age-appropriate level. If the patient is nonverbal, use of an infant score, such as the FLACC Scale, may be necessary. In addition, the parents may be able to assist in describing some of the child’s pain behaviors or facial expressions. Monitoring requirements for these children may require the addition of cardiac rhythm assessment for children with cardiovascular problems. After the pro- cedure, these children may require monitoring for a longer period than typically utilized to guard against an enhanced risk for respiratory depression. Discharge criteria should still be met, although reaching some of the child’s baseline behaviors may depend on the par- ents’ assessment. FOLLOW-UP/DISCHARGE CONSIDERATIONS Specific discharge criteria for children following seda- tion events should include the following: 1. Cardiovascular function and airway patency are satisfactory and at baseline. 2. The patient is easily arousable and protective reflexes are intact. 3. The patient can talk (if age appropriate). 4. The patient can sit up unaided (if age appropriate). 5. The patient has returned to the presedation level of responsiveness. 6. The child’s hydration status is adequate. A reliable adult should be given discharge instructions for the pediatric patie nt at the time of discharge from the ED. These should note that the child may be drowsy for a few hours, the adult should not leave the child unattended in a car seat, and the child should be pro- hibited from unattended swimming or bathing for 8 hr. Postdischarge feeding should include precautions con- cerning the avoidance of a heavy meal for a few hours, as some children will have mild nausea after PSA. SUMMARY Over the years, emergency physicians are increasingly asked to provide sedation and analgesia to pediatric patients for numerous diagnostic and therapeutic pro- cedures. Adherence to existing guidelines for patient assessment, medical personnel, patient monitoring, age-specific equipment, and discharge criteria should be routine in all pediatric patient analgesia and sedation encounters. BIBLIOGRAPHY 1. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006;367 (9512):766–780. 2. Doyle L, Colletti JE. Pediatric procedural sedation. Pediatr Clin North Am 2006;53:279–292. 3. Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2004;44(5):460–471. 4. American S ociety of Anesthesiologists, Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for s edation and analgesia by non-anesthesiologists. Anesthesi- ology 2002;96(4):1004–1017. 5. American Academy of Pediatrics, Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: Addendum. Pediatrics 2002;110 (4):836–838. 6. EMSC Grant Panel on Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department. Clinical policy: Evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med 2004;44:342–377. 7. American College of Emergency Physicians, Clinical Policies Subcommittee on Procedural Sedation and Analgesia. Clinical policy: Procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005;45:177–196. 8. American Academy of Pediatrics, Committee on Psycho- social Aspects of Child and Family Health, and American Pain Society, Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001;108:793–797. 9. Askin DF, Wilson D. Health problems of newborns. In Wong’s essentials of pediatric nursing, 7th edn, ed. MJ Hockenbery. St Louis, MO: Elsevier Mosby, 2005, pp. 244– 247. 10. Merkel SI, Shayevitz JR, Voepel-Lewis T, Malviya S. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293–297. 11. Wong DL, Baker CM. Pain in children: Comparison of assessment scales. Pediatr Nurs 1988:14:9–17. 12. Powell CV, Kelley A-M, Williams A. Determining the minimum clinically significant difference n visual analog pain score for children. Ann Emerg Med 2001;37:28–31. 13. Soud TE Rogers JS. Nonpharmacologic intervention for pain relief. In Manual of pediatric nursing, ed. TE Soud, JS Rogers. St Louis, MO: Mosby, 1998. 14. Rusy LM, Weisman SJ. Complementary therapies for acute pediatric pain management. Pediatr Clin North Am 2000;47(3):589–599. 16 Overview and Principles in Emergency Analgesia and Procedural Sedation 15. Roback MG, Bajaj L, Wahen JE, Bothner J. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: Are they related? Ann Emerg Med 2004;44:454–459. 16. Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003;42:636–646. 17. Hoffman GM, Nowakowski R, Troshynski TJ, Berens RJ, Wesiman SJ. Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics 2002;109:236–243. 