Gender differences in post-operative pain and patient controlled analgesia use among adolescent surgical patients

Involvement of intra-articular corticotropin-releasing hormone in postoperative pain modulation

OBJECTIVES

Opioid receptors are expressed on peripheral nerve endings and opioid peptides (beta-endorphin, END) are produced in various immune cells of synovial tissue after knee trauma. Because corticotropin-releasing hormone (CRH) acts through its receptors on END-containing immune cells, this randomized controlled trial investigated whether the intra-articular (IA) injection of CRH reduces postoperative pain intensity and supplemental analgesic consumption in patients undergoing arthroscopic knee surgery.

METHODS

Patients were randomly assigned to one of the following IA and IV treatments: group saline (SAL) (n=17) received isotonic SAL IA and 10 microg CRH IV; group CRH (n=16) received 10 microg CRH IA and SAL IV; group CNL (n=18) received 10 microg CRH plus 0.12 mg naloxone IA and SAL IV. Patients pain intensity at rest and during exercise, cortisol plasma concentrations as well as supplemental analgesics were documented. Immunohistochemistry analyzed colocalization of CRH receptors and END.

RESULTS

IA but not IV CRH resulted in a significant but short lasting reduction of postoperative pain under both resting and exercise conditions without changes in cortisol plasma concentrations. Coadministration of naloxone reversed this pain reduction under resting but not exercise conditions. The majority of CRH receptor expressing cells contained END within synovial tissue.

DISCUSSION

In conclusion, this first clinical trial provides preliminary evidence for a short but not robust analgesic effect of a single dose of IA CRH in patients undergoing arthroscopic knee surgery. Further clinical studies will have to examine different doses of IA CRH-induced analgesia and to support the involvement of opioid peptides.

Postoperative pain after paediatric adenoidectomy and differences between the pain scores made by the recovery room staff, the parent and the child

CONCLUSIONS

The parents scored the postoperative pain higher than the nurse. The nurse's score correlated better than the parent's to the child's score. There was no gender difference regarding the pain after adenoidectomy.

OBJECTIVE

To evaluate the correlation between the parents and the health care professionals regarding how postoperative pain is estimated and to identify age and gender differences regarding the pain after adenoidectomy.

PATIENTS AND METHODS

The study included 100 children aged 3-10 years scheduled for adenoidectomy. The nurse and the parent assessed the postoperative pain of the child at different time intervals using a visual analogue scale (VAS). The child rated its pain by using the Wong-Baker FACES pain rating scale.

RESULTS

The postoperative pain scores were higher at 10 min after the operation than after 30 min. The parents scored the pain higher than the nurse did, but there was still a strong correlation between the observers' rating of the pain. The correlation between the nurse's and the child's assessments was stronger than the correlation between the parent's and the child's assessments. There was no gender difference in how the pain was perceived by the child. The parents tended to score the pain higher with older age of the child.

Pre-surgical child behavior ratings and pain management after two different techniques of tonsil surgery

OBJECTIVE

The purpose of this investigation was to compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery, to relate previous experiences of surgery/tonsillitis with anxiety and pain, and to compare the children's, parent's and nurse's rating of pain.

METHOD

Ninety-two children (5-15 years) with sleep-disordered breathing (SDB) and with or without recurrent tonsillitis were randomized to partial tonsil resection/tonsillotomy (TT) or full tonsillectomy (TE).

MEASURES

Parents: Child Behavior Checklist (CBCL). Children: State-Trait-Anxiety Inventory for Children (STAIC) and seven-point Faces Pain Scale (FPS). Parents/staff: seven-point Verbal Pain Rating Scale (VPRS). Pain relievers were opoids, paracetamol and diclophenac.

RESULTS

These children with SDB scored significantly higher on CBCL than did normative groups, but no connection was observed between CBCL rating and experience of pain. There was no relation between pre-operative anxiety and pain. The post-operative anxiety level (STAIC) correlated with pain. The TE-group scored higher on STAIC after surgery. Previous experience of surgery or tonsillitis did not influence post-operative pain. The TE-group rated higher experience of pain despite more medication. The nurses scored pain lower than the parents/children and under-medicated.

CONCLUSION

SDB may influence children's behavior, but with no relation to post-operative pain. The surgical method predicts pain better than does the child's behavior rating. The nurses underestimated the pain experienced by the child.

Sex differences in adolescent chronic pain and pain-related coping

Sex differences exist in pain and the strategies used to cope with pain. Although it is has been proposed that such differences become apparent around puberty, somewhat surprisingly very little research has specifically investigated sex as a moderator of pain within adolescents. The primary aim of the current study was to investigate sex differences in pain and coping within a group of 46 male and 115 female adolescent chronic pain sufferers. All were aged between 11 and 19 years and had been referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases, United Kingdom. Patients completed a battery of measures including pain experiences and a pain coping questionnaire. No sex differences were found in pain chronicity, although males and females did differ in self-reported pain experiences (females reported higher pain). Sex differences were also found in coping behaviours. Females used more social support, positive statements and internalizing/catastrophizing, whereas males reported engaging in more behavioural distraction. Of these strategies internalizing/catastrophizing was found to mediate the relationship between sex and pain. This suggests that not only do sex differences exist in the pain experiences and pain-coping strategies of adolescents with chronic pain, but that internalizing/catastrophizing may be an important mechanism in understanding such differences. More research examining potential sex differences in children and adolescents is recommended.

