Acute Pain Management Practices Research Articles

Pneumorrhachis complicating acute pain management using a thoracic epidural catheter

The use of thoracic epidural catheters to infuse local anaesthetics and opioids is a common practice in acute pain management to attenuate the pain associated with thoracic and abdominal surgical procedures. The placement and maintenance of epidural analgesia is known to be associated with a variety of potential complications. A rare complication is the development of air of within the spinal canal (pneumorrhachis). Although pneumorrhachis is typically asymptomatic and resolves spontaneously, it rarely can be associated with neurological dysfunction. Here we describea case of pneumorrhachis that led to symptomatic acute spinal cord compression in a 27 year old man who had a thoracic epidural placed to help with pain management following laparotomy for the management of Crohn’sdisease. Postoperatively, the patient developed unilateral weakness in his upper and lower extremities and sensory dysfunction in the upper extremity. Urgent neuroimaging demonstrated epidural air causing mass effect on the cervical spinal cord. His symptoms resolved completely following conservative management. This rare presentation of pneumorrhachis highlights the need for close vigilance regarding neurological function in patients with epidural catheters for acute pain management. This presentation also promotes mitigation of factors that may be associated withthe administration of air into the epidural space, such as changing epidural infusion solution bags and malfunction of epidural infusion pumps.

Exparel for Postoperative Pain Management: a Comprehensive Review.

Multimodal pain management is the most effective way to treat postsurgical pain. However,theuse of opioids for acute pain management has unfortunately been a significant contributor to the current opioid epidemic. The use of opioids should be limited and only considered a "rescue" pain medication after other modalities of pain managementhave been utilized. It may be difficult to curtail the use of opioids in the treatment of chronic pain; however, in the postsurgical setting, there is compelling evidence that anopioid-centric analgesic approach is not necessary for good patient outcomes and healthcare cost benefits. Opioid-related adverse effects are the leading cause of preventable harm in the hospital setting. After the realization in recent years of the many harmful effects of opioids, alternative regimens including the use of multimodal analgesia have become a standard practice in acute pain management. Exparel, a long-lasting liposomal bupivacaine local anesthetic agent, has many significant benefits in the management of postoperative pain. Overall, the literature suggests that Exparel may be a significant component for postoperative multimodal pain control owing to its efficacy and long duration of action.

Prehospital acute traumatic pain assessment and management practices in the Western Cape, South Africa: a retrospective review

BackgroundTrauma is a common aetiology of acute pain in the emergency setting, and traumatic injuries have been recognised as a global public health crisis leading to numerous deaths and disabilities. This study aimed to identify the prevalence of acute pain among high acuity trauma patients presenting to a public sector emergency medical service and to describe prehospital acute traumatic pain assessment and management practices amongst emergency care providers in the Western Cape Province, South Africa.MethodsA retrospective review of electronic patient care reports of trauma patients treated by the South African Western Cape Emergency Medical Services between January 1 and December 31, 2017 was conducted. Stratified random sampling was utilised to select 2401 trauma patients out of 24,575 that met the inclusion criteria.ResultsOf the 2401 patients reviewed, 435 (18.1%) had a pain score recorded, of which 423 (97.2%) were experiencing pain. An additional 8.1% (n = 194) of patients had pain or tenderness mentioned in the working diagnosis but no pain score noted. Eighty-one (18.6%) patients experienced mild pain, 175 (40.2%) moderate pain and 167 (38.2%) severe pain. No association was found between a pain score recorded and age group (≤ 14 versus > 14 years) (p = 0.649) or gender (p = 0.139). Only 7.6% of patients with moderate-to-severe pain and 2.8% of all trauma patients received any form of analgesic medication. No association was found between the administration of analgesia and age group (≤ 14 versus > 14 years) (p = 0.151) or gender (p = 0.054). Patients were more likely to receive analgesia if they had a pain score recorded (p < 0.001), were managed by advanced life support practitioners (p < 0.001) or had severe pain (p = 0.001).ConclusionAcute trauma pain assessment and management practices in this prehospital cohort are less well established than reported elsewhere and whether this reflects emergency care training, institutional culture, scopes of practice or analgesic resources, requires further research. Emergency medical services need to monitor and promote quality pain care, enhance pain education and ensure that all levels of emergency care providers have access to analgesic medication approved for prehospital use. Clear and rational guidelines would enable better pain management by all cadres of providers, for all levels of pain.