18. Sacchetti A, Turco T, Carraccio C, Hasher W, Cho D, Gerardi M. Procedural sedation for children with special health are needs. Pediatr Emerg Care 2003;19:231–239. Sedation in the Pediatric Department 17 4 Pain and Analgesia in the Infant Michelle P. Tomassi SCOPE OF THE PROBLEM CLINICAL ASSESSMENT Definition of Pain in Infants Development of Nociception PAIN CONSIDERATIONS Pain and Memory Pain Assessment in the Infant Pain Scales for Infants PAIN MANAG EMENT Nonpharmacologic Interventions Pharmacologic Interventions Topical and Injected Local Anesthetics FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM Pain in infants poses a major challenge for health pro- fessionals. Although infants are uniquely vulnerable to pain and its consequences, pain is less adequately con- trolled in this patient population than in any other. Many reasons account for the undertreatment of pain in infants with the most common problem being a paucity of knowledge regarding pain and analgesia for the infant population. CLINICAL AS SESSMENT Definition of Pain in Infants The International Association for the Study of Pain (IASP) has defined pain as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’’ (from reference 3). It has been suggested that this defi- nition is inappropriate for infants. The interpretation of pain is subjective and infants lack the ability of self-report in the traditional sense. This inability to verbalize pain contributes to the failure of health-care professionals to recognize and treat pain aggressively in infants. It has also been hypothesized that pain perception occurs in a less-organized fashion in the infant than the child or adult. Pain is a combination of sensory (dis- criminative) and emotional (affective) components. The sensory component of pain is defined as nociception. Nociception incorporates the physiologic and be havioral responses of infants to a painful stimulus but not the cognitive responses that are part of pain perception. Consequently, health-care professionals are required to rely on physiologic and behavio ral responses when assessing pain in an infant. Finally, the IASP definition indicates that pain is an association based on previous actual or potential tissue damage. In most neonates and infants, no opportunity has existed for gaining previous experience with pain recogn ition. Development of Nociception Health-care professionals have historically believed that infants are unable to feel pain because of inadequately 18 developed central and peripheral nervous systems. It has been hypothesized that immature myelinated nerves would not allow for transmission of noxious stimuli from the site of the injury to the central nervous system. An abundance of evidence refutes these beliefs and demonstrates that the fetus has the anatomic, neu- rophysiologic, hormonal, and functional requirements for processing pain by mid- to late gestation. By 20 weeks gestational age, the fetal cerebral cortex has a full complement of neurons and sensory receptors spread to all cutaneous and mucosal surfaces. At birth, the density of nociceptive nerve endings in the new- born’s skin is some times greater than in adults. Lack of myelination does not support the argument that infants are incapable of perceiving pain given that adults may have as many as 80% of unmyelinated fibers that are responsible fo r transmitting pain information. It should be noted that incomplete myelination does affect transmission by slowing the conduction speed of pain impulses. However, this decrease in conduction speed is believed to be offset by the shorter distance traveled for impulses to the central nervous system. PAIN CONSIDERATIONS Pain and Memory The issue of whether infants remember pain has been a topic of significant debate. Memory and learni ng depend on cerebral malleability, which is particularly evident during the late prenatal and neonatal periods. Although the structural and functional capacity for memory is thought to be present in neonates, there is no evidence to support that an infant has the ability to remember pain. Nevertheless, a growing number of research studies suggest that early exposure to unrelieved pain and the stress related to an event may exaggerate affective and behavioral responses during subsequent painful events. Taddio et al. have explored the effect of neonatal circumcision on pain response during subsequent rou- tine vaccination at 4 and 6 months of age. Their findings