharmacologic modalities in a pediatric ED setting - including nitrous oxide, buffered lidocaine, early oral oxycodone, and "positions of comfort" - to lessen anxiety and pain during procedures.
Dr. Kennedy, in collaboration with pediatric anesthesiologists at St. Louis Children's Hospital, first began to study ways to improve sedation during fracture reductions nearly two decades ago. This early effort included use of fentanyl with midazolam (Versed®) and later ketamine with midazolam.
"Our randomized study comparing fentanyl with midazolam, to ketamine with midazolam, clearly showed the ketamine regimen caused less respiratory depression and was more effective at reducing patient distress," Dr. Kennedy remarks. "However, we also realized that for minor procedures, this drug combination was like using a cannon when all we needed was a 'flyswatter,' i.e., a small amount of sedation."
Dr. Luhmann was a pediatric resident at the time, and became interested in working to reduce distress with less painful procedures. "Many common yet distressful emergency procedures such as suturing were accomplished by holding the patient down or restraining them on a board," Dr. Luhmann recalls.
Although topical and local anesthesia minimized the pain of suturing, anxiety was still an issue. A regimen was needed for procedures that were not as painful yet still resulted in great distress. "We began to search for alternatives that were painless to administer, effective with short recovery times and most importantly, caused minimal adverse effects," she adds. "Nitrous oxide seemed to fit this description."
"When we decided to pursue the use of nitrous, we recognized that the equipment in use and described in the literature was an apparatus that delivered a fixed percentage of nitrous oxide and required a large inspiration by the patient to open a valve to release the nitrous," recalls Dr. Kennedy.
By working with pediatric anesthesiologists and biomedical engineers, Drs. Kennedy and Luhmann developed an improved delivery device modeled after operating room systems.
"We recognized that children often can't take a deep enough breath to trigger the delivery valve, especially if they were distressed and crying," Dr. Luhmann points out. "The system that is now in place offers continuous flow, at an adjustable percentage, without a valve. Patients receive the nitrous oxide as they breathe normally."
With a recent expansion and renovation of the Emergency Department at St. Louis Children's Hospital, emergency medicine physicians have the benefit of built-in nitrous oxide in select treatment rooms, somewhat unique for emergency settings. In a randomized clinical trial of continuous flow nitrous oxide during laceration repair, Drs. Luhmann and Kennedy found that nitrous oxide was an effective sedative and provided a very rapid recovery.
"In this study of 2-to-6-year-old children with facial lacerations requiring sutures, children who received 50 percent nitrous oxide had less distress compared to those who received midazolam and local anesthesia," cites Dr. Luhmann.
This collaborative work was published in the January 2001 Annals of Emergency Medicine. In order to share these and other findings, these clinicians have authored numerous other journal articles in Pediatrics, Annals of Emergency Medicine, Pediatric Clinics of North America, Clinical Pediatric Emergency Medicine, and Pediatric Drugs and Pediatric Emergency Care.
"When used alone, 50 percent nitrous oxide provides minimal to moderate pain relief for other emergency department procedures, including foreign object removal, IV insertion and lumbar puncture," observes Dr. Luhmann. "Nitrous oxide offers a very controlled duration, unlike many of the medications that can be somewhat unpredictable."
"We both learned that nitrous administration is an art. The clinician must help the patient be amenable to the gas' effects," explains Dr. Kennedy. "A large part of what we do is engage patients and their parents in the process as much as possible, working with them to relax. We get the kids to imagine they're flying, perhaps to Disney World or the moon."
One of their latest attempts is to determine how to match the sedation technique with a patient's personality and tendencies. In concert with these efforts, Dr. Luhmann says that they are evaluating non-pharmacologic methods, such as distraction, guided imagery, coping mechanisms and local anesthesia in combination with pain medications in order to use less of the more potent agents.
According to Dr. Kennedy, their emphasis for the last few years has focused on the use of local anesthesia for IV starts. "We know that for many kids, IV sticks and blood draws are the worst part of hospitalization. Even when they come in for an operation, they remember the needle sticks," he notes.
Dr. Luhmann adds that children are very fearful of blood draws and shots. "It's probably a greater problem than we recognize," she says.
Use of buffered lidocaine, injected through a 30-gauge needle, is now a part of the department's standard protocol for starting IVs.
Dr. Kennedy explains that even though it is injected, it's amazing how painless it can be. "Studies show buffering lidocaine dramatically reduces pain on injection," he says. "As an example, we've started IVs on sleeping infants. They may have fidgeted a little bit upon injection of the lidocaine, but didn't wake up. After these babies settled back into sleep, the IV was inserted through the anesthetized area as the babies slept. However, needle phobia remains an issue with this technique when treating children that are awake, thus use of distraction during the injection and IV insertion is important."
A recent, dramatic change in department policy goes into play when a child presents to the triage desk with a painful injury. Following guidelines, nurses are empowered with a standing order to provide oxycodone at triage.
"This is an important change in our practice and allows children to receive pain medication when indicated much more promptly," Dr. Luhmann says. "By the time a patient's physical examination is underway by a physician or radiographs are obtained, both of which can exacerbate pain, the pain medication is working. Our hope is that all our patients will experience only minimal pain when they come to see us."