Sandra Merkel - Academia.edu (original) (raw)
Papers by Sandra Merkel
Nursing Management, Oct 1, 1980
An instructional program was quite effective, especially in improving knowledge and skill and in ... more An instructional program was quite effective, especially in improving knowledge and skill and in changing attitudes.
American Journal of Critical Care, 2010
Background Few investigators have evaluated pain assessment tools in the critical care setting. O... more Background Few investigators have evaluated pain assessment tools in the critical care setting. Objective To evaluate the reliability and validity of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain. Methods Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the administration or procedure. Two nurses used the FLACC scale, the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children). Results For 73 observations, FLACC scores correlated highly with the other 2 scores (ρ = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P < .001). Exact agreement and κ statistics, as well as intraclass correlation coefficients (0.67-0.95), support excellent interrater reliability of the tool. Internal consistency was excellent; the Cronbach α was 0.882 when all items were included. Conclusions Although similar in content to other behavioral pain scales, the FLACC can be used across populations of patients and settings, and the scores are comparable to those of the commonly used 0-to-10 number rating scale.
PubMed, Dec 1, 1991
Pain assessment is a complex yet essential aspect of holistic care of the pediatric patient durin... more Pain assessment is a complex yet essential aspect of holistic care of the pediatric patient during the postoperative period. Because children cannot verbalize pain, the PACU nurse is faced with the challenge of assessing pain. This article attempts to provide guidelines in assessing postoperative pediatric pain and reviews common analgesic drugs.
PubMed, Oct 1, 1980
An instructional program was quite effective, especially in improving knowledge and skill and in ... more An instructional program was quite effective, especially in improving knowledge and skill and in changing attitudes.
Anesthesiology, Sep 1, 2000
Patient Experience Journal
A phlebotomist's words and actions play a crucial role in success of a blood draw and in providin... more A phlebotomist's words and actions play a crucial role in success of a blood draw and in providing a supportive patient experience. This study examined use of comfort measures during a pediatric blood draw. The phlebotomist's use of soft words, positioning, distraction, coaching/support were observed with sixty children between 3-14 years of age during a blood draw. The level of fear /anxiety before and during the blood draw was recorded by an RA. The child's level of fear/anxiety was observed and reported by the parent/caregiver after the procedure. Comfort measures provided by phlebotomists, the parent/caregiver's report of their child's usual response, and the parent's level of fear with needles were compared. Comfort measures were offered inconsistently across age groups. Distraction was the most frequent measure (85%), followed by coaching/support (72%). Positioning was used more often with younger children (42%) than with older children (7%). Despite the high use of comfort measures, many children (56%) had levels of 2-4 fear/anxiety. The parent/caregiver often predicted their child's level of fear/anxiety. Phlebotomists can benefit from interdisciplinary collaboration opportunities and developmentally appropriate education, including comfort measures, to mitigate patients' pain and fear. Given the importance of creating a positive patient-family centered environment, introductions, and interactions to build a trusting rapport are crucial. Additionally, this research highlighted the importance of self-advocacy by pediatric patients and families. When providers ask and listen, and children are brave enough to share their voice...the human experience will improve on all sides.
Background: Difficulty with pain assessment in individuals who cannot self-report their pain pose... more Background: Difficulty with pain assessment in individuals who cannot self-report their pain poses a significant barrier to effective pain management. However, available assessment tools lack consistent reliability as pain measures in children with cognitive impairment (CI). This study evaluated the validity and reliability of the revised and individualized Face Legs Activity Cry and Consolability (FLACC) behavioral pain assessment tool in children with CI. Methods: Children with CI scheduled for elective surgery were studied. The FLACC was revised to include specific descriptors and parent-identified, unique behaviors for individual children. The child's ability to self-report pain was evaluated. Postoperatively, two nurses scored pain using the revised FLACC scale before and after analgesic administration, and, children self-reported a pain score, if able. Observations were videotaped and later viewed by experienced nurses blinded to analgesic administration. Results: Eighty observations were recorded in 52 children aged 4-19 years. Twenty-one parents added individualized pain behaviors to the revised FLACC. Interrater reliability was supported by excellent intraclass correlation coefficients (ICC, ranging from 0.76 to 0.90) and adequate j statistics (0.44-0.57). Criterion validity was supported by the correlations between FLACC, parent, and child scores (q ¼ 0.65-0.87; P < 0.001). Construct validity was demonstrated by the decrease in FLACC scores following analgesic administration (6.1 ± 2.6 vs 1.9 ± 2.7; P < 0.001). Conclusions: Findings support the reliability and validity of the FLACC as a measure of pain in children with CI.
