Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

Psychometric Testing and Validation of the Italian Version of the Helsinki Chronic Pain Index (I-HCPI) in Dogs with Pain Related to Osteoarthritis

Pain assessment is of paramount importance for properly managing dogs with osteoarthritis (OA) pain. The aim of the present study was to develop and psychometrically validate the Italian version of the Helsinki Chronic Pain Index (I-HCPI). Owners of OA painful (n = 87) and healthy dogs (n = 40) were administered the I-HCPI once or twice after an eight-week meloxicam treatment. Sixty-nine owners of healthy and OA dogs also completed the Italian version of the Canine Brief Pain Inventory (I-CBPI). Pain on palpation on a 0-4 scale was assessed on all recruited dogs. Construct validity was tested both with hypothesis testing and principal component analysis, confirming the I-HCPI accurately measured chronic pain. Good convergent and criterion validity were shown through correlations with I-CBPI subscores and distribution among pain on palpation scores (p < 0.0001). The significant difference between the pre- and post-treatment I-HCPI scores (p < 0.0001) and Cohen's effect size (2.27) indicated excellent responsiveness. The I-HCPI was shown to be reliable through communalities (range 0.47-0.90) and Cronbach α (≥0.95). Discriminative ability and cut-off point, as tested through Receiver Operating Characteristic analysis, showed excellent diagnostic accuracy with a threshold value of 11 (specificity 0.98 and sensitivity 0.94). The I-HCPI was confirmed to be a valid, sensitive, reliable, and accurate tool to discriminate between dogs with and without pain.

Is the equimolar mixture of oxygen and nitrous oxide (EMONO) associated with audiovisuals effective in reducing pain and side effects during peripheral venous access placement in children? Protocol for a single-centre randomised controlled trial from Italy

INTRODUCTION

Nurses frequently place a peripheral venous catheter during children's hospitalisation. Many studies suggest treatment of venipuncture-related pain. The administration of an equimolar mixture of oxygen and nitrous oxide (EMONO) is employed for pain control; however, no studies have analysed the association between EMONO and audiovisuals.The purpose of the study is to evaluate the effect of EMONO administration when combined with audiovisuals (EMONO+Audiovisual) versus EMONO alone on perceived pain, side effects and level of cooperation during peripheral venous access placement in children aged 2-5 years.

METHODS AND ANALYSIS

The first 120 eligible children admitted to the paediatric ward of the Lodi Hospital and presenting the indication for peripheral venous access will be enrolled. Sixty children will be randomly assigned to the experimental group (EMONO+Audiovisual) and 60 to the control group (EMONO alone).The Face, Legs, Activity, Cry, Consolability scale will be used to assess pain in the children aged 2-years old; pain in the children aged 3-5 years will be assessed using the Wong-Baker scale. The cooperation throughout the procedure will be measured using the Groningen Distress Rating Scale.

ETHICS AND DISSEMINATION

The Milan Area 1 Ethics Committee approved the study protocol (Experiment Registry No. 2020/ST/295). The trial results will be presented at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05435118.

Pain assessment tools for use in infants: a meta-review

BACKGROUND

Identifying pain in infants is challenging due to their inability to self-report pain, therefore the availability of valid and reliable means of assessing pain is critical.

OBJECTIVE

This meta-review sought to identify evidence that could guide the selection of appropriate tools in this vulnerable population.

METHODS

We searched Scopus, Medline, Embase, CINAHL, MIDRIS, EMCare and Google Scholar for eligible systematic reviews. Eligible reviews documented psychometric properties of available observational tools used to assess pain in infants.

RESULTS

A total of 516 reviews were identified of which 11 met our inclusion criteria. We identified 36 pain assessment tools (evaluated in 11 reviews) of which seven were reported in at least three reviews. The level of evidence reported on the psychometric properties of pain assessment tools varied widely ranging from low to good reliability and validity, whilst there are limited data on usability and clinical utility.

CONCLUSIONS

Currently, no observer administered pain assessment tool can be recommended as the gold standard due to limited availability and quality of the evidence that supports their validity, reliability and clinical utility. This meta-review attempts to collate the available evidence to assist clinicians to decide on what is the most appropriate tool to use in their clinical practice setting. It is important that researchers adopt a standard approach to evaluating the psychometric properties of pain assessment tools and evaluations of the clinical utility in order that the highest level of evidence can be used to guide tool selection.

A Systematic Review of the Measurement Properties of Face, Legs, Activity, Cry and Consolability Scale for Pediatric Pain Assessment

Purpose

We performed this systematic review to summarize the psychometric properties of Face, Legs, Activity, Cry and Consolability (FLACC) scale in pediatric patients in different settings.

Methods

Two investigators independently searched PubMed, EMBASE, OVID and China National Knowledge Infrastructure (CNKI) for eligible studies through July 2021. We assessed the psychometric properties using the modified critical appraisal tool (CAT). Finally, we systematically reviewed the results of the included studies.

Results

A total of 15 studies were eventually included. The overall quality of each eligible study was low to moderate. The FLACC scale has been available in different versions and in different settings. Although eligible studies have demonstrated significant clinical benefit in assessing postoperative pain in pediatric patients aged 0 to 10 years from post-anesthetic care unit (PACU), pediatric intensive care unit (PICU) and inpatient unit, and in assessing procedural pain in pediatric patients aged 0.5 to 7 years from emergency unit, immunization center and PICU, mostly without test-retest analysis.

Conclusion

Although the absence of a gold standard of pain assessment, the currently available data support the usefulness of the FLACC from the perspective of criterion validity. Therefore, the FLACC scale can be considered for measuring observational pain in infants and children. However, further studies are still needed to provide more robust evidence.

Effectiveness of Procedural Sedation and Analgesia in Pediatric Emergencies. A Cross-Sectional Study

INTRODUCTION

Pain is defined as an unpleasant emotional and sensory experience associated with bodily harm or with situations that cause fear and anxiety. However, it is often undertreated in pediatric emergency departments. This study aims to assess the effectiveness of sedation-analgesia techniques, level of satisfaction among health care professionals and relatives, and agreement between the satisfaction of health care professionals and relatives.

METHODS

A cross-sectional design was conducted. Sociodemographic and clinical variables were recorded, together with those for effectiveness using the Face, Legs, Activity, Cry, and Consolability scale and the Wong-Baker FACES scale, and the satisfaction using the 10-point Likert scale. Stata 16.1 was used for data analysis.

