This paper encompasses nursing knowledge that was used in a PICOT question which was researched through health data bases. The PICOT question explores whether using pre-operative versed (midazolam) in pediatric patients provides better post-operative pain control than not using versed (midazolam). The methodology, levels of evidence and a review of the research literature is produced in detail. Using the results of the research, the significance to nursing and future research are demonstrated and suggestions for changing current practices are noted.
Nursing care is directed by Evidence Based Practice (EBP) which in turn is founded on evidence based research. When new data is produced from research it must clearly be communicated within the healthcare setting. Nursing and related personnel must collaborate efficiently in supporting the EBP and incorporating it in their everyday practice. “The purpose of this assignment is to reflect how nursing knowledge is disseminated for use in personal and professional practice” (Ursuy, 2014). This paper explores whether using preoperative versed (midazolam) in pediatric patients provides better post-operative pain control than not using versed (midazolam).
Working in the Surgery, Prep and Recovery Unit of a local hospital, I encounter pediatric patients that are having surgical procedures. Children under the age of 10 years old have their IV started in the operating room under general anesthesia, while children over the age of 10 years old have their IV started in the preoperative area. Both categories of children could be given oral midazolam preoperatively, however, due to limited IV access, IV midazolam is not given, only oral midazolam. The anesthesiologist is the one who evaluates the children and orders the midazolam, however there is no set policy or protocol for that. I began to notice inconsistencies of the children being medicated with midazolam prior to surgery and it appeared the children who were medicated with midazolam preoperatively had better post-operative pain control.
When questions arise for discussion or research, the acronym PICOT is a common way to format the question. P stands for the population/patient, I stands for the area of interest/intervention, C stands for the comparison/current practice, O stands for the desired outcome and T denotes the time frame (Niewswiadomy, 2012, p. 282). The PICOT question being explored in this paper is “Does medicating with oral versed (midazolam) preoperatively reduce post-operative pain compared to patients who do not receive preoperative versed (midazolam) in pediatric patients?” P is represents pediatric patients, I is represented by the administration of oral versed, C is comparing not medicating preoperatively, O signifies post-operative pain management and T is during the post-operative period. It is believed the quality and safety of the pediatric population undergoing surgical procedures would be improved if there were consistent preoperative medication policies and procedures in place. Post-operative pain could be improved, thus patient and parent satisfaction could also potentially increase.
When researching the PICOT question at hand, I utilized three databases relevant to the nursing/medical field, which were Cinahl, Cochrane Reviews and Pub-Med. In each database, I would use the advance search when possible and included key words or phrases. At first, using the word versed did not reveal many articles, but upon advancing the search to include midazolam and adding parenthesis around the key words provided more options. So, the search included (versed or oral midazolam), (pediatric or children) and (post-operative pain or preoperative pain).
The selection process was further narrowed down after reading the abstracts of numerous articles. The abstracts provided me with valuable information that easily allowed me to either include or exclude the article. I tried to include articles that were current, 12 years ago to present.
Levels of evidence is a way to categorize articles based on types of trials, studies, and expert opinions by using a numerical hierarchy. Each article reviewed was assigned a level of evidence using the following level of evidence chart, one being the highest level and seven being the lowest level.
Levels of Evidence
Level 1- Systematic review and meta-analysis of randomized controlled trials
Level 2- One or more randomized controlled trials
Level 3- Controlled trial (no randomization)
Level 4- Case-control or cohort study
Level 5- Systematic review of descriptive and qualitative studies
Level 6- Single descriptive or qualitative study
Level 7- Expert opinion
(Melnyk & Fineout-Overholt, 2011)
Choosing the levels of evidence to assign to the chosen articles was not an easy process and the articles chosen for the PICOT question were not done so based only on the level of evidence given to them. Nursing articles were favored along with the content relevant to the PICOT question in conjunction with the level of evidence assigned.
Resource utilization is something all nurses in healthcare should participate in according their scope of practice (White & O’Sullivan, 2012, p. 194). Nurses often shy away from research and quality related utilization because change is often difficult and why change something that is working just fine? At the registered nurse level, an RN should evaluate evidence in deciding the level of care and interventions for the patient outcomes (White & O’Sullivan, 2012, p. 194).
Discussion of Literature Article One
The first article reviewed is called “Premedicating children for painful invasive procedures” by Elizabeth R. Klein, which is nursing research. Klein used a descriptive survey/questionnaire for her research questions and there were 108 participants. The participants were broken down to include 55 physicians and 53 nurses. The physicians were pediatric professors and staff oncologists while the nurses involved were clinical nurses or clinical nurse specialists (Klein, 1992, p. 172). Questions included on the questionnaire reflected current premedicating practices in their pediatric clients and then they were asked about the patients post procedure pain using the Likert Scale of 1 to 5 (1 being no pain and 5 being excruciating pain) (Klein, 1992).