reveal that circumcised infants demonstrate a stronger pain response to subsequent routine vaccination than uncircumcised infants. Among circumcised infants, an attenuated pain response to vaccination has been observed with preoperative eutectic mixture of local anesthetics (EMLAÔ) treatment. A repeated painful experience may cause the newborn to eventually recognize the activities of the event and demonstrate altered conduct. Barba et al. (see reference 7) have analyzed the behavioral and physiologic responses of newborns to repeated heel lancing. In their findings, infants exhibit respons es indicating awareness of a forthcoming painful event after experiencing repe ated painful stimuli with similar procedures. Pain Assessment in the Infant The misconception that infants are incapable of expressing pain has been pervasive. Although infants are unable to verbalize their pain, the combination of physiologic indicators and behavioral cues are consid- ered by many to be a valid and reliable means of assessing pain in this patient population. Physiologic indicators of pain in the infant include  increases in heart rate, respiratory rate, blood pressure, mean airway pressure, muscle tone, and intracranial pressure  decreases in vagal tone, oxygen saturation, and peripheral blood flow  autonomic changes (mydriasis, diaphoresis, flushing, pallor, and palmar hydrosis). Acute behavioral cues of pain in the infant include  crying (robust, intense, extended, high-pitched cries)  facial expression (Figure 4-1)  body posturing (finger clenching, limb thrashing, writhing, backarching, tremulousness). Pain Scales for Infants Several composite measures for assessing pain in infants have been developed. The two neonatal scales that are most comprehensive and have been tested more thor- oughly for reliability are the  Neonatal Infant Pain Scale (NIPS )  CRIES Neonatal Postoperative Pain Measurement Score. The NIPS is composed of six indicators of pain: five behavioral and one physiologic. This scale evaluates pain for an average gest ational age of 33.5 weeks. A score of zero represents no pain whereas a score of seven suggests severe pain (Table 4-1). Pain and Analgesia in the Infant 19 PAIN MANAGEMENT The management of infant pain relies primarily on  awareness of an infant’s capacity to perceive pain  sensitivity toward clinical situations where pain may be encountered  appropriate steps to preven t and treat pain. There is a wide variation in strategies for pain man- agement in the infant population. Like other popula- tions, the general consensus among health-care providers is that pain management is likely most effec- tive when a combination of both nonpharmacologic and pharmacologic interventions is employed. Nonpharmacologic Interventions Nonpharmacologic interventions have the allure of being easy to administer and requiring no intensive monitoring. These techniques are believed to enhance activity in descending neuronal inhibitory pathways with a corresponding decrease in pain experience. Attenuation of spinal cord impulse transmission can be achieved by stimulation of large sensory nerve fibers mediating tactile and temperature sensations. Some recommended nonpharmacologic infant analgesic interventions are listed in Figure 4-2. Kangaroo care or skin-to-skin contact between mother and child was developed as a low-cost method of assisting low birth weight infants with thermoregulation. Patterned after marsupial caregiver behaviors, kangaroo care consists of placing the naked infant against the mother’s bare chest, between her breasts, in an upright position for several hours a day. This technique has been characterized as a potent intervention against the pain experienced during heel stick stimuli in newborns. Oral sucrose solutions, with nonnutritive sucking, briefly produce analgesia in neonates. Sucrose con- centrations between 24% and 50% are most often recommended as several studies have shown lower concentrations to be less effective for analgesia. The initial dose should be given within 3 min of the painful procedure and repeated as needed throughout the duration of the procedure. Oral sucrose is most appro- priately used for brief painful events, not exceeding 2–3 min duration, such as heel stick or venipuncture. For treatment of moderate to severe pain with longer duration, oral sucrose may be used in conjunction with other analgesics techniques. Pharmacologic Interventions For moderate to severe pain, pharmacologic interven- tions should be added to the pain management regimen. Although all medications used most commonly for infant analgesia and sedation are potentially dangerous, they can be administered safely when carefully titrated (Figure 4-3). The most commonly used analgesic for mild infant pain remains acetaminophen, as it is considered safe and effective in all age groups, including newborns. Proper initial dosing of rectal acetaminophen is 25–40 mg/kg, followed by 20 mg/kg q6 hr for subsequent dosing. Codeine is not typically used in neonates, but is utilized in older infants, often in combination with acetaminophen. