Postoperative pain assessment in preverbal children and children with cognitive impairment

Postoperative pain assessment and management in preverbal children and children with cognitive impairment poses major challenges to pediatric anesthesiologists. An accurate diagnosis of extent of pain is the keystone for the successful management of pain. This article reviews the neurobiology of pain at birth, long-term consequences of early pain and different pediatric pain assessment tools used for postoperative assessment in infants, young children, and children with cognitive disabilities.     

Cholecystectomy in Danish children — A nationwide study

Background

An increase in the frequency of cholecystectomy in children has been described during the last decades. Part of the reason is that more cholecystectomies in children are performed for dyskinesia of the gallbladder and not only for gallstone disease. We conducted the first nationwide study to describe outcome of cholecystectomies performed in children in Denmark by using data from the national Danish Cholecystectomy Database (DCD).

Methods

In the DCD, two data sources were combined: administrative data from the National Patient Registry (NPR) and clinical data entered into the secure Web site by the surgeon immediately after the operation. In the present analysis, we have included children ≤ 15 years from the five year period January 1, 2006, to December 31, 2010.

Results

In the study period 35,444 patients were operated with a cholecystectomy. Of these, 196 (0.5%) were ≤ 15 years. The median age was 14 years, and 82% were girls. Predisposing medical factors for gallstones (despite obesity) were found in only 5%. More than 50% were overweight, and one third were obese. Ninety-seven percent of the operations were completed laparoscopically, and the conversion rate was 0. 5%. Nearly half of the operations (45%) were performed as same day surgery, and 80% of the children stayed in hospital 0–1 day without readmission. 91% were discharged within 3 days and not readmitted. Morbidity was low, and no bile duct lesions occurred. The 30 day mortality was zero.

Conclusion

Our nationwide outcome results indicate good quality with 91% of the patients discharged within 3 days without readmission, no bile duct injuries, and no mortality. All patients except two were operated for symptomatic gallstone disease in accordance to the Danish national guidelines. We have not experienced a demand or a need to expand the indications for cholecystectomy beyond gallstone disease.     

A qualitative systematic review of morphine treatment in children with postoperative pain

BACKGROUND: Postoperative pain management in children is often empirical rather than evidence based. Morphine is the pharmacological treatment most widely used and although considered safe for children, adequate scientific data on morphine's pharmacokinetics, efficacy and safety are lacking. This systematic review aimed to evaluate the available literature examining different pediatric morphine regimens with respect to dosage, analgesic efficacy and incidence of side effects. METHODS: Thirty-six randomized, double-blind controlled clinical trials with 49 comparisons, including multiple dosage regimens and routes of administration were included. The primary outcome measures for analgesic efficacy (pain intensity, time to first analgesic request and need for rescue analgesics) together with the incidence of morphine-related side effects were evaluated qualitatively by significant difference (P < 0.05) as reported in the original investigations. RESULTS: Overall, significant improvements in the defined outcome measures on analgesic efficacy were only observed when morphine was compared with inactive control interventions. No relation between morphine dosage and analgesic efficacy was detected. The most common morphine-related side effects were vomiting and sedation, with significantly higher incidences observed after morphine administration in half of all comparisons. CONCLUSIONS: Although several factors may justify its use as first line therapy in many parts of the world, morphine alone is not the most suitable analgesic for postoperative pain in pediatric patients, as it does not have superior analgesic effect and a higher incidence of side effects compared with active control interventions. More standardized clinical trials with multimodal regimens as well as guidelines for evaluating pediatric medicines are desirable in the future.     

Validating the Derbyshire Children's Hospital Pain Tool: a pilot study

BACKGROUND: The Derbyshire Children's Hospital Paediatric Pain Chart (DPC) is the current pain assessment tool used at the Derbyshire Children's Hospital. It was originally devised as a simple pain tool for use in the clinical area, and it is applicable for use in children of all ages within the postoperative setting. The pain assessment chart encompasses pain assessment by utilizing facial expression, body movement and verbal expression. An exploratory study was performed to define its reliability and validity. METHODS: The research nurse (V.P.) assessed 40 children aged 1-5 undergoing minor and intermediate surgery comparing the Toddler Preschooler Postoperative Pain Scale and the DPC. Assessments were performed preoperatively and for 4 h postoperatively. Any analgesia administered postoperatively was recorded. RESULTS: All the children scored 0 preoperatively with both pain scales, thus demonstrating known groups validity. There were 116 dual assessments by the research nurse using both pain scales. There was a strong correlation (r = 0.89) demonstrating convergent validity. There was a significant correlation between 182 joint assessments by the research nurse (V.P.) and the nursing staff using the DPC (Spearmans rank correlation, 0.81) and the Cronbach alpha coefficient ranged from 0.83 to 0.98. Construct validity was demonstrated by a fall in the mean pain scores from 1.8 to 0.1 following analgesia in 19 children. CONCLUSIONS: This exploratory study suggests the DPC holds construct, convergent and known groups validity and is a reliable pain assessment tool for children aged 1-5 years undergoing minor and intermediate surgery.     

