American Society of Anesthesiologists (ASA): Annual Meeting

CHICAGO – A newly developed assessment tool can identify child and parent coping behaviors, and ultimately could be used to guide real-time behavioral and medical interventions to make the perioperative experience less traumatic for children.

Research on the novel assessment tool called the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) earned a "Best Clinical Abstract" award at the annual meeting of the American Society of Anesthesiologists.

"Behavioral factors during pediatric surgery significantly contribute to postoperative outcomes, including delayed hospital discharge and poor parental satisfaction. While the existing real-time scales identify preoperative anxiety, they are limited because they don’t assess children’s coping efforts or parent behaviors," said Dr. Nancy Hagerman of Cincinnati Children’s Hospital Medical Center.

With PACBIS, if the child is anxious and the parent is exhibiting distress-promoting behavior during induction, an anesthesiologist can distract the child and engage the parents in the process of distraction and nonprocedural talk. If the child has excessive anxiety before anesthesia, child life specialists can explain to the child and parents what to expect during induction, offer sedation, or teach parents how to promote coping behaviors by engaging their child in nonprocedural discussions and distractions during induction of anesthesia.

PACBIS uses a scale of 1-5, with 1 being the lowest, to rate child coping and distress as well as parent and staff promotion of coping and distress (Anesth. Analg. 2009;108:822-6).

The study correlated PACBIS results with postoperative and postdischarge maladaptive behaviors by prospectively assessing 405 children, aged 3-12 years, undergoing tonsillectomies and adenoidectomies and their parents before surgery, during induction of anesthesia, upon emergence, and in the pediatric acute care unit with removal of the parenteral intravenous lines.

The researchers assessed for coping, distress, and anxiety behaviors using the PACBIS, the modified Yale Preoperative Anxiety Scale (mYPAS), and the Induction Compliance Checklist (ICC). They correlated findings on the PACBIS with postoperative pain and behavioral outcomes using the Pediatric Anesthesia Emergence Delirium (PAED) scores, the Post-discharge Parental Pain Measurements (PPPM), and Post-Hospitalization Behavior Questionnaire (PHBQ) on day 1 and day 7 (or later) after surgery (Anesthesiology 2004;100:1138-45).

"The PACBIS strongly predicted postoperative and postdischarge maladaptive behaviors and postoperative pain in children" undergoing tonsillectomy or adenoidectomy, Dr. Hagerman said. The PACBIS had strong concurrent validity with existing scales in assessing perioperative behaviors at all phases, perhaps most importantly during induction of anesthesia.

The PACBIS measures of child and parent coping and distress correlated well with those of the PAED, PPPM, and PHBQ. A 2-unit increase in PACBIS child distress measure during induction correlated with a 6-point increase in the PAED. As the PACBIS child coping measure improved 2 units (mild = 0; extreme = 2), there was a 45% reduction in the odds of the child having severe pain as measured by the PPPM on postoperative days 1-2. A preoperative child distress increase of 2 units was associated with a 4.6-fold increase in the odds of having severe pain as measured by the PPPM on postoperative days 7-8.

Higher PACBIS child distress during induction was associated with increased separation anxiety, sleep disturbances, aggression, and withdrawal (P less than .01). Higher parent distress on the PACBIS during induction was associated with increased separation anxiety and sleep disturbances (P less than .01).

Higher parent coping on the PACBIS during induction was associated with less withdrawal (P less than .01) and fewer eating disturbances (P less than .05).

The parents’ scores are very important, Dr. Hagerman emphasized, in keeping children calm during the surgical experience. "Parents who cope well and provide distracting nonprocedural talk help their child reduce distress and emergence delirium, postoperative pain, and new-onset maladaptive behaviors," she said, adding that members of the surgical team are also influential in achieving optimal perioperative behavioral outcomes.

Dr. Hagerman said she had no relevant conflicts of interest.

CHICAGO – A newly developed assessment tool can identify child and parent coping behaviors, and ultimately could be used to guide real-time behavioral and medical interventions to make the perioperative experience less traumatic for children.

Research on the novel assessment tool called the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) earned a "Best Clinical Abstract" award at the annual meeting of the American Society of Anesthesiologists.