Pediatric nursing
The purpose of this study was to further test the validity of the Faces, Legs, Activity, Cry and ... more The purpose of this study was to further test the validity of the Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale for use with children. Thirty children aged 3-7 years (5.01 +/- 1.44) who had undergone a variety of surgical procedures were observed and assessed for pain intensity at 20 + 2 hours after surgery. FLACC scores were assigned by one of the nurse investigators, and a self-report of pain using the FACES scale was obtained from the child. There were significant and positive correlations between the FLACC and FACES scores for the entire sample and for the scores of children 5-7 years of age, but not for children < age 5. These findings provide additional support for the construct validity of the FLACC Pain Assessment Tool.
AANA journal, 1996
Postoperative pain is a significant problem that continues to be undertreated in the pediatric po... more Postoperative pain is a significant problem that continues to be undertreated in the pediatric population. Preemptive administration of analgesics has recently emerged as a method to enhance pain management associated with surgery. The purpose of this study was to compare postoperative pain scores, rescue analgesic use, and oral fluid intake in children who received acetaminophen preoperatively to children who received postoperative acetaminophen. The sample consisted of 28 children, 2-8 years of age, scheduled for elective tonsillectomy. Children were randomized into the control or the experimental groups. Anesthesia induction and maintenance were standardized. The experimental group received 15 mg/kg of oral acetaminophen preoperatively, and the control group received 20 mg/kg of rectal acetaminophen postoperatively. Pain was scored with the FLACC (faces, legs, activity, cry, consolability) behavioral assessment tool. Scores were significantly lower for the experimental group at 3...
The Journal of Continuing Education in Nursing, 1979
Urologic Nursing, 2015
Optimizing pain management is a component of enhanced perioperative recovery for children undergo... more Optimizing pain management is a component of enhanced perioperative recovery for children undergoing urologic surgery. Incisional pain and discomfort from bladder spasms are two types of pain associated with bladder surgery. A child&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s developmental level and verbal skills must be considered when selecting pain assessment tools. Assessing pain location, type, and intensity is essential in developing a multimodal plan of care for post-operative pain. Pharmacological interventions provide effective pain management, which facilitates early ambulation, return to oral intake, and recovery. Pre-operative preparation, non-pharmacological interventions, and parental presence help decrease anxiety and promote comfort, as well as support a child&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s coping skills.
Insight (American Society of Ophthalmic Registered Nurses)
Pediatric nursing
To evaluate the reliability and validity of the FLACC Pain Assessment Tool which incorporates fiv... more To evaluate the reliability and validity of the FLACC Pain Assessment Tool which incorporates five categories of pain behaviors: facial expression; leg movement; activity; cry; and consolability. Eighty-nine children aged 2 months to 7 years, (3.0 +/- 2.0 yrs.) who had undergone a variety of surgical procedures, were observed in the Post Anesthesia Care Unit (PACU). The study consisted of: 1) measuring interrater reliability; 2) testing validity by measuring changes in FLACC scores in response to administration of analgesics; and 3) comparing FLACC scores to other pain ratings. The FLACC tool was found to have high interrater reliability. Preliminary evidence of validity was provided by the significant decrease in FLACC scores related to administration of analgesics. Validity was also supported by the correlation with scores assigned by the Objective Pain Scale (OPS) and nurses' global ratings of pain. The FLACC provides a simple framework for quantifying pain behaviors in child...