The cardiac analgesic assessment scale (CAAS): a pain assessment tool for intubated and ventilated children after cardiac surgery

BACKGROUND: This study evaluated the reliability and validity of the Cardiac Analgesic Assessment Scale (CAAS) as a postoperative pain instrument for children after cardiac surgery. METHODS: Two prospective studies included 69 children (aged 0-16 years) admitted to the intensive care following cardiac surgery with a sternotomy incision. Four concurrent observers performed paired observations with the CAAS or a visual analogue scale (VAS) for 32 patients. After a stimulus to the patient, two nursing observers independently scored the patient with the CAAS, and another two independent nursing observers simultaneously scored the patient using a VAS. In the second part of this study the CAAS was evaluated with respect to its ability to detect changes in pain status and responses to analgesia over time in 37 patients. RESULTS: Interrater reliability, represented by Lin's concordance correlation coefficient proved to be almost perfect for the CAAS score 0.97 (95% CI: 0.95, 0.99). About 91% of patients received the same total CAAS score from the two raters. The dichotomized CAAS scores of the two nurses indicated that in 97% of cases the nurses agreed upon whether there was an indication for treatment of pain. The CAAS was shown to significantly reflect changes in pain status over time. The average Spearman's rank correlation between VAS and CAAS was low (0.27), indicating that CAAS did not correlate well with VAS. CONCLUSION: This study provides evidence that postoperative pain in sedated and intubated children after cardiac surgery can be assessed reliably using a formal pain tool.     

Breakthrough pain in opioid-treated chronic non-malignant pain patients referred to a multidisciplinary pain centre: a preliminary study

BACKGROUND: Breakthrough pain (BTP) has not formerly been discussed as such in chronic non-malignant pain patients referred to pain centres and clinics. The purpose of the study was to investigate the prevalence, characteristics and mechanisms of BTP in opioid-treated chronic non-malignant pain patients referred to a pain centre and to assess the short-term effects of pain treatment. METHODS: Patients were assessed at referral (T(0)) and after a treatment period of 3 months (T(3)) using the visual analogue scale (VAS) of the brief pain inventory (BPI) within somatic nociceptive, neuropathic and/or visceral pain conditions, the mini mental state examination (MMSE) and the hospital anxiety and depression scale (HADS). The main treatment intervention from T(0) to T(3) was to convert short-acting oral opioids to long-acting oral opioids and to discontinue on demand and parenteral use of opioids. RESULTS: Thirty-three patients were assessed at T(0) and 27 at T(3). The prevalence of BTP declined significantly from T(0) (90%) to T(3) (70.4%). Worst, least, average and current pain intensities as well as duration of BTP were significantly reduced from T(0) to T(3.) The majority of BTPs were exacerbation of background pain assumed to be of the same pain mechanisms. High average pain intensity (BPI) was significantly associated with high scores for both anxiety and depression (HADS). CONCLUSION: BTP in chronic non-malignant pain patients seems to be surprisingly frequent and severe. Stabilizing the opioid regimen seems to reduce pain intensity in general as well as the intensity and duration of BTP. Average pain intensity was associated with anxiety and depression.     

烧伤患者疼痛体验及疼痛管理期望的质性研究

目的探讨烧伤患者疼痛体验及疼痛管理需求,为采取针对性疼痛管理措施提供依据。方法采用目的抽样法对11例住院烧伤患者进行半结构式访谈,资料分析采用Nvivo10.0软件。结果共析出4个主题:烧伤患者经历了剧烈的疼痛;烧伤疼痛管理的现状不容乐观;家属的支持和医护人员的鼓励对患者缓解疼痛很重要;患者期望更好的疼痛管理方法。结论烧伤患者身心经历了镇痛不完善的体验,应建立规范的烧伤疼痛管理模式,加强烧伤患者疼痛知识方面的健康教育,为烧伤患者提供方便、安全、有效的疼痛控制策略,从而缓解烧伤患者疼痛。     

Pain assessment in children

Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be inconsistent and suboptimal in many organizations. Pain and its perception are multi-factorial, hence an approach to pain assessment and treatment must also be multi-faceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variability, therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variability. This article outlines the different tools available for pain assessment in infants and children (excluding neonates).     

Pain assessment in children

Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be a challenge and is often inconsistent and suboptimal in many organizations. Pain and its perception are multi-factorial, hence an approach to pain assessment and treatment must also be multi-faceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variation; therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variation. This article outlines the different tools available for pain assessment in infants and children (excluding neonates).     

Pain assessment in children

Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be a challenge and is often inconsistent and suboptimal in many organizations. Pain and its perception are multifactorial, hence an approach to pain assessment and treatment must also be multifaceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variation; therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variation. This article outlines the different tools available for pain assessment in infants and children (excluding neonates).     

Work related characteristics of back and neck pain among employees of a Swiss University Hospital

Objectives

1) To explore the staff- and work-related risk factors for spinal pain among hospital employees, 2) to investigate the effect of staff- and work-related variables on the consequences of spinal pain, such as doctor visits and sick leave.