Adolescent–Parent Relationships in the Context of Adolescent Chronic Pain Conditions

OBJECTIVE

This study explored adolescent-parent relationships in families of adolescents with chronic pain.

METHODS

A retrospective review was conducted on 112 adolescents with chronic pain who presented for clinical evaluation at an outpatient pediatric multidisciplinary pain management clinic. Adolescents reported on pain severity and duration, functional disability, and psychological distress. Parents responded to a measure of adolescent-parent relationship distress.

RESULTS

The findings show that as a group, parents of adolescents with chronic pain syndromes reported less adolescent-parent relationship distress compared to normative data. Adolescent-parent relationship distress was inversely correlated with pain severity. A multiple regression model containing indicators of global psychological distress, pain severity, and adolescent-parent relationship distress predicted levels of adolescents' functional disability. Pain severity and functional disability were more closely linked at the low end of Adolescent-Parent Relationship Domain scores.

DISCUSSION

The findings suggest important directions for future research to advance our understanding of the role of adolescent-parent relationships in the pain-disability cycle.

Analysis of the acute postoperative pain experience following oral surgery: identification of 'unaffected', 'disabled' and 'depressed, anxious and disabled' patient clusters

BACKGROUND

Pain is defined as both a sensory and an emotional experience. Acute postoperative tooth extraction pain is assessed and treated as a physiological (sensory) pain while chronic pain is a biopsychosocial problem. The purpose of this study was to assess whether psychological and social changes occur in the acute pain state.

METHODS

A biopsychosocial pain questionnaire was completed by 438 subjects (165 males, 273 females) with acute postoperative pain at 24 hours following the surgical extraction of teeth and compared with 273 subjects (78 males, 195 females) with chronic orofacial pain. Statistical methods used a k-means cluster analysis.

RESULTS

Three clusters were identified in the acute pain group: 'unaffected', 'disabled' and 'depressed, anxious and disabled'. Psychosocial effects showed 24.8 per cent feeling 'distress/suffering' and 15.1 per cent 'sad and depressed'. Females reported higher pain intensity and more distress, depression and inadequate medication for pain relief (p < 0.001). Distress and depression were associated with higher pain intensity. The developed questionnaire had tested reliability (test-retest r = 0.89) and estimated validity.

CONCLUSION

Cluster analysis showed constituent groups with a range of psychosocial effects in acute postoperative dental extraction pain and is associated with an increase in pain intensity.

What postoperative outcomes matter to pediatric patients?

Children are often excluded from making decisions related to their medical treatment, and parents' proxy reports are often used. This approach fails to consider that parents and children may differ in their perception of the child's health. In this study, we assessed children's decision-making processes related to postoperative pain management. Forty-five children who underwent an anterior cruciate ligament repair or Nuss procedure for pectus excavatum repair were studied. A standard gamble technique was used to assess children's perceptions of the utility of a hypothetical treatment that would provide them with perfect pain control, with respect to different rates of risk for vomiting during the postoperative period. The maximum risk of vomiting that the overall study population was willing to accept to decrease the pain level to zero was 32% +/- 24%. Girls were willing to take a significantly higher risk (41% +/- 24%) compared to boys (25% +/- 22%) (P = 0.02). Children who actually experienced vomiting before they were questioned were willing to take a higher risk (46% +/- 26%) compared to those who did not (23% +/- 17%) (P = 0.035). Children can express opinions about preferred postoperative outcomes and provide useful input about their care. Girls, more than boys, seem to perceive vomiting as less important than improved pain control in the postoperative period.

Gender differences in postoperative pain after laparoscopic cholecystectomy

BACKGROUND

Some evidence suggests that females have a lower pain threshold and a lower tolerance to painful stimuli. This study investigated gender differences in postoperative pain after laparoscopic cholecystectomy (LC) on the basis of visual analog pain scale (VAS) scores and the clinical course.

METHODS

The 100 patients in this study (46 males and 54 females) underwent LC for cholecystolithiasis or gallbladder polyps without intraoperative complications. An 8-mm Penrose drain was retained for 42 h below the liver bed. All the patients were hospitalized for 4 days after LC, and the pain reported by patients, the time course of changes in the highest body temperature, the leukocyte count, and the C-reactive protein level were studied comparatively for the male and female patients.

RESULTS

The VAS scores were significantly higher for the female patients than for the male patients at 24 h (62.7 +/- 24.6 vs 47.0 +/- 23.3; p = 0.0015) and at 48 h (39.2 +/- 24.3 vs 28.3 +/- 19.1; p = 0.0137) after LC. The female patients used analgesics more frequently and had significantly higher body temperatures than the male patients on day 1 (37.2 +/- 0.6 vs 36.9 +/- 0.4; p = 0.0037) and day 2 (36.9 +/- 0.6 vs 36.6 +/- 0.4; p = 0.0037) after surgery.

CONCLUSIONS

Early postoperative pain after LC was more severe in female patients, and patients with high VAS scores tended to use analgesics more frequently.