Opioid Prescriptions for Acute and Chronic Pain Management Among Medicaid Beneficiaries

Millions of Americans are affected by acute or chronic pain every year. This study investigates opioid prescription patterns for acute and chronic pain management among U.S. Medicaid patients. The study used medical and pharmacy claims data obtained from the multistate Truven MarketScan Medicaid Database from 2013 to 2015 for Medicaid patients receiving health care. Medicaid beneficiaries who utilized an outpatient healthcare facility for back pain, neck pain (cervicalgia), joint pain (osteoarthritis and rheumatoid arthritis), orthopedics (simple/closed fractures and muscle strains/sprains), headache (cluster headaches and migraines), dental conditions, or otorhinolaryngologic (otalgia) diagnoses, based on the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, and received an opioid prescription within 14 days of diagnosis were included in this study. There were 5,051,288 patients with 1 of the 7 diagnostic groupings; 18.8% had an opioid prescription filled within 14 days of diagnosis. Orthopedic pain (34.8%) was the primary reason for an opioid prescription, followed by dental conditions (17.3%), back pain (14.0%), and headache (12.9%). Patients receiving an opioid for conditions associated with acute pain management, such as otorhinolaryngologic (OR=1.93, 95% CI=1.85, 2.0), dental (OR=1.50, 95% CI=1.48, 1.53), or orthopedic conditions (OR=1.31, 95% CI=1.29, 1.32), were more likely to receive the prescription from an emergency department provider versus a general practitioner. However, compared with general practitioners, other providers were more likely to prescribe opioids for conditions associated with chronic pain management. More than half of Medicaid beneficiaries receiving an opioid for pain management do so for orthopedic- and dental-related reasons, with emergency department providers more likely to prescribe opioids. Modifications to the guidelines addressing temporary acute pain management practices with opioids would be likely to benefit emergency department providers the most.

Sustainability of Evidence-Based Acute Pain Management Practices for Hospitalized Older Adults.

Little is known regarding sustainability of evidence-based practices (EBPs) following implementation. This article reports sustainability of evidence-based acute pain management practices in hospitalized older adults following testing of a multifaceted Translating Research Into Practice (TRIP) implementation intervention. A cluster randomized trial with follow-up period was conducted in 12 Midwest U.S. hospitals (six experimental, six comparison). Use of evidence-based acute pain management practices and mean pain intensity were analyzed using generalized estimating equations across two time points (following implementation and 18 months later) to determine sustainability of TRIP intervention effects. Summative Index scores and six of seven practices were sustained. Experimental and comparison group differences for mean pain intensity over 72 hours following admission were sustained. Results revealed most evidence-based acute pain management practices were sustained for 18 months following implementation. Further work is needed to identify factors affecting sustainability of EBPs to guide development and testing of sustainability strategies.

A multicentre survey of the current acute post-operative pain management practices in tertiary care teaching hospitals in Maharashtra

Background and Aims:Undertreated pain can have negative consequences on patients' health as well as the health-care system. The present study was aimed at identifying the current trends in post-operative pain management and availability of acute pain services (APS). In addition, it is also an attempt to assess the availability of analgesia for non-surgical cases, and the attitudes, beliefs, and perceptions of clinicians regarding acute pain management in the tertiary hospitals in the state of Maharashtra (India).Methods:This was a cross-sectional, multicentre questionnaire survey involving the anaesthesiologists and surgeons. Percentages, median, interquartile ranges were calculated and compared by employing a Wilcoxon sign rank test.Results:Data from thirty centres revealed that the surgeons played a major role in treating pain, while most of the anaesthesiologists treated pain primarily in the operation theatre and recovery room. An APS was operational in seven hospitals. The most frequently employed techniques to achieve analgesia were the administration of non-steroidal anti-inflammatory drugs, opioids and epidural analgesia. The majority of the centres had no written protocol and dedicated staff for pain management, pain assessment was not adequately stressed, and only five out of the thirty centres included in the study provided ongoing pain education to health professionals even when the hospitals claimed to provide APS. The major hurdles in providing optimal analgesia and implementing APS were a lack of pain education, equipment and administrative problems.Conclusion:Thus, the tertiary centres in Maharashtra fall short of providing optimal acute post-operative pain management.

Current practice of acute pain management in children-a national follow-up survey in Germany.