Background Few investigators have evaluated pain assessment tools in the critical care setting. O... more Background Few investigators have evaluated pain assessment tools in the critical care setting. Objective To evaluate the reliability and validity of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain. Methods Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the administration or procedure. Two nurses used the FLACC scale, the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children). Results For 73 observations, FLACC scores correlated highly with the other 2 scores (ρ = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P < .001). Exact agreement and κ statistics, as well as intraclass correlation coefficients (0.67-0.95), support excellent interrater reliability of the tool. Internal consistency was excellent; the Cronbach α was 0.882 when all items were included. Conclusions Although similar in content to other behavioral pain scales, the FLACC can be used across populations of patients and settings, and the scores are comparable to those of the commonly used 0-to-10 number rating scale.
Pediatric Anesthesia, 2001
We compared pain assessment and management practices in children with and without cognitive impai... more We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery. The medical records of 42 children (19 with CI and 23 without) were reviewed and data related to demographics, surgery, pain assessment and management, and side-effects were recorded. Fewer children with CI were assessed for pain on postoperative days (POD) 0-4 compared to those without CI (P < 0.002). Self-report was used for 81% of pain assessments in children without CI, while a behavioural tool was used for 75% of assessments in cognitively impaired children. Children with CI received smaller total opioid doses on POD 1-3 compared to those without CI (P < or = 0.02). Furthermore, children without CI received patient/nurse-controlled analgesia for more postoperative days than children with CI (P=0.02). Our data demonstrate a discrepancy in pain management practices in children with and without CI following spine fusion.
Nursing Management (Springhouse), 1980
An instructional program was quite effective, especially in improving knowledge and skill and in ... more An instructional program was quite effective, especially in improving knowledge and skill and in changing attitudes.
Journal of PeriAnesthesia Nursing, 2000
Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with... more Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.
Journal of Cardiothoracic and Vascular Anesthesia, 1996
To determine whether outcomes and costs in children undergoing cardiac surgery are affected by th... more To determine whether outcomes and costs in children undergoing cardiac surgery are affected by the method of postoperative pain management. Retrospective, case control. Tertiary care children's hospital in a university setting. Two groups of children undergoing cardiac surgery for palliation or repair of congenital heart disease oer a 21-month period between January 1993 and September 1994. Lumbar epidural morphine infusions (LEM) in one group, and IV opioid (IVO) medication in the other for postoperative pain control. Hospital courses of 27 LEM patients and 27 IVO patients were analyzed. In LEM patients, epidural catheters were placed following anesthetic induction, but before anticoagulation. A bolus of 50 micrograms/kg of preservative-free morphine sulfate was administered through the catheter, followed by a continuous infusion at 3 to 4 micrograms/kg/h for 22 to 102 (median, 46) hours postoperatively. The IVO patients received 50 micrograms/kg, IV, of fentanyl before incision followed by a continuous infusion at 0.3 microgram/kg/min. The fentanyl infusion rate was decreased to 0.1 microgram/kg/min postoperatively and maintained for 24 hours. Although the LEM group was demographically similar to the IVO group, times to tracheal extubation, transfer from the intensive care unit, and resumption of regular diet were significantly shorter in LEM patients. LEM and IVO patients received similar amounts of fentanyl during surgery (10.4 +/- 19.3 micrograms/kg/h v 13.7 +/- 8.1 micrograms/kg/h, p = 0.4). However, during postoperative recovery, LEM patients who were extubated late received significantly less supplemental opioid medication than IVO patients extubated late during the first 5 postoperative days. No complications related to dural puncture, bleeding into the epidural space, or respiratory depression were encountered. Pruritus and nausea/vomiting were the most commonly reported morbidities in both groups. Fifty-six percent (15/27) of LEM patients and 41% of IVO patients reported pruritus (p = 0.4). There was no significant difference in the incidence of nausea and vomiting between the groups (34% v 30%, respectively). Given the present methodologic limitations, the authors found improved outcomes only in LEM patients extubated late compared with IVO patients. Randomized, prospective studies to evaluate this conclusion and to determine the comparative efficacy and safety of LEM infusions are in progress.