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ketorolac, can be used as an alternative to acetaminophen in children over 6 months Table 4-2. CRIES Neonatal Postoperative Pain Measurement Scale 01 2 Crying No High pitched High pitched Consolable Inconsolable Requires oxygen (goal O 2 sat >95%) No <30% O 2 required >30% O 2 required Increased vital signs HR and BP HR, BP " <20% HR, BP >20% Normal Preop value Preop value Expression No grimace Grimace Grimace/grunt Sleeplessness No Frequent awakening Continuously awake Note: O 2, oxygen; HR, heart rate; BP, blood pressure Pain and Analgesia in the Infant 21 Sucrose-dipped pacifier *2–3 min before painful procedures Distraction *auditory/visual stimulation (music/mobiles) *rhythmic rocking Touch *cuddle/caress *simple massage *warm blanket Positioning *swaddling *blanket nesting *hugging/holding Environment *blanket tent *minimal noise *undisturbed rest Interventions for pain relief Figure 4-2. Nonpharmacologic intervention considerations for infant analgesia. Infant with pain SevereMild/moderate Acetaminophen 10–15 mg/kg q4 hr (PO) 20 mg/kg q6 hr (PR) Ibuprofen 6–10 mg/kg q6 hr (PO) Ketolorac 0.5–1 mg/kg q6 hr (IV/IM) Fentanyl 1–3 mcg/kg q30 min (IV) Morphine 0.05–0.1 mg/kg q2–4 hr (IV) Figure 4-3. Infant pharmacologic analgesic agent dosing. 22 Overview and Principles in Emergency Analgesia and Procedural Sedation of age. NSAID agents should not be used in children allergic to aspirin due the cross-sensitivity of aspirin and NSAIDs. Ketorolac is a potent analgesic agent with a more attractive side effect profile (less gastrointestinal irritation) when compared to other NSAID agents. The duration of ketorolac therapy should not exceed 5 days in infants. Additionally, limited clinical data exists for the use of ketorolac in patients less than 16 years of age. The efficacy and safety of cyclooxygenase-2 inhibitors, such as celecoxib, have not been evaluated in patients younger than the age of 18. Opiates are the most flexible and widely used narcotic analgesics, with morphine and fentanyl being the most appropriately used for pain due to invasive procedures. Morphine and fentanyl should be administered as fre- quent small aliquots or as a continuous infusion. For prolonged use, continuous infusion is preferred to avoid large variations in plasma concentration. Whenever medications in this category are administered, there must be accompanying vigilance for potential adverse effects on the respiratory and cardiovascular systems. Intravenous boluses of the synthetic opiates, such as fentanyl (80–100 more potent than morphine), may be associated with glottic and chest wall rigidity. The risk of adverse effects is a result of immature hepatic and renal function in the infant and is, therefore, directly related to rate of drug administration, total dose, and combi- nation with other medications capable of central ner- vous system depression. The propensity for adverse effects, such as marked fluctuations in intracranial pressure and subsequent brain dam age, is reduced by avoiding rapid bolus injection. Naloxone should be readily available when opiates are being utilized in infants. Naloxone can be administered in incremental doses of 0.01–0.1 mg/kg, to a maximum dose of 2 mg (Table 4-3). Benzodiazepines are often used as sedative and amnesiacs during painful procedures in infants. Mid- azolam has been approv ed for use in neonates. If mid- azolam is used, a continuous infusion (0.02 mg/kg/hr, no loading required in neonates) or administrati on of individual doses (0.5–0.75 mg/kg PO, 0.3–1 mg/kg IM, 0.05–0.1 mg/kg IV) over at least 10 min is recommended to reduce the risk of adverse effects. Although excellent as a sedative analgesic for proce- dural sedation in children, ketamine is contraindicated in those less than 3 months of age. Topical and Injected