"Behavioral factors during pediatric surgery significantly contribute to postoperative outcomes, including delayed hospital discharge and poor parental satisfaction. While the existing real-time scales identify preoperative anxiety, they are limited because they don’t assess children’s coping efforts or parent behaviors," said Dr. Nancy Hagerman of Cincinnati Children’s Hospital Medical Center.

With PACBIS, if the child is anxious and the parent is exhibiting distress-promoting behavior during induction, an anesthesiologist can distract the child and engage the parents in the process of distraction and nonprocedural talk. If the child has excessive anxiety before anesthesia, child life specialists can explain to the child and parents what to expect during induction, offer sedation, or teach parents how to promote coping behaviors by engaging their child in nonprocedural discussions and distractions during induction of anesthesia.

PACBIS uses a scale of 1-5, with 1 being the lowest, to rate child coping and distress as well as parent and staff promotion of coping and distress (Anesth. Analg. 2009;108:822-6).

The study correlated PACBIS results with postoperative and postdischarge maladaptive behaviors by prospectively assessing 405 children, aged 3-12 years, undergoing tonsillectomies and adenoidectomies and their parents before surgery, during induction of anesthesia, upon emergence, and in the pediatric acute care unit with removal of the parenteral intravenous lines.

The researchers assessed for coping, distress, and anxiety behaviors using the PACBIS, the modified Yale Preoperative Anxiety Scale (mYPAS), and the Induction Compliance Checklist (ICC). They correlated findings on the PACBIS with postoperative pain and behavioral outcomes using the Pediatric Anesthesia Emergence Delirium (PAED) scores, the Post-discharge Parental Pain Measurements (PPPM), and Post-Hospitalization Behavior Questionnaire (PHBQ) on day 1 and day 7 (or later) after surgery (Anesthesiology 2004;100:1138-45).

"The PACBIS strongly predicted postoperative and postdischarge maladaptive behaviors and postoperative pain in children" undergoing tonsillectomy or adenoidectomy, Dr. Hagerman said. The PACBIS had strong concurrent validity with existing scales in assessing perioperative behaviors at all phases, perhaps most importantly during induction of anesthesia.

The PACBIS measures of child and parent coping and distress correlated well with those of the PAED, PPPM, and PHBQ. A 2-unit increase in PACBIS child distress measure during induction correlated with a 6-point increase in the PAED. As the PACBIS child coping measure improved 2 units (mild = 0; extreme = 2), there was a 45% reduction in the odds of the child having severe pain as measured by the PPPM on postoperative days 1-2. A preoperative child distress increase of 2 units was associated with a 4.6-fold increase in the odds of having severe pain as measured by the PPPM on postoperative days 7-8.

Higher PACBIS child distress during induction was associated with increased separation anxiety, sleep disturbances, aggression, and withdrawal (P less than .01). Higher parent distress on the PACBIS during induction was associated with increased separation anxiety and sleep disturbances (P less than .01).

Higher parent coping on the PACBIS during induction was associated with less withdrawal (P less than .01) and fewer eating disturbances (P less than .05).

The parents’ scores are very important, Dr. Hagerman emphasized, in keeping children calm during the surgical experience. "Parents who cope well and provide distracting nonprocedural talk help their child reduce distress and emergence delirium, postoperative pain, and new-onset maladaptive behaviors," she said, adding that members of the surgical team are also influential in achieving optimal perioperative behavioral outcomes.

Dr. Hagerman said she had no relevant conflicts of interest.

CHICAGO – A newly developed assessment tool can identify child and parent coping behaviors, and ultimately could be used to guide real-time behavioral and medical interventions to make the perioperative experience less traumatic for children.

Research on the novel assessment tool called the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) earned a "Best Clinical Abstract" award at the annual meeting of the American Society of Anesthesiologists.

"Behavioral factors during pediatric surgery significantly contribute to postoperative outcomes, including delayed hospital discharge and poor parental satisfaction. While the existing real-time scales identify preoperative anxiety, they are limited because they don’t assess children’s coping efforts or parent behaviors," said Dr. Nancy Hagerman of Cincinnati Children’s Hospital Medical Center.