This study aimed to summarize the current standard practices for acute pain management in children in Germany and the implementation of these procedures. The last survey on acute pain management in children was performed in 1999, highlighting the need for an up to date review. A questionnaire was mailed to German departments of anesthesiology (n=885), asking for structures and processes of acute pain management in children. Results were compared between hospitals with and without an acute pain service and with and without a pediatric department. Of the 407 responding hospitals (response rate of 46%), 342 treated children younger than 14years. These were considered for analysis. Of the 342 hospitals, 42% contained either a general pediatric department or a department of pediatric surgery, and the majority of the responding hospitals had an acute pain service (83%). Pain intensities were measured at least once per shift in 40% of the institutions, and at least once or twice a day in 27%. Of the institutions, 31% did not document pain scores regularly, without any difference between hospitals with or without a pediatric department. Standard operating procedures for acute pain management existed in 68% of the hospitals, with large differences in content and length. Opioids were administered to children in 85% of the hospitals. Nonopioid analgesics were the first choice baseline analgesics in most hospitals. Peripheral regional and epidural analgesia were performed in children in 18% and 8% of the hospitals, respectively (21%/16% with a paediatric department, 16%/1% without; P<0.001). Current practice of pediatric pain management varied widely and the recommendations of guidelines, like regular pain management, were frequently not met. However, improvements could be observed since 1999, for example, an increase in regular pain measurements (4% vs 67%). Furthermore, pain management in hospitals running a pediatric department had a higher degree of organization, and more sophisticated analgesic techniques.

Time to analgesia and pain score documentation best practice standards for the Emergency Department - A literature review.

Emergency Department pain management is an often overlooked aspect of acute care and is of paramount importance. Patients are often forced to wait extended periods of time without pain assessment or being offered analgesia for their painful condition. This has been associated with poor psychological and physiological consequences both for the health system and the patient. This is suggestive of a lack of clarity around best practice standards for time to analgesia and pain score documentation in the ED. A literature review was undertaken to investigate best practice in relation to acute pain management. Key outcomes were pain score documentation and time to analgesia. After a search of the electronic databases, a total of 992 abstracts were screened and 38 potentially relevant full articles were reviewed. There were 23 articles excluded for a variety of reasons including poor methodology, indirect specialty and inappropriate focus or age of study. A total of 15 studies were appropriate for inclusion in the review. Of the 15 studies, only eight included pain score as an outcome and 13 used time to analgesia as a measure. Four studies specifically investigated nurse initiated analgesia programs in relation to improving acute pain management. A higher incidence of pain assessment, reassessment and pain score documentation was generally correlated with decreased time to analgesia. Whilst there is an abundance of evidence available on the current practice and challenges of quality acute pain management in the ED, there is a lack of well-controlled studies on best practice standards for health care services to benchmark their practice and improve. Mandating pain score reporting, pain assessment and reassessment within specific timeframes and analgesia administration within 30 min of arrival is highly recommended. The implementation of nurse led analgesia protocols should be encouraged to increase incidence of documented pain assessment and reduce time to analgesia.

Field Hospital Analgesia

Acute pain is every health care worker's responsibility, a key area of clinical management and one of Surgeon General's four focus points for improving quality of life after battlefield injury....

Effect of Evidence‐Based Acute Pain Management Practices on Inpatient Costs

To estimate hospital cost changes associated with a behavioral intervention designed to increase the use of evidence-based acute pain management practices in an inpatient setting and to estimate the direct effect that changes in evidence-based acute pain management practices have on inpatient cost. Data from a randomized "translating research into practice" (TRIP) behavioral intervention designed to increase the use of evidence-based acute pain management practices for patients hospitalized with hip fractures. Experimental design and observational "as-treated" and instrumental variable (IV) methods. Abstraction from medical records and Uniform Billing 1992 (UB92) discharge abstracts. The TRIP intervention cost on average $17,714 to implement within a hospital but led to cost savings per inpatient stay of more than $1,500. The intervention increased the cost of nursing services, special operating rooms, and therapy services per inpatient stay, but these costs were more than offset by cost reductions within other cost categories. "As-treated" estimates of the effect of changes in evidence-based acute pain management practices on inpatient cost appear significantly underestimated, whereas IV estimates are statistically significant and are distinct from, but consistent with, estimates associated with the intervention. A hospital treating more that 12 patients with acute hip fractures can expect to lower overall cost by implementing the TRIP intervention. We also demonstrated the advantages of using IV methods over "as-treated" methods to assess the direct effect of practice changes on cost.

Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients

To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults. Experimental design with the hospital as the unit of randomization. Twelve acute care hospitals in the Midwest. (a) Medical records (MRs) of patients > or =65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients. Data were abstracted from MRs and questions distributed to nurses and physicians. The Summative Index for Quality of Acute Pain Care (0-18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001). The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.