RESULTS

A total of 94 procedures were registered. The results suggested that these techniques were effective or mildly effective in only half of the cases. Satisfaction was considered good across the board, and the agreement between health care professionals (ie, pediatric nurses and pediatricians) was considered substantial. However, the agreement between health care professionals and relatives was moderate.

DISCUSSION

Our results suggested that the adequate management of pain in pediatric emergency departments is still a challenge, despite the availability of international guidelines. Future research lines should be focused on analyzing possible causes of the inefficacy of some sedation-analgesia techniques and the causes of the differences between the perspectives of health care professionals and relatives. These research lines may be useful to improve quality of care and pediatric patient comfort.

Les pratiques exemplaires pour l’évaluation et le traitement de la douleur chez les enfants

L’évaluation et le traitement de la douleur sont des aspects essentiels des soins pédiatriques. L’évaluation de la douleur adaptée au développement représente une première étape importante pour en optimiser la prise en charge. L’autoévaluation de la douleur est à prioriser. Si c’est impossible, des outils appropriés d’évaluation du comportement, adaptés au développement, doivent être utilisés. Des directives et stratégies de prise en charge et de prévention de la douleur aiguë, qui combinent des approches physiques, psychologiques et pharmacologiques, doivent être accessibles dans tous les milieux de soins. Le meilleur traitement de la douleur chronique fait appel à une combinaison de modalités thérapeutiques et de counseling, dans l’objectif premier d’obtenir une amélioration fonctionnelle. La planification et la mise en œuvre de stratégies de prise en charge de la douleur chez les enfants doivent toujours être personnalisées et axées sur la famille.

Best practices in pain assessment and management for children

Pain assessment and management are essential components of paediatric care. Developmentally appropriate pain assessment is an important first step in optimizing pain management. Self-reported pain should be prioritized. Alternatively, developmentally appropriate behavioural tools should be used. Acute pain management and prevention guidelines and strategies that combine physical, psychological, and pharmacological approaches should be accessible in all health care settings. Chronic pain is best managed using combined treatment modalities and counselling, with the primary goal of attaining functional improvement. The planning and implementation of pain management strategies for children should always be personalized and family-centred.

Discriminant properties of the Behavioral Pain Scale for assessment of procedural pain-related distress in ventilated children

OBJECTIVES

Children hospitalized in a pediatric intensive care unit (PICU) are frequently exposed to distressing and painful medical procedures and interventions. There is a lack of clinical scales to measure procedural pain-related distress in ventilated children. The Behavioral Pain Scale (BPS) was initially developed to detect procedural pain in critically ill adults. This study aims to assess the BPS's discriminant properties for measuring procedural pain-related distress in ventilated pediatric patients incorporating two instruments validated for pediatric patients.

METHODS

This prospective exploratory study was performed with ventilated children admitted to the interdisciplinary 14-bed PICU of the University Children's Hospital, University Medical Center Hamburg-Eppendorf, Germany. The nurse in charge and an independent observer simultaneously assessed the patients using German versions of the BPS, the COMFORT-B scale (CBS), and the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale immediately before and during endotracheal suctioning.

RESULTS

We analyzed 170 parallel assessments in n=34 ventilated children. Patients were (mean ± SD) 9.5 ± 4.8 years old. Internal consistency for the BPS was excellent (α=0.93). We found a high rater agreement for all clinical scales (BPS: k=0.73, CBS: k=0.80, mFLACC: k=0.71). Strong correlations were identified between BPS and CBS (r=0.89) and BPS and mFLACC (r=0.79). The BPS cutoff values showed likewise excellent results (area under the curve CBS >16: 0.97; mFLACC >2: 0.91).

CONCLUSIONS

In our population of ventilated children, the BPS was well suited to detect procedural pain-related distress compared with two validated pain scales. Further extensive validation studies should follow to support our findings.

Medical Clowning: A Cost-Effective Way to Reduce Stress Among Children Undergoing Invasive Procedures

Background

Distraction techniques like medical clowning and the use of soap bubbles can aid in reducing children’s stress levels while undergoing invasive medical procedures. Such complementary therapies are not a common practice in Pakistan, and data exploring the potential benefits of complementary therapies are sparse. This study aimed to determine whether distractions like medical clowns and soap bubbles could reduce anxiety and pain perceived by children undergoing invasive medical procedures in a hospital in Pakistan.

Material and methods

We conducted a randomized controlled trial of 76 pediatric patients (aged six to 12 years) whose treatment required a peripheral intravenous (IV) catheter insertion at the pediatric ward of the Fauji Foundation Hospital in Rawalpindi, Pakistan, from March 2016 to June 2016. Peripheral IV catheter insertion was required for all patients as part of their treatments (no participants received IV catheter placement solely for this study). Our sample size was selected via random sampling, and we excluded patients whose parents or legal guardians did not consent for their inclusion. Study participants were randomly assigned to either a clown group (n=38) or a control group (n=38). The patients in the clown group underwent IV catheter placement while interacting with the medical student clown and soap bubbles in the presence of a parent. Patients in the control group underwent IV catheter placement with support provided only by the parent. We assessed the patient’s distress and anxiety before, during, and after the procedure. We used the Observation Scale of Behavioral Distress (OSBD), before and after the procedure with the short version of self-reported Spielberger’s State-Trait Anxiety Inventory-Children (STAI-C), the visual analog anxiety scale (VAS), and pain experienced with the Wong-Baker Faces pain scale (FPS) only after the procedure. Additionally, we collected demographic information. The hospital's ethical review committee approved our study design.

Results

Of the 76 study participants, 53.9% were male and 46.1% were female. Most patients lived in a rural setting (67%). Mean values of the FPS, OSBD, and STAI-C for the clown group (3.21, 6.23, and 8.52, respectively) were all lower than those for the control group (8.00, 18.02, and 15.29, respectively; p<.001); however, the difference was not statistically significant for children older than 10 years. After IV catheter placement, the mean VAS score for the clown group was also significantly lower than that for the control group (2.84 vs. 8.92, respectively; p<.001).

Conclusion

The use of distractions via medical clowns and soap bubbles was an effective nonpharmacological method of reducing anxiety and perceived pain in children undergoing invasive medical procedures. Therefore, proceduralists could use such techniques as powerful, noninvasive, and cost-effective complementary and alternative medicine tools in pediatric treatment settings in Pakistan. Further studies on the potential benefits of the aforementioned techniques are warranted.

Be Sweet to Hospitalized Toddlers During Venipuncture: A Randomized Controlled Trial of Sucrose Compared With Water

OBJECTIVES

High-quality evidence demonstrates analgesic effects of sweet-tasting solutions for infants during painful procedures. However, evidence of the analgesic effects of sucrose beyond 12 months of age is less certain. The aim of this study was to ascertain the efficacy of oral sucrose in hospitalized toddlers (ages 12 to 36 mo) compared with placebo (water) during venipuncture.