Nursing Management, Oct 1, 1980
An instructional program was quite effective, especially in improving knowledge and skill and in ... more An instructional program was quite effective, especially in improving knowledge and skill and in changing attitudes.
American Journal of Critical Care, 2010
Background Few investigators have evaluated pain assessment tools in the critical care setting. O... more Background Few investigators have evaluated pain assessment tools in the critical care setting. Objective To evaluate the reliability and validity of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain. Methods Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the administration or procedure. Two nurses used the FLACC scale, the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children). Results For 73 observations, FLACC scores correlated highly with the other 2 scores (ρ = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P < .001). Exact agreement and κ statistics, as well as intraclass correlation coefficients (0.67-0.95), support excellent interrater reliability of the tool. Internal consistency was excellent; the Cronbach α was 0.882 when all items were included. Conclusions Although similar in content to other behavioral pain scales, the FLACC can be used across populations of patients and settings, and the scores are comparable to those of the commonly used 0-to-10 number rating scale.
PubMed, Dec 1, 1991
Pain assessment is a complex yet essential aspect of holistic care of the pediatric patient durin... more Pain assessment is a complex yet essential aspect of holistic care of the pediatric patient during the postoperative period. Because children cannot verbalize pain, the PACU nurse is faced with the challenge of assessing pain. This article attempts to provide guidelines in assessing postoperative pediatric pain and reviews common analgesic drugs.
PubMed, Oct 1, 1980
An instructional program was quite effective, especially in improving knowledge and skill and in ... more An instructional program was quite effective, especially in improving knowledge and skill and in changing attitudes.
Anesthesiology, Sep 1, 2000
Patient Experience Journal
A phlebotomist's words and actions play a crucial role in success of a blood draw and in providin... more A phlebotomist's words and actions play a crucial role in success of a blood draw and in providing a supportive patient experience. This study examined use of comfort measures during a pediatric blood draw. The phlebotomist's use of soft words, positioning, distraction, coaching/support were observed with sixty children between 3-14 years of age during a blood draw. The level of fear /anxiety before and during the blood draw was recorded by an RA. The child's level of fear/anxiety was observed and reported by the parent/caregiver after the procedure. Comfort measures provided by phlebotomists, the parent/caregiver's report of their child's usual response, and the parent's level of fear with needles were compared. Comfort measures were offered inconsistently across age groups. Distraction was the most frequent measure (85%), followed by coaching/support (72%). Positioning was used more often with younger children (42%) than with older children (7%). Despite the high use of comfort measures, many children (56%) had levels of 2-4 fear/anxiety. The parent/caregiver often predicted their child's level of fear/anxiety. Phlebotomists can benefit from interdisciplinary collaboration opportunities and developmentally appropriate education, including comfort measures, to mitigate patients' pain and fear. Given the importance of creating a positive patient-family centered environment, introductions, and interactions to build a trusting rapport are crucial. Additionally, this research highlighted the importance of self-advocacy by pediatric patients and families. When providers ask and listen, and children are brave enough to share their voice...the human experience will improve on all sides.
Background: Difficulty with pain assessment in individuals who cannot self-report their pain pose... more Background: Difficulty with pain assessment in individuals who cannot self-report their pain poses a significant barrier to effective pain management. However, available assessment tools lack consistent reliability as pain measures in children with cognitive impairment (CI). This study evaluated the validity and reliability of the revised and individualized Face Legs Activity Cry and Consolability (FLACC) behavioral pain assessment tool in children with CI. Methods: Children with CI scheduled for elective surgery were studied. The FLACC was revised to include specific descriptors and parent-identified, unique behaviors for individual children. The child's ability to self-report pain was evaluated. Postoperatively, two nurses scored pain using the revised FLACC scale before and after analgesic administration, and, children self-reported a pain score, if able. Observations were videotaped and later viewed by experienced nurses blinded to analgesic administration. Results: Eighty observations were recorded in 52 children aged 4-19 years. Twenty-one parents added individualized pain behaviors to the revised FLACC. Interrater reliability was supported by excellent intraclass correlation coefficients (ICC, ranging from 0.76 to 0.90) and adequate j statistics (0.44-0.57). Criterion validity was supported by the correlations between FLACC, parent, and child scores (q ¼ 0.65-0.87; P < 0.001). Construct validity was demonstrated by the decrease in FLACC scores following analgesic administration (6.1 ± 2.6 vs 1.9 ± 2.7; P < 0.001). Conclusions: Findings support the reliability and validity of the FLACC as a measure of pain in children with CI.