An Examination of the Factors Enabling the Successful Implementation of Evidence-Based Acute Pain Practices into Pediatric Nursing

The aim of this article is to examine the factors contributing to the effective implementation of evidence-based acute pain practices in pediatric nursing. The Promoting Action on Research Implementation in Health Services (PARIHS; Kitson, Harvey, & McCormack, 1998; Rycroft-Malone, 2004) framework is applied as a basis for this examination. Exploration of the roles of context and facilitation in integrating pain management evidence into nursing practice is supplemented by Schein's (1992a,b) model of the levels of organizational culture and discussion of leadership. Implications of the PARIHS framework for nursing theory, research, and practice in pediatric acute pain management are discussed.

Fundamentals of Perioperative Management

Fundamentals of Perioperative Management. D. W. Green, M. Ervine, S. White. Greenwich Medical Media: London, UK, 2003, 320 pp; indexed, illustrated ISBN: 1-84110-135-4; Price £32.50 This book fills a useful place in the education of junior hospital doctors or senior medical students. It will be especially valuable for senior house officers in anaesthesia and surgery, because the treatment and management of conditions are closely linked with the scientific principles on which the management is based, thus helping the trainee to understand and to remember the facts covered. Each chapter is laid out in the same clear fashion with aims, objectives and introduction; the index of chapters lists the topics covered within each chapter, which in turn is easily identifiable by the coloured bands at the edge of the page. I particularly liked the clarity of layout and the way diagrams, tables, flowcharts and algorithms are used to explain and clarify the text, thus helping the learning and retention. For example, the physiology of the correlation of blood volume and perioperative fluid-replacement therapy (which in my experience is very badly managed by junior medical staff), blood gas physiology, cardiac and respiratory function, central nervous, renal and hepatic function, as well as pregnancy, are clearly described. In some chapters, however, I felt that in a book aimed at this group of doctors, the detail was a little bit more than may be necessary; these parts can always be initially skimmed through and be used as a reference in the future. Practical procedures are admirably dealt with in the chapters. These include insertion of central venous pressure lines, urinary catheterization, insertion of chest drains, arterial puncture, passing a naso-gastric tube, as well as some local anaesthetic regional blocks. I liked the chapters on the patient's view-point and legal aspects of the perioperative period. Although much of this is now available in some hospitals in introductory booklets, it is an essential part of obtaining consent and explaining an often frightening situation to patients. The principles and problems of blood transfusion are described, and the reasons for this, as well as the difficulties encountered with Jehovah's Witnesses and consent to transfusion. I felt that perhaps the chapter on surgical infections and their management was a little bit involved for this stage of a junior doctor's career, but it will certainly be a valuable reference and an aid to appropriate management. A subject frequently omitted in the education of junior doctors, i.e. the principles of nutrition in perioperative medicine, is clearly explained. Hopefully, this will ensure that the trainee does not allow perioperative patients to starve for days without appropriate oral or parenteral nutrition. The theory and practice of acute pain management, also often badly taught at Medical School, is likewise well covered. Finally, the chapter on statistics, a vital part of every modern doctor's education that is often poorly understood, is covered at the end of the book. However, for a non-mathematician, some of it may be difficult to understand - but that, perhaps, is always the case with statistics! There is a helpful section with tables of useful values and formulae with a few multiple choice questions towards the end of the book which can enable the reader to assess his understanding of any particular subject. Overall, I think the authors are to be commended on an admirable book which is clearly laid out with good diagrams and tables and which has a useful combination of theory and practice. It will become an essential part of the library of every newly qualified doctor.

Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers

This article examines acute pain management practices for patients 65 years of age and older who were hospitalized during 1999 for hip fracture. Data were collected from the medical records of patients ( N = 709) admitted to 12 hospitals in the Midwest and from questionnaires on pain practices completed by nurses ( N = 172) caring for these patients. The major variables examined were (1) pharmacological and nonpharmacological treatments for acute pain in hospitalized elders, (2) nurses’ perceived stage of adoption for avoiding meperidine use and for administering analgesics around-the-clock, and (3) nurses’ perceived barriers to optimal treatment of acute pain in elders. Acetaminophen was the most frequently administered analgesic, but administered doses were far less than the maximum daily recommended dose. More than one third (39%) of the nurses reported that they always avoided the use of meperidine, and over half reporting avoiding its use sometimes. However, the majority of patients (56.8%) received at least one dose of meperidine, even though evidence suggests that other analgesic agents are more appropriate for treatment of acute pain in elders. Only 27% of patients received patient-controlled analgesia, and only 22.3% of patients received around-the-clock administration during the first 24 hours after admission of analgesics that had been ordered on a prn basis. The majority of nurses were aware that around-the-clock administration of analgesics was preferable, but only 33.7% were persuaded (believed) that this method should be used. Intramuscular injection was used for 52.2% of patients, even though this route is not recommended for older adults. The most frequently used nonpharmacological intervention was repositioning, followed by use of pressure relief devices and cold application. Nurses reported difficulty contacting physicians and difficulty communicating with them about type and/or dose of analgesics as the greatest barriers to pain management. Findings from this multi-site study show that active and focused “translation” interventions are needed to promote adoption of evidence-based acute pain management practices by health care providers.