MATERIALS AND METHODS

Blinded, 2-armed randomized controlled trial including hospitalized toddlers aged 12 to 36 months. Toddlers were randomized to either 25% sucrose or water before venipuncture, stratified by age (12 to 24 mo and more than 24 to 36 mo). Standard of care included topical anesthetics for both groups. Pain assessment included cry duration and FLACC (Face, Legs, Activity, Cry, Consolability) scores. Descriptive statistics and linear models were used to report the percentage of time crying and mean differences in FLACC scores. Data analysis was performed using R, version 3.6.3.

RESULTS

A total of 95 toddlers were randomized and 85 subsequently studied. The median percentage of time spent crying between insertion of the first needle and 30 seconds after the end of procedure in both groups was 81% (interquartile range=66%). There was no significant difference in crying time and FLACC scores between groups (P>0.05). When examining effects of sucrose for the younger toddlers (less than 24 mo of age) there was a reduction in crying time of 10% and a 1.2-point reduction in mean FLACC scores compared with the toddlers older than 24 months.

DISCUSSION

Findings highlight that toddlers become highly distressed during venipuncture, despite the standard care of topical anesthetics. In addition, sucrose does not effectively reduce distress especially in the older group of toddlers.

An Evaluation of High Preprocedural Anxiety and Venipuncture Pain Experienced by Young Children

OBJECTIVE

The aim of this study was to determine if young children with high preprocedural anxiety experience increased pain at venipuncture.

METHODS

This was secondary analysis of prospectively obtained data from a randomized controlled trial comparing vapocoolant spray with jet-injected lidocaine for venipuncture pain. Children aged 1 to 6 years were enrolled and videotaped. Videos were reviewed and scored for anxiety using the modified Yale Preoperative Anxiety Scale score for preprocedural anxiety (score range, 23-100). High anxiety was defined as greater than 40. Pain at the time of venipuncture was scored using the Face, Legs, Activity, Cry, and Consolability scale (score range 0-10). Moderate to severe pain was defined as greater than 3. Logistic regression assessed patient factors associated with high preprocedural anxiety and evaluated the relationship between preprocedural anxiety and pain during venipuncture.

RESULTS

Two hundred five patients were enrolled; 59.5% of patients were male, and 53.7% were White. Mean age was 3.2 years. Prior to the procedure, 67% of patients had high anxiety. Patient age, race, sex, and previous venipuncture were not associated with increased odds of high anxiety. Moderate to severe pain at venipuncture was observed in 65% of children. High preprocedural anxiety was associated with increased odds of moderate to severe pain at venipuncture when controlled for patient characteristics (adjusted odds ratio, 4.62; 95% confidence interval, 2.03-8.54).

CONCLUSIONS

Most young children undergoing venipuncture experienced high preprocedural anxiety. Children with high preprocedural anxiety had increased odds of moderate to severe pain at venipuncture. Anxiety-reducing interventions should be explored to reduce pain experienced during venipuncture.

Intranasal dexmedetomidine versus oral midazolam premedication to prevent emergence delirium in children undergoing strabismus surgery: A randomised controlled trial

BACKGROUND

Dexmedetomidine is being used increasingly as a premedicant in the paediatric population. However, the effectiveness of pre-operative intranasal dexmedetomidine premedication, compared with oral midazolam, for emergence delirium is not well characterised.

OBJECTIVE

To identify the effectiveness of pre-operative intranasal dexmedetomidine for emergence delirium in the paediatric patient population following general anaesthesia.

DESIGN

A prospective, randomised, double-blind, parallel-group, placebo-controlled trial.

SETTING

Single university teaching hospital, from September 2013 to August 2014.

PATIENTS

One hundred and fifty-six patients undergoing anaesthesia for strabismus surgery were included in the study.

INTERVENTION

Patients were randomised in a 1 : 1 : 1 ratio to receive premedication with intranasal dexmedetomidine 2 μg kg (the dexmedetomidine group), oral midazolam 0.5 mg kg (the midazolam group), or 0.9% saline (the placebo group).

MAIN OUTCOME MEASURES

The primary outcome was the incidence of emergence delirium assessed by the Paediatric Anaesthesia Emergence Delirium scale. Secondary outcomes included the quality of the inhalational induction, emergence time, postoperative pain intensity, length of stay in the postanaesthesia care unit, the incidence of postoperative nausea or vomiting (PONV) and parents' satisfaction.

RESULTS

The incidence of emergence delirium was lower in patients given dexmedetomidine compared with that in patients given midazolam (11.5 versus 44%, relative risk = 0.262, 95% confidence interval 0.116 to 0.592) or 0.9% saline (11.5 versus 49%, relative risk = 0.235, 95% confidence interval 0.105 to 0.525). Likewise, the incidence of PONV was lower in the dexmedetomidine group (3.8%) than that in the midazolam (22%; P = 0.006) or placebo (29.4%; P < 0.001) groups. However, there was no difference among the groups concerning postoperative pain scores and length of postanaesthesia care unit stay.

CONCLUSION

In paediatric patients undergoing strabismus surgery intranasal dexmedetomidine 2 μg kg premedication decreases the incidence of emergence delirium and PONV, and improves parents' satisfaction compared with oral midazolam.

TRIAL REGISTRATION

ClinicalTrials.gov (identifier: NCT01895023).

Postoperative inguinal pain and disability after Lichtenstein versus ONSTEP hernia repair: analysis of responses to the inguinal pain questionnaire in Spanish

PURPOSE

To validate the Inguinal Pain Questionnaire (IPQ) in the Spanish Language and test its use in a randomized controlled trial (RCT) of hernia repair using the Lichtenstein technique vs. the ONSTEP technique. We simplified the IPQ using a principal component analysis (PCA) approach as a secondary objective.

METHODS

The IPQ was translated into Spanish and validated in a cohort of 21 patients. Thereafter, 40 patients were randomized to undergo hernia repair by the Lichtenstein technique or the ONSTEP technique. IPQ and pain visual analogue (VAS) score trends over time were compared using a repeated-measures mixed-effects model.

RESULTS

The Spanish version of the IPQ showed an internal consistency similar to that of the original score. No significant differences were found in the IPQ responses, pain VAS, or the rate of self-reported pain between patients who underwent the Lichtenstein technique and those who underwent the ONSTEP technique. Following PCA analysis, the number of items on the IPQ was reduced from 18 to 10.

