PICOT Paper: Analyzing a Case Study on Preoperative Midazolam

This report presents a PICOT analysis of a clinical question regarding the effectiveness of preoperative midazolam in reducing post-operative pain in pediatric patients. The paper begins by formulating the clinical question using the PICOT framework (Population, Intervention, Comparison, Outcome, Time). It then details the methodology used to search relevant databases (Cinahl, Cochrane, and Pub-Med), including the keywords and article selection criteria. The report discusses the levels of evidence used to evaluate the articles. The paper reviews three articles related to the topic: one using descriptive questionnaires, another a randomized controlled trial comparing two medications, and a third using a randomized and controlled approach. The report concludes that while the research provides both supportive and non-supportive information, further research is needed to establish standard care practices. The report emphasizes the importance of evidence-based practice for nurses to provide quality patient care.

PICOT PAPER 1
PICO Framework, Analyzing a Case Study
Student Name
Institution Affiliation
Course
Date

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PICO Framework, Analyzing a Case Study
Current nursing care is based on Evidence-Based Practices (EBPs) which have been
founded on evidence-based research. New data which is acquired or utilized in research must,
therefore, be communicated clearly among all the stakeholders within the health setting. All
stakeholders are hence entitled to efficiently collaborate to support and incorporate EBP in their
everyday practices. In order to explore whether the use of midazolam in preoperative care for
pediatric provides better post-operative pain control, this paper reflects on how knowledge on
nursing care is disseminated bother under professional and personal practices (Usury, 2014).
Clinical Question
In the course of my work at a Surgery Recovery Unit in a local hospital, I came across
pediatric patients who were undergoing surgical procedures. Children who were below 10 years
had their IV starting at the operating room when undergoing general anesthesia whereas those
who were over 10 years had theirs while in the preoperative phase. The two victim categories
were given oral midazolam preoperatively. However, because the access to IV was limited, IV
midazolam was not administered, midazolam was only administered orally. An anesthesiologist
was responsible for evaluating the children and ordering the midazolam; also there were no set
policies and protocols for that. I started to observe some inconsistencies with the children who
had been administered with midazolam prior to the surgery which dawned to me that the children
who had been given midazolam preoperatively had their post-operative pain controlled in an
effective way.
Generally, when research or a discussion brings about questions like presented in my case
above, the PICOT framework has always been the best way to formulate the questions. In the
PICOT framework (Niewswiadomy, 2012), P denoted the population or patients, I denoted the

PICOT 3
area of interest, C denoted comparison, O denoted the desired outcomes while T denoted the
duration of time. In this paper, the question to be explored using the PICOT framework “is
midazolam medication when administered preoperatively to patients more effective in reducing
post-operative pain than when it is not administered in pediatric cases?” in this case, P stood for
pediatric patients, I denoted the administration of midazolam in an orally, C was its comparison
with failed administration, O was the pain management post-operative while T denoted post-
operative duration. Pediatric patient safety after undergoing surgical procedures is believed to
improve when there are consistent preoperative medication procedures and policies
implemented. If post-operative pain management can be improved, the satisfaction of patients
can also increase.
Methodology
Three databases which are related to the medical and nursing fields (Cinahl, Cochrane,
and Pub-Med) where used to research the PICOT question in this case. In each of these three
databases, an advanced search was used where possible, which included the keywords and
phrases. In most of the searches, the versed word did not reveal enough articles as it was
expected, but when the search was advanced to cover midazolam and parenthesis were added to
the keywords, there were more options displayed. So, the advanced search entailed “oral or
versed midazolam”, “children or pediatric” and “preoperative or postoperative pain”.
Article selection was further squeezed after several abstracts for sampled articles were
read. The abstracts were important because they provided hints on whether an article was to be
included or excluded from the list easily. Mainly, the articles which were12 years old and below
were preferred in the research.

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Levels of evidence were also utilized in the research. Levels of evidence were used to
group the found articles in regard to trial types, studies, and expert opinions which were utilized
in the numerical hierarchy. All the sampled articles were assigned to a certain level of evidence.
Levels of Evidence
First level- two or more randomized and controlled trials
Second level- Controlled trials only (without randomizations)
Third level- Case-controls
Fourth level- Systematic reviews of descriptive and qualitative studies
Fifth level- Sole qualitative studies
Sixth level- Expert opinions
(Fineout & Melnyk, 2011)
Making the choice on evidence levels to be assigned to the sampled articles was not an
easy job which made it very difficult for the PICOT question chosen. This made the PICOT
question chosen to be done based on the level of evidence given only. The articles on nursing
were favored.
All nurses working in healthcare facilities should participate in the utilization of
resources as per their scope of practices (O’Sullivan & White, 2012). However, most of the
nurses tend to shy away from further because they don’t see the essence of changing what is still
working effectively. This should not be the case with registered nurses; they should always
evaluate evidence in order to decide the level of care and intervention to achieve desired patient
outcomes (O’Sullivan & White, 2012).

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The Literature
First article
The first article by Elizabeth “Premedication children for painful invasive procedures”
had used descriptive questionnaires to answer its research questions which composed of 108
participants. Participants consisted of two groups, one group with 53 nurses and another one with
55 physicians. Physicians, in this case, consisted of staff oncologists and pediatric professors
while the nurse category consisted of clinical nurses (Klein, 1992).
Article Two
The second article which had the title, “Pre-anesthetic medication with intranasal
dexmedetomidine and oral midazolam as an anxiolytic a clinical trial”, compared two
medications which are administered during preoperative anxiety. The trial, in this case, was
prospective, double-blind, randomized and controlled. It was conducted for children between 2-
12 years (Linares et al., 2014). 108 pediatric patients were assessed in a modified Yale scale.
Article Three
The last article “A comparison of oral clonidine and oral midazolam as pre-anesthetic
medications in the pediatric tonsillectomy patient” by Fazi et al. used a randomized and
controlled approach (Fazi, Kurth, Jantzen, Watcha & Rose, 2001). The participants of the study
ranged between 4-12 years and were all medicated prior to the anesthesia with clonidine or
midazolam.

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Conclusion
PICOT question which has been explored in this paper has non-supportive as well as
supportive information. Materials were overwhelmingly supportive of the pediatric victims who
were receiving medication prior to the painful surgery process. Minimizing pain and anxiety both
postoperatively and preoperatively was imperative for both patient satisfaction and patients
healing process. From the research, midazolam might or might not be the best medication to
reduce anxiety and pain, but it has been outlined that further research would be required to
establish standard care practices when providing medication for preoperatively pediatric patients.
This is important for nurses taking care of children because it will enable them to provide quality
and optimal care.

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References
Black, B. P. (2014). Professional Nursing Concepts & Challenges (7th ed.). St. Louis, Missouri:
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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 pre-anesthetic 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
dexmedetomidine and oral midazolam as an anxiolytic. A clinical trial. A Pediatr (Barc).
http://dx.doi.org/10.1016/j.anpedi.2013.12.006
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and
healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.
Niewswiadomy, R. M. (2012). Foundation of Nursing Research (6th ed.). Upper Saddle River,
NJ: Pearson Education, Inc.
Quality and Safety Education for Nurses. (2013). Retrieved from www.qsen.org
Ursuy, P. (2014). Class Syllabus. Ferris State University. Retrieved from www.myfsu/ferries
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White, K. M., & O’Sullivan, A. (2012). The essential guide to nursing practice. Washington
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