Methods

A mailed survey was carried out in a random sample of 2700 employees stratified for occupational categories (administration staff, nurses, nurse assistants, physicians, support staff and allied health professionals). The questionnaire measured self-reported spinal pain, consequences of pain, and work characteristics.

Results

The response rate was 48.1% (1298/2700). The one-year prevalence of spinal pain was 67.3%, highest among nurses (75.6%) and lowest among support staff (54.9%). Reported work characteristics associated with spinal pain included frequent work at a poorly adapted work station (odds ratio (OR) 1.90 [1.24–2.93]) and having to maintain a position for a long time (OR 1.71 [1.25–2.34]). No significant correlations were observed with lifting, patient handling, material handling, or working on nightshift. Sickness leave due to spinal pain was significantly associated with duration of pain episode (OR 4.08 for > 3 months compared to less than 10 days), and with work categories (OR 2.58 for nurse assistants compared to nurses).

Conclusion

In this population of hospital employees, being a nurse, working at a poorly adapted work place, and having to maintain positions for a long time were related independently to spinal pain. Nurse assistants had a higher risk of work absenteeism.     

Pain management in children with and without cognitive impairment following spine fusion surgery

BACKGROUND: We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery. METHODS: The medical records of 42 children (19 with CI and 23 without) were reviewed and data related to demographics, surgery, pain assessment and management, and side-effects were recorded. RESULTS: Fewer children with CI were assessed for pain on postoperative days (POD) 0-4 compared to those without CI (P < 0.002). Self-report was used for 81% of pain assessments in children without CI, while a behavioural tool was used for 75% of assessments in cognitively impaired children. Children with CI received smaller total opioid doses on POD 1-3 compared to those without CI (P < or = 0.02). Furthermore, children without CI received patient/nurse-controlled analgesia for more postoperative days than children with CI (P=0.02). CONCLUSION: Our data demonstrate a discrepancy in pain management practices in children with and without CI following spine fusion.     

Chronic pain in children in the UK: a survey of pain clinicians and general practitioners

Background: There is a lack of information about the prevalence, manifestations, and management of chronic pain in children in the UK. We surveyed consultants with an interest in chronic pain management and general practitioners (GPs) in the UK in order to understand their perspective on chronic pain in children. Methods: We conducted a postal survey of clinicians with an interest in chronic pain management and GPs in the UK. The survey contained questions relating to the following aspects of managing children with chronic pain: (i) clinicians’ training and experience; (ii) available resources; (iii) perceived prevalence, presentation, and referral patterns; (iv) interventions; and (v) outcomes. Results: 472 pain clinicians and 131 GPs were contacted. The response rates were 55% and 61% respectively. Of the respondents, 77% of pain clinicians and 95% of GPs acknowledged a lack of adequate training for managing children with chronic pain. 57% of the pain clinicians and 63% of the GPs reported that the prevalence of chronic pain in children was <5%. In the comments section, 22% of those respondents who frequently manage children with chronic pain reported an increase in the incidence of this problem over the last 5 years. The common chronic pain syndromes in children were reported to be: musculoskeletal and limb pain, recurrent abdominal and pelvic pain, and headache. 15% of the respondents advised that children with chronic pain would be best managed in specialist pediatric centers and 75% opined that majority of children with chronic pain have a fair to good prognosis. Conclusions: More information is required about prevalence, manifestations and long‐term effects of chronic pain in children in the UK. There is a need for increasing training and resources amongst GPs and pain clinicians for managing chronic pain in the pediatric age group.     

Perioperative management in children with chronic pain

Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.     

Prevalence of moderate–severe pain in hospitalized children

Background: Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown. Methods: We reviewed clinical characteristics of all pediatric patients admitted to Mayo Eugenio Litta Children’s hospital during July 2009. Patients with moderate–severe pain were identified. For patients identified as having moderate–severe pain risk factors, analgesia regimens, and pain outcomes were reviewed. Results: The prevalence of moderate–severe in‐hospital pain was 27% (95% C.I. 23% to 32%). Teenagers and infants experienced higher prevalence rates of moderate–severe pain (38% and 32% respectively) than children (17%, P < 0.001). In addition, patients admitted to medical services had much lower rates of moderate–severe pain (13%) than those admitted to surgical services (44%, P < 0.001). Regional anesthesia was used in eleven (7.2%) of the patients on surgical services. Acetaminophen was administered to 75% of patients with moderate–severe pain. Only 21% of these patients had nonsteroidal anti‐inflammatory drugs (NSAIDS) available. Opioids were given scheduled to 36% of patients with moderate–severe pain and as needed to another 40%. Fifty‐five percent of patients still had one or more episode of moderate–severe pain on the day following an initial diagnosis; however, this number decreased steadily over subsequent days. Eleven patients (13% of those diagnosed with moderate–severe pain) still had one or more episodes of daily moderate–severe pain by day four. Conclusions: The prevalence of moderate–severe pain in hospitalized children remains high. Analgesia regimens may not be optimal. Underutilization of regional anesthesia techniques may have contributed to increased pain scores. A large proportion of children diagnosed with moderate–severe pain may have persistent clinically significant pain in subsequent days.