CONCLUSIONS

The Spanish version of the IPQ measures postoperative inguinal pain adequately. Based on our findings, the ONSTEP technique was not superior to the Lichtenstein technique. The simplified version of the IPQ is not significantly different from the full version and it is easier to complete.

CLINICAL TRIAL REGISTRATION

NCT04138329, registered on October 24, 2019.

Observation of Emergency Room Nurses Managing Pediatric Pain: Care to Be Given… Care Given…

BACKGROUND

Although pain undeniably has negative consequences, pain management often remains suboptimal, particularly in the pediatric population in the emergency room (ER).

AIM

In this observational study using qualitative and quantitative methods, we investigated everyday adherence to current nursing best-practice pediatric guidelines in the ER paying particular attention to the interaction between children, parents, and nurses.

METHODS

An adapted version of the nursing observation tool for pain management was used to describe pediatric pain management provided by nurses caring for children (0-14 years old) admitted to the ER. We also assessed child-parent-nurse interactions. (The aim of the study was presented to the nurses as part of the survey on interactions without specifying the focus on pain management.) RESULTS: Forty-seven children were included (91 painful episodes) during the observation period (112 hours). There was a screening for pain in 55% of cases, and pain scales were used in 10% of cases. Analgesic treatments were administered in 75% of cases (procedural or disease-related pain). Follow-up evaluations were performed in 19% of cases. Nonpharmacologic approaches were scarcely used. The use of both helpful and nonhelpful languages were noted during interactions with children and parents. Parents' collaboration was rarely requested to help relieve their child's pain.

CONCLUSIONS

Our results show that pediatric pain management in the ER could be optimized. Parents are still not considerably involved in their child's pain management. Parents' involvement could contribute to improving pediatric pain management.

Validation of the UNESP-Botucatu pig composite acute pain scale (UPAPS)

The creation of species-specific valid tools for pain assessment is essential to recognize pain and determine the requirement and efficacy of analgesic treatments. This study aimed to assess behaviour and investigate the validity and reliability of an acute pain scale in pigs undergoing orchiectomy. Forty-five pigs aged 38±3 days were castrated under local anaesthesia. Behaviour was video-recorded 30 minutes before and intermittently up to 24 hours after castration. Edited footage (before surgery, after surgery before and after rescue analgesia, and 24 hours postoperatively) was analysed twice (one month apart) by one observer who was present during video-recording (in-person researcher) and three blinded observers. Statistical analysis was performed using R software and differences were considered significant when p<0.05. Intra and inter-observer agreement, based on intra-class correlation coefficient, was good or very good between most observers (>0.60), except between observers 1 and 3 (moderate agreement 0.57). The scale was unidimensional according to principal component analysis. The scale showed acceptable item-total Spearman correlation, excellent predictive and concurrent criterion validity (Spearman correlation ≥ 0.85 between the proposed scale versus visual analogue, numerical rating, and simple descriptive scales), internal consistency (Cronbach's α coefficient >0.80 for all items), responsiveness (the pain scores of all items of the scale increased after castration and decreased after intervention analgesia according to Friedman test), and specificity (> 95%). Sensitivity was good or excellent for most of the items. The optimal cut-off point for rescue analgesia was ≥ 6 of 18. Discriminatory ability was excellent for all observers according to the area under the curve (>0.95). The proposed scale is a reliable and valid instrument and may be used clinically and experimentally to assess postoperative acute pain in pigs. The well-defined cut-off point supports the evaluator´s decision to provide or not analgesia.

Development, Preliminary Validation, and Refinement of the Composite Oral and Maxillofacial Pain Scale-Canine/Feline (COPS-C/F)

Objectives: Oral pain is underrecognized and undertreated in small animal practice. This study aimed to develop and perform a preliminary validation of an instrument to evaluate oral and maxillofacial pain in dogs and cats. Methods: Indicators potentially associated with oral pain in dogs and cats were identified and selected. The Composite Oral Pain Scale-Canine/Feline (COPS-C/F) in the Italian language was developed using a two-part questionnaire (owner and veterinary specific questionnaires). The instrument was used to score the intensity of oral and maxillofacial pain in patients with oral disease. Content validity was performed and the COPS-C/F was applied to 20 dogs and 16 cats with oral disease at baseline and 15 days after dental treatment for construct validity. Criterion validity was assessed by comparing the COPS-C/F with a visual analog scale (VAS), a numeric rating scale (NRS), and a simple descriptive scale (SDS). Construct validity/responsiveness and criterion validity were assessed with Wilcoxon and Spearman Pearson tests, respectively (p ≤ 0.05). The Cronbach's alpha coefficient was used to calculate internal consistency. Thereafter, the instrument was refined and translated to English and back-translated for semantic equivalence. Results: Construct validity was confirmed with a significant reduction of pain scores after treatment (p < 0.05) for most items. Criterion validity was confirmed by a significant correlation among the COPS-C/F total pain scores and those from VAS, NRS, and SDS (p < 0.05). Cronbach's alpha coefficient was 0.876 and 0.860 for the owner and the veterinary specific questionnaires, respectively, indicating good internal consistency. The items that did not present significant differences between time-points and the VAS, NRS, and SDS were removed prior to translation to English (COPS-C/F ENG). Conclusions and Clinical Relevance: The study described the development and preliminary validation of the COPS-C/F as an instrument for pain assessment in dogs and cats. Refinement and back-translation of COPS-C/F with semantic equivalency resulted in the COPS-C/F ENG consisting of six and four items for the owner and veterinary specific questionnaires, respectively. The English version requires further validation and testing using a larger number of patients in the clinical setting.

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period

Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.

Effectiveness of a hydrogel dressing as an analgesic adjunct to first aid for the treatment of acute paediatric thermal burn injuries: study protocol for a randomised controlled trial

Background

Burns are a painful and traumatic experience, particularly in children. Reduced pain and anxiety positively influences re-epithelialisation rates in paediatric burn patients, however current literature fails to fully explain the effects of pain and anxiety and their links with wound healing. This study will determine if Burnaid® hydrogel dressing is an effective treatment for reducing pain in the acute period of a burn injury. It is hypothesised that a reduction in pain will then improve re-epithelialisation time in comparison to plastic wrap, which is standard practice at our institution — a metropolitan tertiary paediatric hospital located in Brisbane, Australia.