With PACBIS, if the child is anxious and the parent is exhibiting distress-promoting behavior during induction, an anesthesiologist can distract the child and engage the parents in the process of distraction and nonprocedural talk. If the child has excessive anxiety before anesthesia, child life specialists can explain to the child and parents what to expect during induction, offer sedation, or teach parents how to promote coping behaviors by engaging their child in nonprocedural discussions and distractions during induction of anesthesia.

PACBIS uses a scale of 1-5, with 1 being the lowest, to rate child coping and distress as well as parent and staff promotion of coping and distress (Anesth. Analg. 2009;108:822-6).

The study correlated PACBIS results with postoperative and postdischarge maladaptive behaviors by prospectively assessing 405 children, aged 3-12 years, undergoing tonsillectomies and adenoidectomies and their parents before surgery, during induction of anesthesia, upon emergence, and in the pediatric acute care unit with removal of the parenteral intravenous lines.

The researchers assessed for coping, distress, and anxiety behaviors using the PACBIS, the modified Yale Preoperative Anxiety Scale (mYPAS), and the Induction Compliance Checklist (ICC). They correlated findings on the PACBIS with postoperative pain and behavioral outcomes using the Pediatric Anesthesia Emergence Delirium (PAED) scores, the Post-discharge Parental Pain Measurements (PPPM), and Post-Hospitalization Behavior Questionnaire (PHBQ) on day 1 and day 7 (or later) after surgery (Anesthesiology 2004;100:1138-45).

"The PACBIS strongly predicted postoperative and postdischarge maladaptive behaviors and postoperative pain in children" undergoing tonsillectomy or adenoidectomy, Dr. Hagerman said. The PACBIS had strong concurrent validity with existing scales in assessing perioperative behaviors at all phases, perhaps most importantly during induction of anesthesia.

The PACBIS measures of child and parent coping and distress correlated well with those of the PAED, PPPM, and PHBQ. A 2-unit increase in PACBIS child distress measure during induction correlated with a 6-point increase in the PAED. As the PACBIS child coping measure improved 2 units (mild = 0; extreme = 2), there was a 45% reduction in the odds of the child having severe pain as measured by the PPPM on postoperative days 1-2. A preoperative child distress increase of 2 units was associated with a 4.6-fold increase in the odds of having severe pain as measured by the PPPM on postoperative days 7-8.

Higher PACBIS child distress during induction was associated with increased separation anxiety, sleep disturbances, aggression, and withdrawal (P less than .01). Higher parent distress on the PACBIS during induction was associated with increased separation anxiety and sleep disturbances (P less than .01).

Higher parent coping on the PACBIS during induction was associated with less withdrawal (P less than .01) and fewer eating disturbances (P less than .05).

The parents’ scores are very important, Dr. Hagerman emphasized, in keeping children calm during the surgical experience. "Parents who cope well and provide distracting nonprocedural talk help their child reduce distress and emergence delirium, postoperative pain, and new-onset maladaptive behaviors," she said, adding that members of the surgical team are also influential in achieving optimal perioperative behavioral outcomes.

Dr. Hagerman said she had no relevant conflicts of interest.

CHICAGO – More than 40% of patients who presented to a tertiary pain center with axial spine pain met the criteria for fibromyalgia. These patients may represent a subset of the spine pain population who will be unresponsive to standard interventions.

The presence of fibromyalgia may undermine the effectiveness of opioids, according to the investigators.

"Our group is very interested in the concept of centralized pain and in trying to better differentiate patients based on phenotype at the point of care. Many patients seek care for axial spine pain, and the outcomes are mixed," Dr. Chad M. Brummett noted at the annual meeting of the American Society of Anesthesiologists.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed."

"We are interested in applying what has been learned about fibromyalgia to the spine community. The field has been writing about personalized care for 20 years, but we still tend to give all patients the same drugs. Our aim is to provide physicians with information that will guide therapy," said Dr. Brummett, director of adult pain research at the University of Michigan Back and Pain Center in Ann Arbor.

He noted that failure rates for facet interventions for the treatment of axial spine pain have ranged from 39% to 47%, and persistent pain is common. There is a growing appreciation in the pain community of a subset of patients with altered central pain processing leading to widespread body pain, such as fibromyalgia, who may require a different treatment approach, he said.

