Error traps in acute pediatric pain management: Part 1
Myron Yaster MD and Lynne Maxwell MD
Today’s Pediatric Anesthesia Article of the Day is another in a series of articles published in the Journal Pediatric Anesthesia on “error traps” in anesthesia. What is an error trap? “Cognitive errors, a subset of medical errors involving faulty-thought processes and subconscious biases, are important contributors to missed diagnoses and patient injury. Indeed, most medical errors are mistakes in thinking and not procedural or technical mistakes.”1
What are some common cognitive errors? Stiegler et al.1 identify 14 including: anchoring, focusing on one issue at the expense of understanding the whole situation, availability bias, choosing a diagnosis because it is in the forefront of your mind due to an emotionally charged memory of a bad experience, confirmation bias, seeking or acknowledging only information that confirms the desired or suspected diagnosis; premature closure, accepting a diagnosis prematurely, failure to consider reasonable differential of possibilities; overconfidence bias, inappropriate boldness, not recognizing the need for help, tendency to believe we are infallible; framing effect, subsequent thinking is swayed by leading aspects of initial presentation; commission bias, tendency toward action rather than inaction; performing un-indicated maneuvers, deviating from protocol -may be due to overconfidence, desperation, or pressure from others; to name just a few. This paper by Stiegler et al is so foundationally important to this topic, that we will review it as separate PAAD in the next couple of weeks even though it was published almost a decade ago.
Today’s PAAD focuses on 5 areas in which error traps occur in acute pediatric pain management (figure) and is written by our close friends and colleagues, Tricia Vecchione, Rita Agarwal, and Connie Monitto. I highly recommend it as a primer on acute pain management and think it can be very useful in the “handouts” (do they still exist?) given to students on a pediatric pain rotation. Finally, very much by design, the PAADs are meant to be read while you drink a cup of coffee or tea in the morning, or about 5-6 minutes to read. I simply couldn’t do justice to today’s article, so I decided to break our review into 2 parts. Myron Yaster MD
Original article
Tricia M Vecchione, Rita Agarwal, Constance L Monitto. Error traps in acute pain management in children. Paediatr Anaesth. 2022 Sep;32(9):982-992. PMID: 35751474
Pain is a universal human experience and occurs regardless of age. “Effective pain management requires a coordinated, multistep approach to patient care. Circumstances that can result in common mistakes and undesirable consequences (error traps) can occur as a result of knowledge gaps and cognitive (thought process) errors.”2 They discuss 5 areas (figure) in which error traps in acute pediatric pain management commonly occur.
Pain Assessment
“When you can measure what you are speaking about, and express it in numbers, you know something about it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts advanced to the stage of science.” Lord Kelvin
When the “big bang” of pediatric pain management occurred in 1989 at the first world congress of pediatric pain in Seattle WA (thank you Elliot Krane and Don Tyler!) pain assessment was the area in which most studies were conducted. A slew of different age and development appropriate pain scales were developed and validated. Many practitioners and researchers often wonder which one to use? Vecchione et al.2 provide a terrific and well referenced resource for those of you who need it. A common error trap in pain assessment is treating the pain score number rather than the patient (“framing effect”). “Aiming for a low pain score but ending up with a patient too nauseated to eat or too high a number leaving a patient too sedated to participate in needed physical therapy is not a desired outcome”.2
Failure to utilize regional anesthesia
The use of regional anesthesia has revolutionized pediatric pain management. However, complete analgesia is not always possible and blocks fail. Overconfidence bias by the anesthesia team is common…even the most competent anesthesiologist cannot claim a 100% success rate. “Experience suggests that if we block 60% of the nerves innervating a region, patients do not experience 60% less pain. Rather, 100% of their pain is instead focused on the remaining 40% of the region, joint, or organ”.2
As discussed in a previous PAAD (“A dose of pediatric regional” June 30, 2021), choosing the appropriate drug, concentration, and volume delivered when performing a block is a key to success. Vecchione et al.2 provide an excellent table.
References
1. Stiegler MP, Neelankavil JP, Canales C, Dhillon A: Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth 2012; 108: 229-35
2. Vecchione TM, Agarwal R, Monitto CL: Error traps in acute pain management in children. Paediatr Anaesth 2022; 32: 982-992