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PEDIATRIC ANESTHESIA

The Safety and Efficacy of Parent-/Nurse-Controlled Analgesia in Patients Less than Six Years of Age

Constance L. Monitto, MD^*, Robert S. Greenberg, MD^*,, Sabine Kost-Byerly, MD^*, Randall Wetzel, MBBS, Carol Billett, RN, MS^§, Ruth M. Lebet, RN, MS^§, and Myron Yaster, MD^*,

Departments of *Anesthesiology and Critical Care Medicine and Pediatrics, The Johns Hopkins Hospital, Baltimore, Maryland; Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California; and the §Pediatric Pain Service, The Johns Hopkins Hospital, Baltimore, Maryland

Address correspondence and reprint requests to Constance L. Monitto, MD, Blalock 943, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 600 North Wolfe St., Baltimore, MD 21287. Address e-mail to cmonitto{at}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 3/10 (objective pain scale) 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-controled 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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