The observational cohort study included 256 new patients categorized as having axial spine pain; of the 244 who completed the American College of Rheumatology fibromyalgia survey, 101 patients (41.4%) met the ACR fibromyalgia criteria.

"We saw profound phenotypic differences between the two groups," Dr. Brummett noted, although he acknowledged that as a tertiary care facility his group is "bound to see a more failed population."

"Some would argue whether this means they have fibromyalgia or not, and that is not clear, but certainly this is a different group," he emphasized.

Dr. Brummett and colleagues observed significant differences in pain, function, mood, and anxiety in the fibromyalgia-positive pain population, compared with patients who did not meet the ACR criteria for fibromyalgia. For example, among the 101 patients with fibromyalgia, the mean pain intensity score on the Brief Pain Inventory was 7.05, while it was 6.10 in those without fibromyalgia. Scores for both depression and anxiety were higher for those with fibromyalgia than those without (mean depression and anxiety scores on the Hospital Anxiety and Depression Scale were 11.33 and 11.38, respectively, for those with fibromyalgia and 7.47 and 6.81, respectively, for those without). Likewise, the mean Patient Reported Outcomes Measurement Information System score for physical function was 27.96 for those with fibromyalgia and 32.24 for those without.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed," reported Dr. Brummett, who along with his colleagues was awarded for having the "Best Clinical Abstract" at the meeting.

The investigators also asked the patients questions about the efficacy of previous interventions. Current use of opioid medications was reported by 60.4% of fibromyalgia-positive patients and 43.4% of fibromyalgia-negative patients (P = .012). Although not significant, fibromyalgia-positive patients taking opioids reported lower efficacy. Epidural interventions were common in both groups, at 37.6% and 43.8%, respectively, but fibromyalgia-positive patients rated the epidurals as being less effective (P = .036).

"We are not saying that patients meeting fibromyalgia criteria, if they have clear-cut radiculopathy, should not have steroid injections. But there may be a difference in response to these interventions," he explained.

"I don’t think our ability to predict response to treatment is very good, even with diagnostic algorithms laid out to us," he added. "Our data should help us better define the most appropriate treatments for these patients."

There were significantly more women in the fibromyalgia-positive group than there were in the fibromyalgia-negative group (64% vs. 50%). This was the only demographic characteristic that was significantly different between the two groups.

Fibromyalgia patients are known to have alterations of central pain processing and may respond differently to interventions and medications. "If patients understand that they may have only a 50/50 chance of responding to a standard intervention for spine pain, they may rethink it," he suggested.

He maintained that future studies of pain medications and interventions should include a measure of central sensitization, such as the fibromyalgia survey. "It is our belief that these are different patients, but we don’t yet have enough objective data to guide treatment. We have to understand our patient population better," Dr. Brummett concluded.

Dr. John Dombrowski, director of the Washington (D.C.) Pain Center and head of the American Society of Anesthesiologists communications committee, commented that the percentage of concurrent fibromyalgia in the study seems high, "but since this is a tertiary setting they are probably seeing the worst of the worse patients."

"While this may be a selected population, the results are still interesting," he said. "Obviously, this subset of patients has issues. They have a predilection for more central pain, and many will need multimodal therapy. Pain patients are challenging, and fibromyalgia makes them even more challenging. This study underlines the fact that we cannot rely on interventional treatments alone."

Dr. Brummett said that he had no relevant disclosures.

CHICAGO – More than 40% of patients who presented to a tertiary pain center with axial spine pain met the criteria for fibromyalgia. These patients may represent a subset of the spine pain population who will be unresponsive to standard interventions.

The presence of fibromyalgia may undermine the effectiveness of opioids, according to the investigators.

"Our group is very interested in the concept of centralized pain and in trying to better differentiate patients based on phenotype at the point of care. Many patients seek care for axial spine pain, and the outcomes are mixed," Dr. Chad M. Brummett noted at the annual meeting of the American Society of Anesthesiologists.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed."

"We are interested in applying what has been learned about fibromyalgia to the spine community. The field has been writing about personalized care for 20 years, but we still tend to give all patients the same drugs. Our aim is to provide physicians with information that will guide therapy," said Dr. Brummett, director of adult pain research at the University of Michigan Back and Pain Center in Ann Arbor.