Methods/design

A randomised controlled trial will be conducted to assess the effectiveness of Burnaid® as an analgesic adjunct to cold running water first aid for the treatment of paediatric burns. Participants will include children aged between 0 and 16 years with an acute thermal burn injury (total burn surface area < 20%) presenting to the Department of Emergency within 24 h of the burn occurring. Participants will be randomised into one of two groups: (1) Burnaid® hydrogel (intervention arm) or (2) plastic wrap (control arm). Participants will also be stratified into one of two groups based on factors that influence pain intensity: (1) high pain risk or (2) low pain risk. High pain risk factors include foot burns, hot coal/ash/fire pit burns, burn area greater than 5%, and circumferential burns. The primary outcome is the intervention’s effect on reducing acute pain. Secondary outcomes include days to re-epithelialisation, pulse rate, temperature, salivary cortisol and α-amylase, anxiety, and cost-effectiveness. Sample size calculations have shown that 36 participants will be recruited into each group.

Discussion

This study will provide comprehensive data on the analgesic properties of Burnaid® as an adjunct to first aid for the treatment of acute paediatric thermal burns. If the intervention is effective in reducing pain, Burnaid® will be integrated as standard practice within the hospital’s Department of Emergency. This study replicates a real-world scenario in order to identify clinically significant analgesic and wound-healing effects.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12617001274369. Prospectively registered on 5 Sept 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3057-x) contains supplementary material, which is available to authorized users.

Effects of remifentanil maintenance during recovery on emergence delirium in children with sevoflurane anesthesia

BACKGROUND

Emergence delirium is a common complication of sevoflurane anesthesia in children.

AIMS

We examined the effects of maintaining remifentanil infusion during the recovery period on the incidence of emergence delirium in preschool-age children undergoing strabismus surgery under sevoflurane anesthesia.

METHODS

Eighty children (aged 3-7 years) were randomly assigned to either the control group (group C; intraoperative remifentanil infusion) or the intervention group (group R; intraoperative remifentanil infusion followed by remifentanil maintenance during the recovery phase). Intraoperative remifentanil infusion (0.2 μg/kg/min) was discontinued upon surgery completion in the group C, and was maintained until the discharge criteria were met at a dose of 0.05 μg/kg/min in the group R. The incidence of emergence delirium was assessed using a five-point agitation scale and the Pediatric Anesthesia Emergence Delirium scale after arrival in the postanesthesia care unit. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale.

RESULTS

The incidence of emergence delirium according to the five-point agitation scale (scores ≥ 4) was lower in the group R (33.3%) compared to the group C (68.3%) (odds ratio 0.206; 95% CI 0.080 to 0.531; P = 0.002). Similar results were obtained using the Pediatric Anesthesia Emergence Delirium scale (scores > 12), with an incidence of 5.1% in the group R and 34.0% in the control group (odds ratio 0.104; 95% CI 0.022 to 0.497; P = 0.001). The Children's Hospital of Eastern Ontario Pain Scale scores and occurrence of postoperative adverse events including laryngospasm, desaturation, nausea, and vomiting were similar between the two groups.

CONCLUSION

Maintaining a low dose of remifentanil (0.05 μg/kg/min) throughout the recovery phase attenuated the incidence of emergence delirium in children undergoing strabismus surgery under sevoflurane anesthesia.

Refinement of the Montreal Instrument for Cat Arthritis Testing, for Use by Veterinarians: detection of naturally occurring osteoarthritis in laboratory cats

Objectives Feline osteoarthritis causes pain and disability. Detection and measurement is challenging, relying heavily on owner report. This study describes refinement of the Montreal Instrument for Cat Arthritis Testing, for Use by Veterinarians. Methods A video analysis of osteoarthritic (n = 6) and non-osteoarthritic (n = 4) cats facilitated expansion of scale items. Three successive therapeutic trials (using gabapentin, tramadol and oral transmucosal meloxicam spray) in laboratory cats with and without natural osteoarthritis (n = 12-20) permitted construct validation (assessments of disease status sensitivity and therapeutic responsiveness) and further scale refinements based on performance. Results Scale osteoarthritic sensitivity improved from phase I to phase III; phase III scale total score ( P = 0.0001) and 4/5 subcategories - body posture ( P = 0.0006), gait ( P = 0.0031), jumping (0.0824) and global distance examination ( P = 0.0001) - detected osteoarthritic cats. Total score inter-rater (intra-class correlation coefficients [ICC] = 0.64-0.75), intra-rater (ICC = 0.90-0.91) and overall internal consistency (Cronbach's alpha = 0.85) reliability were good to excellent. von Frey anesthesiometer-induced paw withdrawal threshold increased with gabapentin in phase I, in osteoarthritic cats ( P <0.001) but not in non-osteoarthritic cats ( P = 0.075). Night-time activity increased during gabapentin treatment. Objective measures also detected tramadol and/or meloxicam treatment effects in osteoarthritic cats in phases II and III. There was some treatment responsiveness: in phase I, 3/10 subcategory scores improved ( P <0.09) in treated osteoarthritic cats; in phase II, 3/8 subcategories improved; and in phase III, 1/5 subcategories improved ( P <0.096). Conclusions and relevance The revised scale detected naturally occurring osteoarthritis, but not treatment effects, in laboratory cats, suggesting future potential for screening of at-risk cats. Further study is needed to confirm reliability, validity (disease sensitivity and treatment responsiveness) and clinical feasibility, as well as cut-off scores for osteoarthritic vs non-osteoarthritic status, in client-owned cats.

Lateral Sinus Floor Elevation Performed with Trapezoidal and Modified Triangular Flap Designs: A Randomized Pilot Study of Post-Operative Pain Using Thermal Infrared Imaging

Purpose: Post-operative pain and swelling are frequently observed after sinus lift procedures. The aim of the present study was the clinical evaluation of swelling and pain of two different sinus flap lift techniques using a visual analogue scale (VAS), verbal rating scale (VRS), and infrared thermal imaging (i.e., thermography). Materials Methods: A randomized controlled trial was conducted with 15 patients (30 sinuses in total) randomly allocated into two groups. For the sinuses of Group I a trapezoidal flap was used, while for Group II a modified triangular flap without anterior release was utilized. Postoperative pain was scored by means of a 100-mm VAS ranging from 0 (no pain) to 100 (worst pain imaginable), and was recorded at 2, 4, 6 and 14 days after surgery. Swelling was recorded by a verbal rating scale (VRS) and was classified into four categories: a score of 1 referred the absence of swelling, patients with intra-oral swelling in the surgical zone scored 2, any extra-oral swelling in the surgical zone scored 3, and intense swelling exhibited by extra-oral swelling extending beyond the surgical zone scored 4. The facial temperature was recorded before and after sinus augmentation, and at 2, 4, 6, and 14 days post-surgery to check the course of healing. Results: In Group I pain intensity was recorded at 2 days after surgery with a mean score of 38.67 ± 6.4 mm. Swelling was greater at 2 and 4 days, and was absent at day 6. The facial temperature difference before and after the procedure was 4.737 &deg;C ± 0.37. In Group II the pain score were lower than in Group I (p < 0.05). The score for swelling was 2 on the first and second days, and was reduced on day 4. After the second day the difference in temperature was significantly reduced as compared to the day of surgery (0.77 &deg;C); at 2 and 4 days no difference was registered. Conclusions: The results of this clinical study show the significant effectiveness of the modified triangular flap in the sinus lift procedure for reducing pain and swelling.