Several drug combinations were used along with oral and intravenous midazolam in practices of premedicating pediatric patients prior to painful procedures, such as lumbar punctures. Although the article is only an evidence level of six (Melnyk & Fineout-Overholt, 2011), the results are significant and can be useful to pediatric nurses. The results revealed that there was a significant reduction of pain if a pediatric patient was medicated prior to a painful procedure with agents such as midazolam. Further implications for nursing are standardizing premeditation care and practices for pediatrics undergoing painful procedures (Klein, 1992, p. 177).
The second article, “Pre-anesthetic medication with intranasal dexmedetomidine and oral midazolam as an anxiolytic. A clinical trial” (Linares et al., 2014) is a comparison trial between two medications for preoperative anxiety. This trial was a prospective, randomized, double-blind, controlled trial that was conducted on children 2-12 years of age (Linares et al., 2014). There were 108 pediatric patients in the trial and their anxiety was assessed using a modified Yale scale. Anxiety is closely related to pain and pain perception with children.
Evidence level is a four (Melnyk & Fineout-Overholt, 2011) and the trial was done in 2013, so I chose to include the article based that the information was relevant to the PICOT question. Although the findings were suggestive of the dexmedetomidine being superior to the midazolam in reducing anxiety, which could also reduce the pain perception for the children, the findings were significant and supportive to the issue that pediatric patients could have better post procedure pain if they were medicated preoperatively. Further research and studies need to be conducted and standardized practices should be made available.
The last article to be discussed is by Fazi et al., “A comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient.” This trial was randomized and controlled and was a comparative study (Fazi, Jantzen, Rose, Kurth, & Watcha, 2001). It is located in The Cochrane Central Register of Controlled Trials. The study participants were the ages of 4-12 years old and all were medicated prior to anesthesia with either the midazolam or clonidine.
Evidence level was rated as a two (Melnyk & Fineout-Overholt, 2011), but the results were significant to the PICOT question and nursing in comparing the preanesthetic sedation and post-operative recovery. The children in the midazolam group required less postoperative analgesia and thus midazolam was considered superior to clonidine as an oral preanesthetic medication (Fazi et al., 2001). Although this trial was limited to patients receiving tonsillectomies, it is indicative of the need for future research on standardizing care practices on medicating children preoperatively to help manage post-operative pain.
Significance to Nursing
When research is conducted, evidence can be supported by Evidence Based Practice (EBP) and thus nursing practice could potentially be changed to increase the safety and efficacy of care. “Interprofessional collaboration will make the research stronger and will increase the likelihood that a satisfactory practice change can eventually be implemented” (White & O’Sullivan, 2012, p. 137). In today’s nursing practice, nurses have the “capabilities to address a wide variety of health issues” (Black, 2014, p. 114), however, nurses must act within their Scope of Practice as defined by the American Nurses Association and outline by The Code of Ethics for Nurses and the Standards of Nursing Practice (White & O’Sullivan, 2012). That is why it is important that nurses participate in nursing research.
Quality and Safety Education for Nurses (QSEN) emphasizes providing quality nursing education to nursing students and that quality is the responsibility of all individuals in healthcare (White & O’Sullivan, 2012). QSEN targets the knowledge, skills and attitude for nurses and incorporates six core competencies. These six competencies are Patient-Centered Care, Teamwork and Collaboration, Evidence Based Practice, Quality Improvement, Safety and Informatics (Quality and Safety Education for Nurses, 2013). With the inquiry of this PICOT question, patient-centered care, evidence based practice, quality improvement and safety were all explored and utilized. I have gained knowledge and insight to information that is not only significant to my own nursing practice, but that could potentially impact others.
The PICOT question explored had supportive and non-supportive data revealed. Material was overwhelming supportive of pediatric patients being medicated prior to painful procedures or surgery. Reducing anxiety and pain preoperatively and postoperatively is imperative for the healing process and patient satisfaction. Midazolam may or may not be the medication of choice to reduce the pain and anxiety, but it is evident that further research is needed in order to establish a set of standardized care practices in regards to medicating pediatric patients preoperatively. This is significant to nurses caring for children to provide optimal and quality care.
Black, B. P. (2014). Professional Nursing Concepts & Challenges (7th ed.). St. Louis, Missouri: Elsevier Saunders.
Fazi, L., Jantzen, E. C., Rose, J. B., Kurth, C. D., & Watcha, M. F. (2001, January). A Comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient. Anesthesia and Analgesia, 92.
Klein, E. R. (1992). Premedicating children for painful invasive procedures. Journal of Pediatric Oncology Nursing, 9(4).
Linares, S. B., Garcia, C. M., Ramirez, C. I., Guerrero, R. J., Botello, B., Monroy, T. R., & Ramirez, G. X. (2014, January). Pre-anesthetic medication with intranasal dexmedetomide and oral midazolam as an anxiolytic. A clinical trial. An Pediatr (Barc). http://dx.doi.org/10.1016/j.anpedi.2013.12.006
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Ursuy, P. (2014). Class Syllabus. Ferris State University. Retrieved from www.myfsu/ferrisconnect/blackboardlearn
White, K. M., & O’Sullivan, A. (2012). The essential guide to nursing practice. Washington D.C.: American Nurses Association