He noted that failure rates for facet interventions for the treatment of axial spine pain have ranged from 39% to 47%, and persistent pain is common. There is a growing appreciation in the pain community of a subset of patients with altered central pain processing leading to widespread body pain, such as fibromyalgia, who may require a different treatment approach, he said.

The observational cohort study included 256 new patients categorized as having axial spine pain; of the 244 who completed the American College of Rheumatology fibromyalgia survey, 101 patients (41.4%) met the ACR fibromyalgia criteria.

"We saw profound phenotypic differences between the two groups," Dr. Brummett noted, although he acknowledged that as a tertiary care facility his group is "bound to see a more failed population."

"Some would argue whether this means they have fibromyalgia or not, and that is not clear, but certainly this is a different group," he emphasized.

Dr. Brummett and colleagues observed significant differences in pain, function, mood, and anxiety in the fibromyalgia-positive pain population, compared with patients who did not meet the ACR criteria for fibromyalgia. For example, among the 101 patients with fibromyalgia, the mean pain intensity score on the Brief Pain Inventory was 7.05, while it was 6.10 in those without fibromyalgia. Scores for both depression and anxiety were higher for those with fibromyalgia than those without (mean depression and anxiety scores on the Hospital Anxiety and Depression Scale were 11.33 and 11.38, respectively, for those with fibromyalgia and 7.47 and 6.81, respectively, for those without). Likewise, the mean Patient Reported Outcomes Measurement Information System score for physical function was 27.96 for those with fibromyalgia and 32.24 for those without.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed," reported Dr. Brummett, who along with his colleagues was awarded for having the "Best Clinical Abstract" at the meeting.

The investigators also asked the patients questions about the efficacy of previous interventions. Current use of opioid medications was reported by 60.4% of fibromyalgia-positive patients and 43.4% of fibromyalgia-negative patients (P = .012). Although not significant, fibromyalgia-positive patients taking opioids reported lower efficacy. Epidural interventions were common in both groups, at 37.6% and 43.8%, respectively, but fibromyalgia-positive patients rated the epidurals as being less effective (P = .036).

"We are not saying that patients meeting fibromyalgia criteria, if they have clear-cut radiculopathy, should not have steroid injections. But there may be a difference in response to these interventions," he explained.

"I don’t think our ability to predict response to treatment is very good, even with diagnostic algorithms laid out to us," he added. "Our data should help us better define the most appropriate treatments for these patients."

There were significantly more women in the fibromyalgia-positive group than there were in the fibromyalgia-negative group (64% vs. 50%). This was the only demographic characteristic that was significantly different between the two groups.

Fibromyalgia patients are known to have alterations of central pain processing and may respond differently to interventions and medications. "If patients understand that they may have only a 50/50 chance of responding to a standard intervention for spine pain, they may rethink it," he suggested.

He maintained that future studies of pain medications and interventions should include a measure of central sensitization, such as the fibromyalgia survey. "It is our belief that these are different patients, but we don’t yet have enough objective data to guide treatment. We have to understand our patient population better," Dr. Brummett concluded.

Dr. John Dombrowski, director of the Washington (D.C.) Pain Center and head of the American Society of Anesthesiologists communications committee, commented that the percentage of concurrent fibromyalgia in the study seems high, "but since this is a tertiary setting they are probably seeing the worst of the worse patients."

"While this may be a selected population, the results are still interesting," he said. "Obviously, this subset of patients has issues. They have a predilection for more central pain, and many will need multimodal therapy. Pain patients are challenging, and fibromyalgia makes them even more challenging. This study underlines the fact that we cannot rely on interventional treatments alone."

Dr. Brummett said that he had no relevant disclosures.

CHICAGO – More than 40% of patients who presented to a tertiary pain center with axial spine pain met the criteria for fibromyalgia. These patients may represent a subset of the spine pain population who will be unresponsive to standard interventions.

The presence of fibromyalgia may undermine the effectiveness of opioids, according to the investigators.