A Systematic Review of the Psychometric Properties of the Modified Behavioral Pain Scale (MBPS)

PROBLEM

Clinicians and researchers require a valid way to assess procedural pain experienced by infants and children. The Modified Behavioral Pain Scale (MBPS) has been used to assess immunisation pain. However, it is unknown whether it is valid for this purpose and whether use can be extended to other procedures. The aim of this study was to rigorously assess evidence addressing the psychometric properties of this scale and to provide recommendations for its use.

ELIGIBILITY CRITERIA

Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the MBPS applied to children (birth to 18years) and randomised controlled trials (RCT) using the MBPS were included.

SAMPLE

Twenty-eight studies (8 psychometric and 20 RCTs) were included.

RESULTS

Studies were of varying quality. Sufficient data was available to cautiously accept the MBPS as valid for assessing immunisation related pain in infants aged 2 to 22months. There was insufficient data to support the psychometrics in other age groups or in circumstances other than immunisation. There is no data addressing the clinical utility of the MBPS.

CONCLUSIONS

It is not possible at this time to confidently accept the MBPS as suitable for assessing all procedural pain in young children.

IMPLICATIONS

Studies to evaluate the capacity of the MBPS to assess pain in a range of procedures and to distinguish between pain and non-pain related distress are needed if it is to be recommended.

The Psychometric Properties of the FLACC Scale Used to Assess Procedural Pain

The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is one of the most commonly and widely used behavioral observation pain scales. The aim of this study was to test the psychometric and practical properties of the FLACC scale to quantify procedural pain in infants and young children. Twenty-six clinicians independently applied the FLACC scale to segments of video collected from 100 children aged 6 to 42 months undergoing a procedure. Video segments were scored by 4 reviewers. Inter- and intrarater reliability coefficients were high (.92 and .87, respectively). Linear mixed modeling confirmed scale responsiveness (differences in difference between FLACC scores across phases for painful versus nonpainful procedures was 4.2, 95% confidence interval = 3.67-4.81). Sensitivity and specificity were 94.9% and 73.5%, respectively, at a cutoff of 2. However, the mean difference across phases for children with baseline scores >3 was much lower than for children with scores <3, P = .0001. Correlations between FLACC and Visual Analog Scale observer pain and distress were good (r = .74 and r = .89, respectively). This study supports the reliability and sensitivity of the FLACC scale for procedural pain assessment. However, the circumstances of procedures interfered with application of the scale and the findings question the capacity of the scale to differentiate between pain- and nonpain-related distress.

PERSPECTIVE

This article provides evidence that the FLACC scale is reliable and sensitive to pain for procedural pain assessment. Concerns remain about specificity and scale design. Identification of a scale valid for this purpose is needed to provide a platform for improved procedural pain management in infants and young children.

Objectively measuring pain using facial expression: is the technology finally ready?

Currently, clinicians observe pain-related behaviors and use patient self-report measures in order to determine pain severity. This paper reviews the evidence when facial expression is used as a measure of pain. We review the literature reporting the relevance of facial expression as a diagnostic measure, which facial movements are indicative of pain, and whether such movements can be reliably used to measure pain. We conclude that although the technology for objective pain measurement is not yet ready for use in clinical settings, the potential benefits to patients in improved pain management, combined with the advances being made in sensor technology and artificial intelligence, provide opportunities for research and innovation.

The Psychometric Properties of the MBPS Scale Used to Assess Procedural Pain

The Modified Behavioral Pain Scale (MBPS) was designed to assess procedural pain in infants and is considered valid for assessing immunization pain. The aim of this study was to assess the practical and psychometric properties of the MBPS when applied to other commonly performed procedures. Twenty-six clinicians independently applied the MBPS scale to segments of video collected from 100 infants and children aged 6 to 42 months undergoing 1 of 4 procedures in the emergency department. Positive correlation between MBPS and Visual Analogue Scale observer applied (VASobs) pain (r = .74) was shown and inter- and intrarater reliability coefficients were high (.87 and .89, respectively). Construct validity was shown by scale responsiveness to painful stimuli (4.6 times increase in scores across phases) and the capacity of the scale to distinguish between painful versus nonpainful procedures (P < .001). However, mean baseline scores for procedures were not 0 (likely a function of item descriptors for a "0" score) and the mean difference increased across phases for children with baseline scores >3, which was much lower than for children with scores <3 (P = .0001). Finally, 28% of scores changed after the second viewing of a video segment. The MBPS appears reliable and sensitive to procedural pain when applied by clinicians. Results question the capacity of the scale to differentiate between pain- and nonpain-related distress, the feasibility of this scale, and the appropriateness of item descriptors for medical procedures.

PERSPECTIVE

This article presents the psychometric and practical properties of the MBPS applied to assess procedural pain. Identification of a suitable scale for this purpose will support improved pain management in infants and young children who undergo painful procedures.

Sedation and analgesia for procedures in the pediatric emergency room

OBJECTIVE

Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area.

DATA SOURCES

Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included.

DATA SYNTHESIS

Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented.

CONCLUSIONS

The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.

Measuring Musculoskeletal Pain in Infants, Children, and Adolescents

Synopsis Accurate, reliable, and timely assessment of pain is critical for effective management of musculoskeletal pain conditions. The assessment of pain in infants, children, and adolescents with and without cognitive impairment can be particularly challenging to clinicians for a number of reasons, including factors related to the consultation (eg, heterogeneous patient population, time constraints), the clinician (eg, awareness/knowledge of available pain scales), standardized assessment scales (eg, availability, psychometric properties, and application of each scale), the patient (eg, developmental stage, ability to communicate), and the context in which the interaction took place (eg, familiarity with the setting and physiological and psychological state). As a result, pain is frequently not assessed or measured during the consultation and, in many instances, underestimated and undertreated in this population. The purpose of this article is to provide clinicians with an overview of scales that may be used to measure pain in infants, children, and adolescents. Specifically, the paper reviews the various approaches to measure pain intensity; identifies factors that can influence the pain experience, expression, and assessment in infants, children, and adolescents; provides age-appropriate suggestions for measuring pain intensity in patients with and without cognitive impairment; and identifies ways to assess the impact of pain using multidimensional pain scales. J Orthop Sports Phys Ther 2017;47(10):712-730. doi:10.2519/jospt.2017.7469.