Local Anesthetics A eutectic mixture of 2.5% lidocaine and 2.5% prilo- caine, designated EMLA, may provide excellent top ic anesthesia. This combination is a mixture of the two drugs in a 1:1 weight ratio, whereby the two crystalline powders melt at a lower temperature than they do separately. This amalgamation increases the concentra- tion of the local anesthet ics in the emulsion droplets, making them more synergistically effective. EMLA cream should be applied in a thick layer and left undisturbed, ideally for 60–90 min prior to the intended procedure. EMLA penetrates skin surfaces to a depth of 5–10 mm, providing anesthesia for 1–2 hr. The depth of EMLA penetration can be increased by apply- ing occlusive dressings over the ung uent-covered area. The major concern for EMLA use is the risk of met- hemoglobinemia. This side effect is typically not encountered without repeated applications. Despite no data demonstrating additive risk, caution should be taken when other agents capable of causing methemo- globinemia, such as acetaminophen, are coadministered. In addition, EMLA must not be used on abraded skin surfaces; a cotton ball soaked with lidocaine-epinephrine- tetracaine (LET) solution should be used instead. Table 4-3. Morphine and fentanyl infusion rates for neonates and infants Patient population Morphine Fentanyl Neonate (<4 weeks old) 0.1 mg/kg (loading) 1 mcg/kg (loading) 0.01–0.15 mg/kg/hr (infusion) 1 mcg/kg/hr (infusion) Infant (>4 weeks old) 0.1 mg/kg (loading) 1–2 mcg/kg (loading) 0.02–0.04 mg/kg/hr (infusion) 1–2 mcg/kg/hr (infusion) Pain and Analgesia in the Infant 23 Cardiac arrhythmias and seizures, although rare, are complications of local anesthetic injection, particularly when administered with improper dosing. It is prudent to initially use the smallest possible dose for adequate anesthesia and later titrate to effect (Table 4-4). FOLLOW-UP/CONSULTATION CONSIDERATIONS As in older patient populations, the goal of pain manage- ment is to keep the infant within a therapeutic window by providing enough medication to reduce pain without causing unwanted deleterious effects. Although the poten- tial for adverse side effects such as respiratory depression and hypotension exist, especially in premature or neuro- logically impaired infants, knowledge of the pharmacoki- netics and proper dosing will reduce this risk substantially. The practice of treating infant pain with analgesic agents requires close monitoring by professionals expe- rienced in infant pain management. Infants should be monitored regularly for common complications such as constipation, as well as those less common such as allergic reactions or central nervous system depression. SUMMARY The assessment and treatment of pain in infants are important components of medical care for the sick and injured infant. Many pain assessment processes exist for pain evaluation in the infant. These practices should be combined with a meaningful analgesic approach with pharmacologic and nonpharmacologic agents selected according to infant pain severity, clinical scenario, and provider experience. BIBLIOGRAPHY 1. Alanis MC, Lucidi RS. Neonatal circumcision: A review of the world’s oldest and most controversial operation. Obstet Gynecol Surv 2004;59(5):379–395. 2. American Academy of Pediatrics, Committee on Psycho- social Aspects of Child and Family Health, Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001;108(3):793–797. 3. Anonymous. Prevention and management of pain and stress in the neonate. American Academy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthesiology. Section on Surgery. Canadian Paediatric Society. Fetus and Newborn Committee. Pediatrics 2000;105(2):454–461. 4. Aucott S, Donohue PK, Atkins E, Allen MC. Neurodeve- lopmental care in the NICU. Ment Retard Dev Disabil Res Rev 2002;8(4):298–308. 5. Birenbaum D, Matti son DR. Analgesics for the treat- ment of pain in children. NEnglJMed2003;348(10): 959–960. 6. Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 2000;105(1):e14. 7. McCaffery M, Pasero C. Pain: Clinical manual, 2nd edn. St. Louis, MO: Mosby, 1999, pp. 626–696. 8. Peters JW, Koot HM, De Boer JB, et al. Major surgery within the first 3 months of life and subsequent biobehavioral pain responses to immunization at later age. Pediatrics 2003;111(1):129–135. 9. Taddio A, Shah V, Gilbert-MacLeod C, Katz J. Condition- ing and hyperalgesia in newborns exposed to repeated heel lances. JAMA 2002;288(7):857–861. 