"Our group is very interested in the concept of centralized pain and in trying to better differentiate patients based on phenotype at the point of care. Many patients seek care for axial spine pain, and the outcomes are mixed," Dr. Chad M. Brummett noted at the annual meeting of the American Society of Anesthesiologists.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed."

"We are interested in applying what has been learned about fibromyalgia to the spine community. The field has been writing about personalized care for 20 years, but we still tend to give all patients the same drugs. Our aim is to provide physicians with information that will guide therapy," said Dr. Brummett, director of adult pain research at the University of Michigan Back and Pain Center in Ann Arbor.

He noted that failure rates for facet interventions for the treatment of axial spine pain have ranged from 39% to 47%, and persistent pain is common. There is a growing appreciation in the pain community of a subset of patients with altered central pain processing leading to widespread body pain, such as fibromyalgia, who may require a different treatment approach, he said.

The observational cohort study included 256 new patients categorized as having axial spine pain; of the 244 who completed the American College of Rheumatology fibromyalgia survey, 101 patients (41.4%) met the ACR fibromyalgia criteria.

"We saw profound phenotypic differences between the two groups," Dr. Brummett noted, although he acknowledged that as a tertiary care facility his group is "bound to see a more failed population."

"Some would argue whether this means they have fibromyalgia or not, and that is not clear, but certainly this is a different group," he emphasized.

Dr. Brummett and colleagues observed significant differences in pain, function, mood, and anxiety in the fibromyalgia-positive pain population, compared with patients who did not meet the ACR criteria for fibromyalgia. For example, among the 101 patients with fibromyalgia, the mean pain intensity score on the Brief Pain Inventory was 7.05, while it was 6.10 in those without fibromyalgia. Scores for both depression and anxiety were higher for those with fibromyalgia than those without (mean depression and anxiety scores on the Hospital Anxiety and Depression Scale were 11.33 and 11.38, respectively, for those with fibromyalgia and 7.47 and 6.81, respectively, for those without). Likewise, the mean Patient Reported Outcomes Measurement Information System score for physical function was 27.96 for those with fibromyalgia and 32.24 for those without.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed," reported Dr. Brummett, who along with his colleagues was awarded for having the "Best Clinical Abstract" at the meeting.

The investigators also asked the patients questions about the efficacy of previous interventions. Current use of opioid medications was reported by 60.4% of fibromyalgia-positive patients and 43.4% of fibromyalgia-negative patients (P = .012). Although not significant, fibromyalgia-positive patients taking opioids reported lower efficacy. Epidural interventions were common in both groups, at 37.6% and 43.8%, respectively, but fibromyalgia-positive patients rated the epidurals as being less effective (P = .036).

"We are not saying that patients meeting fibromyalgia criteria, if they have clear-cut radiculopathy, should not have steroid injections. But there may be a difference in response to these interventions," he explained.

"I don’t think our ability to predict response to treatment is very good, even with diagnostic algorithms laid out to us," he added. "Our data should help us better define the most appropriate treatments for these patients."

There were significantly more women in the fibromyalgia-positive group than there were in the fibromyalgia-negative group (64% vs. 50%). This was the only demographic characteristic that was significantly different between the two groups.

Fibromyalgia patients are known to have alterations of central pain processing and may respond differently to interventions and medications. "If patients understand that they may have only a 50/50 chance of responding to a standard intervention for spine pain, they may rethink it," he suggested.

He maintained that future studies of pain medications and interventions should include a measure of central sensitization, such as the fibromyalgia survey. "It is our belief that these are different patients, but we don’t yet have enough objective data to guide treatment. We have to understand our patient population better," Dr. Brummett concluded.

Dr. John Dombrowski, director of the Washington (D.C.) Pain Center and head of the American Society of Anesthesiologists communications committee, commented that the percentage of concurrent fibromyalgia in the study seems high, "but since this is a tertiary setting they are probably seeing the worst of the worse patients."

"While this may be a selected population, the results are still interesting," he said. "Obviously, this subset of patients has issues. They have a predilection for more central pain, and many will need multimodal therapy. Pain patients are challenging, and fibromyalgia makes them even more challenging. This study underlines the fact that we cannot rely on interventional treatments alone."

Dr. Brummett said that he had no relevant disclosures.