Assessment of paediatric pain: a critical review

Pain is a complex experience, and its quantification involves many aspects including physiological, behavioural, and psychological factors. References related to the topic were selected and analysed, along with a PubMed search of the recent and earlier reports. Assessment of pain in infants and children has always been a dilemma for the clinicians. Unlike in adults, it is difficult to assess and effectively treat pain in paediatric age groups, and it often remains untreated or undertreated. Misperceptions are attributed not only to the difficulties in isolating the specific signs of pain but also in recognising and inferring the meaning of the cues available in the complex of individual differences in the reaction pattern of children to pain. In children, several parameters such as age, cognitive level, type of pain, etc. are required to be considered for the selection of appropriate pain assessment tools. Although considerable progress has been made, there is a critical need for a more accurate measurement tool for both research and clinical purposes. This review has critically analysed the various techniques available to assess pain in children with emphasis on current research and present-day status of paediatric pain assessment.

Validation of the Italian version of the UNESP-Botucatu unidimensional composite pain scale for the assessment of postoperative pain in cattle

OBJECTIVE

The aim of this study was to validate the Italian version of the UNESP-Botucatu Unidimensional Composite Pain Scale (UCPS-IV) for assessing postoperative pain in cattle.

STUDY DESIGN

Video analysis and psychometric testing.

ANIMALS

A total of 40 Nellore cattle, age 2-3 years, weighing 365±51 kg.

METHODS

An English version of the scale was translated to Italian and back translated to English to ensure semantic equivalence. A total of four Italian observers and the researcher who developed the original scale (considered as the gold standard) analysed videos of 40 cattle previously subjected to orchiectomy (recorded for each cattle at four predetermined timepoints during the perioperative period) unaware of the videos' timepoint. They assigned a pain score [ranging from no pain (0) to severe pain (10)] using the Italian version of the scale and verified the need for analgesic treatment for each animal. The obtained scores were subjected to psychometric validity, responsiveness and reliability tests.

RESULTS

The factor analysis of the scale resulted in a one-factor solution. Significant changes in pain scores in response to surgery and analgesics confirmed not only the content and construct validity, but also responsiveness. The agreement between the researcher who developed the original scale and the blinded observers and the correlation between the pain scores determined by the scale and those determined by three classical unidimensional pain scales confirmed criterion and concurrent validity. Internal consistency of the scale was excellent. Inter- and intrarater reliability ranged from moderate to good and from moderate to very good for all scale items, respectively, supporting reproducibility and stability. The cut-off point for rescue analgesia calculated by the receiver operating characteristic curve was > 3.

CONCLUSIONS AND CLINICAL RELEVANCE

The results confirm that the UNESP-Botucatu UCPS-IV appears to be a valid and reliable tool for the assessment of postorchiectomy pain in the bovine species. The determination of a cut-off point for rescue analgesia is also helpful for guiding analgesic therapy.

Topical anaesthetics for pain control during repair of dermal laceration

BACKGROUND

Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine-free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017.

OBJECTIVES

To assess whether benefits of non-invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single-component or multi-component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine.

SEARCH METHODS

For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta-registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence.

MAIN RESULTS

The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self-reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine-phenylephrine (PP) was higher than the mean self-reported VAS (0 to 100 mm) score for topical tetracaine-epinephrine-cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine-free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine-based or cocaine-free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.

AUTHORS' CONCLUSIONS

We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously.Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non-invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine-based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.

Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study

INTRODUCTION

Procedural sedation and analgesia (PSA) are frequently used for fracture reduction in pediatric emergency departments (ED). Combining intranasal (IN) fentanyl with inhalation of nitrous oxide (N₂O) allow for short recovery time and obviates painful and time-consuming IV access insertions.

METHODS

We performed a bicentric, prospective, observational cohort study. Patients aged 4-18years were included if they received combined PSA with IN fentanyl and N₂O for the reduction of mildly/moderately displaced fracture or of dislocation. Facial Pain Scale Revised (FPS-R) and Face, Leg, Activity, Cry, Consolability (FLACC) scores were used to evaluate pain and anxiety before, during and after procedure. University of Michigan Sedation Score (UMSS), adverse events, detailed side effects and satisfaction of patients, parents and medical staff were recorded at discharge. A follow up telephone call was made after 24-72h.

RESULTS

90 patients were included. There was no difference in FPS-R during the procedure (median score 2 versus 2), but the FLACC score was significantly higher as compared to before (median score 4 versus 0, Δ 2, 95% CI 0, 2). Median UMSS was 1 (95% CI 1, 2). We recorded no serious adverse events. Rate of vomiting was 12% (11/84). Satisfaction was high among participants responding to this question 85/88 (97%) of parents, 74/83 (89%) of patients and 82/85 (96%) of physicians would want the same sedation again.

CONCLUSION

PSA with IN fentanyl and N₂O is effective and safe for the reduction of mildly/moderately displaced fracture or dislocation, and has a high satisfaction rate.

Pain Measurement through Temperature Changes in Children Undergoing Dental Extractions

Background and Objective. Pain evaluation in children can be a difficult task, since it possesses sensory and affective components that are often hard to discriminate. Infrared thermography has previously been used as a diagnostic tool for pain detection in animals; therefore, the aim of this study was to assess the presence of temperature changes during dental extractions and to evaluate its correlation with heart rate changes as markers of pain and discomfort. Methods. Thermographic changes in the lacrimal caruncle and heart rate measurements were recorded in healthy children scheduled for dental extraction before and during the procedure and compared. Afterwards, correlation between temperature and heart rate was assessed. Results. We found significant differences in temperature and heart rate before the procedure and during the dental extraction (mean difference 4.07°C, p < 0.001, and 18.11 beats per minute, p < 0.001) and no evidence of correlation between both measurements. Conclusion. Thermographic changes in the lacrimal caruncle can be detected in patients who undergo dental extractions. These changes appear to be stable throughout time and to possess very little intersubject variation, thus making them a candidate for a surrogate marker of pain and discomfort. Future studies should be performed to confirm this claim.