10. Walco GA, Cassidy RC, Schecter NL. Pain, hurt, and harm: The ethics of pain control in infants and children. N Engl J Med 1994;331(8):541–544. 11. White-Traut R. Providing a nurturing environment for infants in adverse situations: Multisensory strategies for newborn care. J Midwifery Women’s Health 2004; 49(4 Suppl 1):36–41. 12. Wood M. The case for pediatric drug development in clinical pain research. Anesthesiology 2004;100(1):2–4. Table 4-4. Doses of injectable local anesthetics without epinephrine (doses increase slightly with epinephrine) Drug Concentration (%) Standard dose (mg/kg) Toxic dose (mg/kg) Bupivacaine 0.25 1.5–2 >2.5 Lidocaine 1 3.5–4 >4.5 24 Overview and Principles in Emergency Analgesia and Procedural Sedation 5 Provider Bias and Patient Selection for Emergency Department Procedural Sedation and Analgesia Knox H. Todd SCOPE OF THE PROBLEM PATIENT ASSESSMENT PAIN CONSIDERATIONS PAIN MANAGEMENT CONCLUSION BIBLIOGRAPHY SCOPE OF THE PROBLEM In 1999, the U.S. Congress requested that the Institute of Medicine (IOM) investigate and report on disparities in health-care delivery among racial and ethnic minorities. In its landmark report, Unequal treatment: Confronting racial and ethnic dispar ities in health care, the IOM documented widespread dispariti es throughout the health-care delivery system and recommended a number of countermeasures to a ddress these inequities. These findings are summarized in Table 5-1. Spe cifically, the IOM reported that racial and ethnic disparities wer- econsistent across a broad range of clinical conditions, medical specialties, and treatment settings and that health disparities persisted after controlling for multiple potential confounders, including socioeconomic status and access to care. With regard to clinician-level factors, physician bias, stereotyping, and clinical uncertainty were felt to contribute to the observed disparities. Given the subjective nature of pain experience and assessment, particularly in clinical conditions where overt tissue damage is not involved (e.g., migraine, low back pain), it is not surp rising that disparities in pain management are prominent in the emerging health disparities literature. Although findings are not uniform, a number of reports from a variety of settings indicate that African Americans and Hispanics are more like ly to be undertreated for pain than similarly presenting white patients. Emergency medicine, by virtue of its mission to provide universal and timely access to health care, affords a unique perspective on the problems of health disparities. The em ergency department (ED) clinical interaction is characterized by lack of patient-physician continuity, diagnostic uncertainty, and significant demands on time. Given this environment, perhaps it is not surprising that ethnic disparities in analgesic ad- ministration were first documented in an ED setting. PATIENT ASSESSMENT In a 1993 retrospective cohort study, investigators reported that Hispanics with isolated humerus, radius, ulna, fem- oral shaft, tibia, and fibula fractures were twice as likely as non-Hispanic whites to receive no pain medication during their ED stay. Although only 26% of non-Hispanic whites received no analgesics in the ED, 55% of Hispanics went without pain medication. These results were not explained by differences in patient characteristics (e.g., gender, pri- mary language, and insurance status), injury severity, or the likelihood of associated alcohol or drug intoxication. The observed effect of ethnicity even persisted after con- trolling for primary language use, suggesting that differ- ential analgesic administration was not based purely on the patient’s degree of U.S. acculturation or on his or her ability to communicate directly with ED staff. Though this study had several methodological limitations, the results suggested that ethnicity might 25 differentially influence ED pain management patterns in four ways: (a) differences in patient pain perceptions; (b) ethnic differences in communications regarding the presence of pain to the physician (by the patient, patient advocate, or a member of the ED team); (c) differential assessments of pain intensity by the health-care pro- vider; and (d) actual differences in action by the emer- gency physician and ED staff to order and administer analgesics unrelated to the patient’s pain experience. Of the proposed me chanisms, logic suggested that pain assessment was the most likely mediator of differences