The emerging role of advanced nursing practice in acute pain management throughout Canada.

The purpose of this study was to describe the role qualifications and responsibilities related to advanced nursing practice in acute pain management across Canada. The Canadian Nurses Association national framework on advanced nursing practice was used as a guide to identify role components for nurses within this specialty. A self-administered questionnaire of fixed choice and open-ended questions was mailed to nurses in acute pain management throughout Canada. Respondents identified their primary role responsibilities as clinical, educational, and administrative. Role challenges included lack of administrative/colleague support, complexity of pain problems, role definition, and acceptance. Key areas of positive outcomes involved the patient as well as interdisciplinary and nursing teams. Nurses described the ability to provide continuity of care, patient and staff education, and leadership in pain management as important and rewarding. The role of advanced nursing practice in acute pain management throughout Canada is evolving. The affect of this role promises to enhance the quality of pain management for healthcare professionals and their patients.

Factors influencing hospital implementation of acute pain management practice guidelines

Study Objective: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings. Design: Two questionnaire surveys. Setting: Healthcare Association of New York State, Albany, NY. Measurement: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital’s chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs’ survey data with the clinical directors’ report of guideline usage. Main Results: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements. Conclusions: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

Pain assessment and management in critically ill postoperative and trauma patients: a multisite study

Pain in critically ill patients is undertreated. To examine patients' perceptions of pain and acute pain management practices in a large metropolitan area to provide direction for improvements in pain relief. In a descriptive, correlational study, data were collected from 213 patients in 13 hospitals. Interviews with patients, chart reviews, and interviews with nurse leaders were used to examine institutional and individual approaches to pain management. Twenty-eight percent of patients did not recall an explanation of a pain management plan, and 64% were often in moderate to severe pain while in the intensive care unit. High pain intensity correlated with wait for an analgesic (P < .001), expectations of less pain (P < .001), and longer stay in the intensive care unit (P < .001). Low satisfaction correlated with expectations of less pain (P < .001), often being in moderate to severe pain (P < .001), and long wait for an analgesic (P < .001). In the first 24 hours postoperatively, only 54% of patients had a numerical pain rating documented; 91% had a pain description. The amount of opioid given on postoperative day 1 was influenced by pain intensity (P < .001), the patient's age (P = .03), type of surgery (P = .002), and route of analgesic (P < .001). Only 33% of patients had nonpharmacological pain interventions documented. Despite moderate to severe pain, patients are generally satisfied with their pain relief. Measuring patients' satisfaction alone is not a reliable outcome for determining the effectiveness of pain management. Realistic expectations of patients about their pain may enhance coping, increase satisfaction, and decrease pain intensity after surgery.

Epidural and intrathecal opioids for postoperative pain management in Europe--a 17-nation questionnaire study of selected hospitals. Euro Pain Study Group on Acute Pain.

A questionnaire study conducted with the help of selected contact persons in 17 countries in Europe attempted to create a picture of the practice of acute pain management with the use of spinal opioid analgesia (SOA). A questionnaire was mailed to anaesthesiologists in 105 European hospitals. Depending on the population, 5-10 hospitals from each country were selected by a country co-ordinator. A total of 101 (96.2%) completed questionnaires were returned. During 1 year SOA was used in 55,117 patients (6.6% of all in-patient surgical procedures); of these, 89.2% received epidural opioids and 10.8% intrathecal opioids (ratio 8:1). The most common opioid for SOA was morphine; fentanyl was also used quite frequently; 12 different opioids and 8 non-opioids had been used. ASA 1-2 patients receiving epidural morphine were nursed on surgical wards in 58.4% of the hospitals; in 25.7% of hospitals even ASA 3-4 were nursed on surgical wards. Respiratory depression (requiring naloxone treatment) was noted in 45 of the 49,183 patients who received epidural opioids (0.09%); 33 of these patients had received morphine. In more than 75% of hospitals the monitoring variables were respiratory rate, sedation level and pulse oximetry. There was a great difference between hospitals and countries regarding duration of monitoring. This questionnaire study showed that SOA was used in about 7% of 836,000 in-patients undergoing surgery at the 105 selected hospitals. Epidural opioids were used eight times more often than intrathecal opioids. Morphine was the commonest opioid for SOA. The duration of monitoring differed greatly between hospitals and countries; the need for official guidelines is emphasized.