Pediatric nursing
The purpose of this study was to further test the validity of the Faces, Legs, Activity, Cry and ... more The purpose of this study was to further test the validity of the Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale for use with children. Thirty children aged 3-7 years (5.01 +/- 1.44) who had undergone a variety of surgical procedures were observed and assessed for pain intensity at 20 + 2 hours after surgery. FLACC scores were assigned by one of the nurse investigators, and a self-report of pain using the FACES scale was obtained from the child. There were significant and positive correlations between the FLACC and FACES scores for the entire sample and for the scores of children 5-7 years of age, but not for children < age 5. These findings provide additional support for the construct validity of the FLACC Pain Assessment Tool.
AANA journal, 1996
Postoperative pain is a significant problem that continues to be undertreated in the pediatric po... more Postoperative pain is a significant problem that continues to be undertreated in the pediatric population. Preemptive administration of analgesics has recently emerged as a method to enhance pain management associated with surgery. The purpose of this study was to compare postoperative pain scores, rescue analgesic use, and oral fluid intake in children who received acetaminophen preoperatively to children who received postoperative acetaminophen. The sample consisted of 28 children, 2-8 years of age, scheduled for elective tonsillectomy. Children were randomized into the control or the experimental groups. Anesthesia induction and maintenance were standardized. The experimental group received 15 mg/kg of oral acetaminophen preoperatively, and the control group received 20 mg/kg of rectal acetaminophen postoperatively. Pain was scored with the FLACC (faces, legs, activity, cry, consolability) behavioral assessment tool. Scores were significantly lower for the experimental group at 3...
The Journal of Continuing Education in Nursing, 1979
Urologic Nursing, 2015
Optimizing pain management is a component of enhanced perioperative recovery for children undergo... more Optimizing pain management is a component of enhanced perioperative recovery for children undergoing urologic surgery. Incisional pain and discomfort from bladder spasms are two types of pain associated with bladder surgery. A child&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s developmental level and verbal skills must be considered when selecting pain assessment tools. Assessing pain location, type, and intensity is essential in developing a multimodal plan of care for post-operative pain. Pharmacological interventions provide effective pain management, which facilitates early ambulation, return to oral intake, and recovery. Pre-operative preparation, non-pharmacological interventions, and parental presence help decrease anxiety and promote comfort, as well as support a child&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s coping skills.
Insight (American Society of Ophthalmic Registered Nurses)
Pediatric nursing
To evaluate the reliability and validity of the FLACC Pain Assessment Tool which incorporates fiv... more To evaluate the reliability and validity of the FLACC Pain Assessment Tool which incorporates five categories of pain behaviors: facial expression; leg movement; activity; cry; and consolability. Eighty-nine children aged 2 months to 7 years, (3.0 +/- 2.0 yrs.) who had undergone a variety of surgical procedures, were observed in the Post Anesthesia Care Unit (PACU). The study consisted of: 1) measuring interrater reliability; 2) testing validity by measuring changes in FLACC scores in response to administration of analgesics; and 3) comparing FLACC scores to other pain ratings. The FLACC tool was found to have high interrater reliability. Preliminary evidence of validity was provided by the significant decrease in FLACC scores related to administration of analgesics. Validity was also supported by the correlation with scores assigned by the Objective Pain Scale (OPS) and nurses' global ratings of pain. The FLACC provides a simple framework for quantifying pain behaviors in child...