in the medical decision-making process. Following up on this issue, the investigators con- ducted a second study at the same institution to deter- mine the influence of patient ethnicity on emergency physicians’ ability to assess acute pain. For 138 non- Hispanic whites and 69 Hispanic ED patients with isolated extremity trauma no differences in patient self- assessed pain intensity were found. Although physicians’ estimates of pain were lower than patients’ reports, there was no difference in physicians’ estimates of pain between the two groups. The report suggested that previous observations of differential analgesic adminis- tration could not be attributed to differences in physi- cians’ abilities to accurately assess pain in the two ethnic groups. When these studies were conducted, guidelines to promote routine pain assessment within health-care systems were only beginning to have an impact on practice. The authors suggested that the routine incor- poration of standardized assessments into patient care might prove an effective intervention to minimize the presence of ethnic disparities in treatment. The third in this series of studies raised doubts about the effectiveness of standardizing physician pain assess- ment alone as a method to decrease racial and ethnic disparities in analgesic administration. In this retrospec- tive cohort study of patients with acute, isolated long- bone fractures at a single ED in Atlanta, Georgia, 127 African American and 90 non-Hispanic whites received analgesics in 57% and 74% of cases, respectively. This Table 5-1. Summary of findings of the IOM Unequal treatment report Finding 1-1: Racial and ethnic disparities in health care exist, and because they are associated with worse outcomes in many cases, these are unacceptable Finding 2-1: Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and there is evidence of persistent racial and ethnic discrimination in many sectors of American life Finding 3-1: Many sources – including health systems, health-care providers, patients, and utilization managers – may contribute to racial and ethnic disparities in health care Finding 4-1: Bias, stereotyping, prejudice, and clinical uncertainty on the part of health-care providers may contribute to racial and ethnic disparities in health care. Although indirect evidence from several lines of research supports this statement, a greater understanding of the prevalence and influence of these processes is needed and should be sought through research Finding 4-2: A small number of studies suggests that racial and ethnic minority patients are more likely than white patients to refuse treatment. These studies find that differences in refusal rates are generally small and that minority patient refusal does not fully explain health-care disparities Finding 5-1: As a result of the increasing linguistic diversity in the United States, professional interpretation services are increasingly needed to assist in low-English proficient racial and ethnic minority patients in health-care settings Finding 5-2: Community health workers offer promise as a community-based resource to increase racial and ethnic minorities’ access to health care and to serve as a liaison between health-care providers and the communities they serve Finding 5-3: Culturally appropriate patient education programs offer promise as an effective means of improving patient participation in clinical decision-making and care-seeking skills, knowledge and self-advocacy Finding 6-1: Sociocultural differences between patient and provider influence communication and decision making. Evidence suggests that provider-patient communications are directly linked to patient satisfaction, adherence, and health outcomes. Finding 6-2: A significant body of literature defines and supports the importance of cross-cultural education in the training of health professionals Finding 6-3: Cross-cultural education offers promise as a tool to improve health-care professionals’ ability to provide quality care to diverse patient populations thereby reducing health-care disparities Source: IOM of the National Academies. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press, 2003. 26 Overview and Principles in Emergency Analgesia and Procedural Sedation [...]