Efficacy of Intraoperative Dexmedetomidine Compared with Placebo for Postoperative Pain Management: A Meta-Analysis of Published Studies

Introduction

Dexmedetomidine (Dex) has sedative, analgesic, and anesthetic-sparing effects. This meta-analysis examines demonstrated intraoperative and postoperative effects of intraoperative Dex administration during pediatric surgery.

Methods

A search for randomized placebo-controlled trials was conducted to identify clinical trials examining intraoperative Dex use in children, infants, and neonates. Primary outcome was postoperative opioid consumption; secondary outcomes were: postoperative pain intensity and postoperative nausea and vomiting (PONV).

Results

Fourteen randomized controlled trials performed during painful procedures were analyzed. Intraoperative Dex administration was associated with significantly reduced postoperative opioid consumption in the postanesthesia care unit [PACU; risk ratio (RR) = 0.31 (0.17, 0.59), I² = 76%, p < 0.0001 and cumulative z score using trial sequential analysis], decreased pain intensity in PACU [standardized mean difference (SMD) = −1.18 (−1.88, −0.48), I² = 91%, p < 0.0001] but had no effect upon PONV incidence [RR = 0.67 (0.41, 1.08), I² = 0%, p = 0.48]. Subgroup analyses found administering Dex during adenotonsillectomy and using a bolus <0.5 µg/kg (irrespective to the use of a continuous administration) without effects on studies outcomes. Heterogeneity was high among results and a high suspicion of publication bias was present for all analyzed outcomes.

Conclusions

This meta-analysis shows that intraoperative Dex administration in children reduces postoperative opioids consumption and postoperative pain in PACU. According to our results, optimal bolus dose was found to be ≥0.5 µg/kg. Future studies have to explore this particular point and the postoperative analgesic effects of Dex during longer periods.

Evaluation of Anesthesia Profile in Pediatric Patients after Inguinal Hernia Repair with Caudal Block or Local Wound Infiltration

AIM:

The aim of this study is to evaluate anesthesia and recovery profile in pediatric patients after inguinal hernia repair with caudal block or local wound infiltration.

MATERIAL AND METHODS:

In this prospective interventional clinical study, the anesthesia and recovery profile was assessed in sixty pediatric patients undergoing inguinal hernia repair. Enrolled children were randomly assigned to either Group Caudal or Group Local infiltration. For caudal blocks, Caudal Group received 1 ml/kg of 0.25% bupivacaine; Local Infiltration Group received 0.2 ml/kg 0.25% bupivacaine. Investigator who was blinded to group allocation provided postoperative care and assessments. Postoperative pain was assessed. Motor functions and sedation were assessed as well.

RESULTS:

The two groups did not differ in terms of patient characteristic data and surgical profiles and there weren’t any hemodynamic changes between groups. Regarding the difference between groups for analgesic requirement there were two major points - on one hand it was statistically significant p < 0.05 whereas on the other hand time to first analgesic administration was not statistically significant p = 0.40. There were significant differences in the incidence of adverse effects in caudal and local group including: vomiting, delirium and urinary retention.

CONCLUSIONS:

Between children undergoing inguinal hernia repair, local wound infiltration insures safety and satisfactory analgesia for surgery. Compared to caudal block it is not overwhelming. Caudal block provides longer analgesia, however complications are rather common.

Preliminary Validation and Reliability Testing of the Montreal Instrument for Cat Arthritis Testing, for Use by Veterinarians, in a Colony of Laboratory Cats

Simple Summary

Feline osteoarthritis (OA) is challenging to diagnose. A pain scale was developed for use by veterinarians, in association with their physical examination, and tested for reliability and validity. The scale items were: Interaction with the examiner, Exploration of the room, Body Posture, Gait, Body Condition, condition of Coat and Claws, and abnormal Findings or Cat Reaction upon joint Palpation. Expert review supported the scale content. Two studies using laboratory-housed cats found the most promising results for Gait and Body Posture, in terms of distinguishing between OA and non-OA cats, repeatability of results, and correlations with objectively measured kinetics (weight-bearing).

Abstract

Subtle signs and conflicting physical and radiographic findings make feline osteoarthritis (OA) challenging to diagnose. A physical examination-based assessment was developed, consisting of eight items: Interaction, Exploration, Posture, Gait, Body Condition, Coat and Claws, (joint) Palpation–Findings, and Palpation–Cat Reaction. Content (experts) and face (veterinary students) validity were excellent. Construct validity, internal consistency, and intra- and inter-rater reliability were assessed via a pilot and main study, using laboratory-housed cats with and without OA. Gait distinguished OA status in the pilot (p = 0.05) study. In the main study, no scale item achieved statistically significant OA detection. Forelimb peak vertical ground reaction force (PVF) correlated inversely with Gait (Rho_s = −0.38 (p = 0.03) to −0.41 (p = 0.02)). Body Posture correlated with Gait, and inversely with forelimb PVF at two of three time points (Rho_s = −0.38 (p = 0.03) to −0.43 (p = 0.01)). Palpation (Findings, Cat Reaction) did not distinguish OA from non-OA cats. Palpation—Cat Reaction (Forelimbs) correlated inversely with forelimb PVF at two time points (Rho_s = −0.41 (p = 0.02) to −0.41 (p = 0.01)), but scores were highly variable, and poorly reliable. Gait and Posture require improved sensitivity, and Palpation should be interpreted cautiously, in diagnosing feline OA.

A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children

STUDY OBJECTIVE

The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray.

METHODS

Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2).

RESULTS

Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups.

CONCLUSION

Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment.

Rapid administration technique of ketamine for pediatric forearm fracture reduction: a dose-finding study

STUDY OBJECTIVE

We estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing forearm fracture reduction in the emergency department.

METHODS

We used the up-down method to estimate the median dose of intravenous ketamine infused during less than or equal to 5 seconds that provided effective sedation in 50% (ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17 years who were undergoing forearm fracture reduction. Most patients were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was assessed by modified Aldrete score.

RESULTS

We enrolled 20 children in each age group. The estimated ED50 was 0.7, 0.5, and 0.6 mg/kg and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups aged 2 to 5, 6 to 11, and 12 to 17 years, respectively. For the group aged 2 to 5 years, an empirically derived ED95 was 0.8 mg/kg. All patients who received the empirically derived ED95 in the group aged 2 to 5 years or the estimated ED95 in the groups aged 6 to 11 and 12 to 17 years had effective sedation. The median total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25 minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if additional doses were administered. No participant experienced serious adverse events.

CONCLUSION

We estimated ED50 and ED95 for rapidly infused ketamine for 3 age groups undergoing fracture reduction. Total sedation time was shorter than that in most previous studies.