Background Few investigators have evaluated pain assessment tools in the critical care setting. O... more Background Few investigators have evaluated pain assessment tools in the critical care setting. Objective To evaluate the reliability and validity of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain. Methods Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the administration or procedure. Two nurses used the FLACC scale, the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children). Results For 73 observations, FLACC scores correlated highly with the other 2 scores (ρ = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P < .001). Exact agreement and κ statistics, as well as intraclass correlation coefficients (0.67-0.95), support excellent interrater reliability of the tool. Internal consistency was excellent; the Cronbach α was 0.882 when all items were included. Conclusions Although similar in content to other behavioral pain scales, the FLACC can be used across populations of patients and settings, and the scores are comparable to those of the commonly used 0-to-10 number rating scale.
Pediatric Anesthesia, 2001
We compared pain assessment and management practices in children with and without cognitive impai... more We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery. The medical records of 42 children (19 with CI and 23 without) were reviewed and data related to demographics, surgery, pain assessment and management, and side-effects were recorded. Fewer children with CI were assessed for pain on postoperative days (POD) 0-4 compared to those without CI (P < 0.002). Self-report was used for 81% of pain assessments in children without CI, while a behavioural tool was used for 75% of assessments in cognitively impaired children. Children with CI received smaller total opioid doses on POD 1-3 compared to those without CI (P < or = 0.02). Furthermore, children without CI received patient/nurse-controlled analgesia for more postoperative days than children with CI (P=0.02). Our data demonstrate a discrepancy in pain management practices in children with and without CI following spine fusion.
Nursing Management (Springhouse), 1980
An instructional program was quite effective, especially in improving knowledge and skill and in ... more An instructional program was quite effective, especially in improving knowledge and skill and in changing attitudes.
Journal of PeriAnesthesia Nursing, 2000
Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with... more Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.
Journal of Cardiothoracic and Vascular Anesthesia, 1996
To determine whether outcomes and costs in children undergoing cardiac surgery are affected by th... more To determine whether outcomes and costs in children undergoing cardiac surgery are affected by the method of postoperative pain management. Retrospective, case control. Tertiary care children's hospital in a university setting. Two groups of children undergoing cardiac surgery for palliation or repair of congenital heart disease oer a 21-month period between January 1993 and September 1994. Lumbar epidural morphine infusions (LEM) in one group, and IV opioid (IVO) medication in the other for postoperative pain control. Hospital courses of 27 LEM patients and 27 IVO patients were analyzed. In LEM patients, epidural catheters were placed following anesthetic induction, but before anticoagulation. A bolus of 50 micrograms/kg of preservative-free morphine sulfate was administered through the catheter, followed by a continuous infusion at 3 to 4 micrograms/kg/h for 22 to 102 (median, 46) hours postoperatively. The IVO patients received 50 micrograms/kg, IV, of fentanyl before incision followed by a continuous infusion at 0.3 microgram/kg/min. The fentanyl infusion rate was decreased to 0.1 microgram/kg/min postoperatively and maintained for 24 hours. Although the LEM group was demographically similar to the IVO group, times to tracheal extubation, transfer from the intensive care unit, and resumption of regular diet were significantly shorter in LEM patients. LEM and IVO patients received similar amounts of fentanyl during surgery (10.4 +/- 19.3 micrograms/kg/h v 13.7 +/- 8.1 micrograms/kg/h, p = 0.4). However, during postoperative recovery, LEM patients who were extubated late received significantly less supplemental opioid medication than IVO patients extubated late during the first 5 postoperative days. No complications related to dural puncture, bleeding into the epidural space, or respiratory depression were encountered. Pruritus and nausea/vomiting were the most commonly reported morbidities in both groups. Fifty-six percent (15/27) of LEM patients and 41% of IVO patients reported pruritus (p = 0.4). There was no significant difference in the incidence of nausea and vomiting between the groups (34% v 30%, respectively). Given the present methodologic limitations, the authors found improved outcomes only in LEM patients extubated late compared with IVO patients. Randomized, prospective studies to evaluate this conclusion and to determine the comparative efficacy and safety of LEM infusions are in progress.