PEDIATRIC ANESTHESIA OUTSIDE THE OPERATING ROOM: The Anesthesiologist as Pioneer

Anesthesiologists have a history of being pioneers in health care. They have been in the forefront of exploring the properties of new medications and their uses. It has been anesthesiologists who have defined the parameters of use of not only anesthetics, such as the volatile agents, but also drugs, such as the synthetic narcotics, that have use outside the realm of operating room anesthesia. Anesthesiologists have also pioneered the use of drugs in new ways, such as nasal midazolam and transmucosal fentanyl. They have been eager and quick to explore the extended range of use of tools available to them. Anesthesiologists have in the last 30 years identified several opportunities to use their expertise to provide service outside the traditional operating room environment. In each instance, the service had two things in common. First, the knowledge and skills of the anesthesia community provided a new level of expertise. Second, at the time anesthesiologists became involved, there was a dearth of other practitioners serving the needs of patients. Anesthesiologists were among the first involved in critical care units , bringing their expertise in hemodynamic and respiratory management to an area that lacked a unified focus in the approach to acutely ill patients. As anesthesiologists increasingly provided support and care in this dynamic area, the potential for careers in critical care became obvious. In later years, anesthesiologists pioneered the principles and practice of acute and chronic pain management . Again, the potential for careers in this dynamic and overlooked area became noticeable. In both these forays outside the operating room, anesthesiologists brought a new level of patient care and service to the medical community. As these practitioners had success, however, other nonanesthesiologists became interested in these areas. Anesthesiologists began to find surgeons, internists, and pediatricians competing with them to provide service for these populations. Anesthesiologists increasingly found stiff competition to maintain their roles in areas where they had pioneered the principles of care. In many cases, anesthesiologists have been content to abandon their new areas and return to the operating room environment. Now, anesthesiologists have been asked to fill a new niche—advisor and provider of services outside the traditional operating room environment. The interest in our involvement has come for several reasons. There is an increase in diagnostic and invasive procedures performed by nonsurgeons outside the operating room. Radiologists, cardiologists, and gastroenterologists, among others, have expanded their practices by noninvasively performing evaluations and treating conditions that they previously had not done. Also, there is an increase in the number of pediatric patients undergoing procedures that require sedation or anesthesia, such as MR imaging. 15 Often the reason for sedation or general anesthesia being needed is that the child is frightened by factors such as a claustrophobic setting, the need for immobility, and the loud noise or discomfort that accompanies these studies. Another important factor is the increased appreciation by radiologists and others that there are benefits to providing sedation and proper analgesia for procedures that are either frightening or painful. Traditionally, the pediatric patient has been undertreated compared with adults in terms of both analgesia and sedation because of the fear of overdose or adverse reactions when administering medication to children. Practitioners of all types have now appreciated that the proper care of children involves provision of adequate sedation and analgesia as well as age and condition-appropriate monitoring and evaluation. Because of uncertainty about how to provide this care, many practitioners have increasingly looked to anesthesiologists to either provide this care or guide the practitioners' efforts to provide it themselves. Anesthesiologists are asked to assist with care outside the operating room in a variety of ways. In the most straightforward situation, the anesthesiologist is asked to provide general anesthesia in a manner similar to that provided in the operating room setting. In other cases, the anesthesiologist is asked to provide monitored anesthesia care (MAC) services for diagnostic and therapeutic procedures. In adults, this often has been associated with administering sedation in addition to monitoring the patient. In children, the usefulness of sedation is tempered by the need to sedate a child that is terrified versus the ease of providing general anesthesia. The anesthesia department of an institution may also be requested to assist with advice about care and development of institution-wide sedation practices that will be provided by nonanesthesiologists. This involvement has the disadvantage of removing the anesthesia service from providing clinical care under their own control (with a consequent loss of revenue). It does provide an opportunity to influence and improve pediatric care within the institution. This change in the type and level of care provided children can precipitate a major growth in sophisticated and humane management of children.