... understand the causes and solutions to the disparities in pain treatment J Law Med Ethics 20 01 ;29 : 52 68 4 Lasch KE Culture, pain, and culturally sensitive pain care Pain Manag Nurs 20 00; 1(Suppl 1):16 22 5 Todd KH, Samaroo N, Hoffman JR Ethnicity as a risk factor for inadequate emergency department analgesia JAMA 1993 ;26 9:1537–1539 6 Kirkman-Liff B, Mondragon D Language of interview: Relevance for... disciplines, and after-care providers should communicate clearly and reaffirm comprehension BIBLIOGRAPHY 1 Godwin SA, et al Clinical policy: Procedural sedation and analgesia in the emergency department Ann Emerg Med 20 05;45:177–196 2 Malviya S, Naughton NN, Tremper KK Sedation and analgesia for diagnostic and therapeutic procedures St Louis, MO: Humana Press, 20 03 3 Lin DM, Wightman MA Sedation, anesthesia and. .. heath-care access, fewer community health-care resources, and higher overall morbidity and mortality rates Health insurance allows improved access; however, 15% of U.S non-Hispanic whites are uninsured compared with 18% of Asians and Pacific Islanders, 20 % of African Americans, and 32% of Hispanics Minority 28 Overview and Principles in Emergency Analgesia and Procedural Sedation members without insurance... J Pain 20 05;6:689–699 22 Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL ‘‘We don’t carry that’’ – Failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics N Engl J Med 20 00;3 42: 1 023 –1 026 6 Federal and Hospital Regulatory Oversight in Emergency Department Procedural Sedation and Analgesia Sharon Roy SCOPE OF THE PROBLEM Regulatory Assessment Definitions Sedation. .. organizations, practice disciplines, and departments may maximize patient safety, the square-peg-into-a-round-hole method of standardization will not work in the implementation of guidelines for sedation in emergency medicine ED patients present with complex sedation needs, often complicated by concurrent diseases, hemodynamic instability, unpredictable NPO status, and untreated pain 30 Sedation in the ED is a... feedback to health-care BIBLIOGRAPHY 1 Institute of Medicine of the National Academies Unequal treatment: Confronting racial and ethnic disparities in health care Washington, DC: National Academies Press, 20 03 2 Johnson S Introduction: Legal and regulatory issues in pain management J Law Med Ethics 1998 ;26 :26 5 26 6 3 Bonham VL Race, ethnicity, and pain treatment: Striving to understand the causes and solutions... BIBLIOGRAPHY 1 American College of Emergency Physicians (ACEP) Clinical policy: Procedural sedation and analgesia in the emergency department Ann Emerg Med 20 05;45:177–196 2 American College of Emergency Physicians (ACEP) Policy statement: Delivery of agents for procedural sedation and analgesia by emergency nurses Ann Emerg Med 20 05;46:368 3 Emergency Nurses Association (ENA) Emergency Nurses Association... Procedural sedation and analgesia in the emergency department Retrieved from http://www.ena.org/about/position/PDFs/DF08CCBA0E4 643 028 8A9EB30B835E350.pdf, last accessed on August 22 , 20 06 4 EMSC Grant Panel (Writing Committee) on Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department Clinical policy: Evidence-based approach to pharmacologic agents used in pediatric sedation. .. Emergency Department, at www.ena.org, last accessed on January 20 07 37 7 Practice guidelines for sedation and analgesia by nonanesthesiologists An updated report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Nonanesthesiologists Anesthesiology 20 02; 96:1004–1017 7 Nursing Considerations in Emergency Department Procedural Sedation and Analgesia Tania D Strout and Dawn... synthesis COX-1 is present in all cells and plays an important role in homeostatic functions COX -2 is induced by injury or inflammation and generates prostaglandins that fuel the inflammatory process Nonselective NSAIDs inhibit both COX-1 and COX -2 , giving rise to not only multiple beneficial effects (reduction of inflammation, pain, and fever), but also many undesirable effects Analgesia for the Emergency . opioid analgesics. N Engl J Med 20 00;3 42: 1 023 –1 026 . Provider Bias and Patient Select ion 29 6 Federal and Hospital Regulatory Oversight in Emergency Department Procedural Sedation and Analgesia Sharon Roy SCOPE. departments may maxi- mize patient safety, the square-peg-into-a-round-hole method of standardization will not work in the imple- mentation of guidelines for sedation in emergency med- icine. ED patients. job Figure 6 -2 . Expectations for sedation management. 32 Overview and Principles in Emergency Analgesia and Procedural Sedation during the procedure, and postprocedural recovery to baseline. A standardized