No Pain Is All Gain for the Cardiac Cath Lab at Children`s Healthcare of Atlanta

Recent technological developments allow procedures that once required general anesthesia and surgery to be performed in the catheterization laboratory on an outpatient basis. As one of the busiest pediatric catheterization laboratories in the nation, Children’s Healthcare of Atlanta (Children’s) features procedure rooms where a child can receive diagnostic and interventional catheterization, electrophysiologic testing and radiofrequency ablation. According to the American Pain Association, Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. From start to finish, there are various aspects of care that can cause pain and distress, such as anxiety, needles, tape, the catheterization procedure itself, and so on. Effective pain and anxiety management of all these factors is a key ingredient to our catheterization laboratory’s success. Children’s is committed to preventing or minimizing experiences of pain and distress whenever possible. This is accomplished through systematic screening for the presence of pain, pain assessment, interventions to relieve or prevent pain, and reassessment and evaluation. The prevention and management of pain and the relief of suffering are crucial responsibilities of the individual healthcare professional and of the interdisciplinary healthcare team. In the early 1970s, Children’s used an intramuscular injection of meperidine, phenergen and chlorpromazine to sedate the pre-catheterization pediatric patient. In our follow-up phone calls, parents stated that the pre-operative intramuscular injection was much more painful than the catheterization site for their child. In the early 1990s, we began giving all preprocedure medications by mouth. In 2000, our department implemented a team approach to pain and anxiety management. The team consists of pediatric cardiologists, nurses, medical assistants, child life specialists and a professional, hospital-based clown-care unit. Successful pain and anxiety management by the healthcare staff requires attention to the preparatory phase of a procedure, pain management interventions during the procedure itself (the intraprocedural phase), and postprocedural interventions. The Preparatory Phase of the Procedure The goal of care for the preparatory phase is to provide information to families and patients and to minimize anticipatory anxiety. When it is determined that a child needs a cardiac catheterization at Children’s, the family receives a booklet entitled Your Child is having a Heart Cath. This booklet explains what will occur prior to, during and after the procedure. The day before the scheduled procedure, a staff member calls the family to discuss the use of premedication and other approaches to pain. Research has identified parental distress and experience of previous procedures as highly predictive of pain and coping during medical procedures. If the child has undergone a previous catheterization, the report is reviewed for medications given prior to and during that procedure and their effectiveness in alleviating pain and anxiety. Our emphasis to the parents is our desire for their child to have a positive experience with minimal anxiety and optimum pain control. The day of the catheterization procedure, each family member is warmly greeted and given a quick tour of our pre- and post-catheterization facility. Each private room contains a TV/VCR combination unit, as well as a Play Station 2. Once the admission assessment is completed, a child life specialist prepares the patient for what he or she will see, feel and hear. Depending on the child’s age and developmental stage, preparation may also include discussion and practice of coping strategies such as relaxation and distraction techniques. Child life specialists use pictures of the laboratory, doctor kits and patient dolls. The dolls are used to demonstrate what is about to happen and where the dressing will go. In addition, when the children arrive, they are given a menu of about 30 different flavors for their medicine. With names like strawberry cream pie and chocolate silk, the list not only makes the medicine go down smoother, but it also empowers the children to make a decision and have a part in managing their situation. An hour before the scheduled procedure time, the local anesthetic cream, EMLA® (AstraZeneca), is applied to all potential catheterization sites. A premedication of pentobarbital and meperidine, mixed with Flavor-x, is given to all conscious sedation patients. The hour period allows the sedation to reach full potential before arrival in the lab. The child life specialist accompanies the patient into the lab and waits there with the child until he feels comfortable that the child is not experiencing any pain or discomfort. Pain Management Interventions during the Procedure (Intraprocedural Phase) Intraprocedural goals include anticipating painful stimuli and delivering medications to prevent pain. During the procedure, analgesics, anxyolytics and anesthetic drugs are used in combination (these include midazolam HCl, fentanyl, ketamine and morphine). Children are observed continuously throughout the procedure for signs of distress and medications are adjusted accordingly. Immediately following the procedure, dressings are applied that are the least painful to remove. Usually, we apply 2 x 2s and Tegaderm Transparent Dressing (3M) to the catheterization sites instead of the Elastoplast® dressings used in the past. Postprocedural Interventions During the postprocedure phase, staff members aim to entertain and distract the child, promote self esteem and future coping skills by reinforcing a job well done on the child’s part. We also solicit feedback that can improve pain management during future procedures. Once back in the pre- and postcatheterization laboratory, the child stays three to five hours for bed rest and recovery. Mental and emotional status can impact the experience of pain. This can be one of our most challenging times, keeping a toddler or school-aged child entertained. The in-room entertainment centers are utilized, along with a cart of games and movies that the child can check out. The clowns come by for a visit to help the time pass; their routines are a big hit for the entire family. Once at home, each family receives a follow-up phone call the day after the catheterization to evaluate the child’s pain management. Relevant comments are added to the catheterization chart so it can be reviewed before any future catheterization procedures. Many of our patients return for additional catheterizations or procedures, so we encourage patients and their parents to provide ongoing input regarding pain and anxiety management. In the summer of 2003, Children’s surveyed patients and families to determine whether our pain and anxiety management techniques were indeed effective. The results showed that our patients and families are very satisfied with our team approach to pain management. The Pain Management Task Force at Children’s As a healthcare provider, Children’s strives to provide optimal pain management for our patients. The Pain Management Task Force is an advisory group of multidisciplinary departmental representatives who meet monthly to share information and plan improvements in pain management. Meetings include educational and business discussions. Children and their families should be informed that pain prevention and control are a critical part of their healthcare plan, that information about options to control pain is available to them, and that they are welcome to discuss their concerns and preferences with the healthcare team at Children’s.

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