Procedural Pain Scale Evaluation (PROPoSE) study: protocol for an evaluation of the psychometric properties of behavioural pain scales for the assessment of procedural pain in infants and children aged 6-42 months

Hydrogel burn dressing effectiveness in burn pain

Severe burns are painful and dramatic injuries. Studies show that pain is underestimated and often not adequately treated. This study aims to evaluate the analgesic efficacy of hydrogel burn dressing and silver sulfadiazine, which are two agents commonly used in first-aid dressings for burn patients. This study, designed as a prospective, observational, and cross-sectional study. Study included 64 pediatric patients admitted to our burn center between 01.03.2020 and 01.09.2020 who were examined by our burn service after their first treatment in the emergency dressing room. Two groups of patients were included in the study. Pain level was assessed in the dressing room before and 10 min after the procedure using the Visual Analog Scale and FLACC (Face, Legs, Activity, Cry, Consolability) pain assessment scales.During the study period, Burnaid® was applied to 62.5% of patients (40 patients) and silver sulfadiazine to 37.5% (24 patients). In terms of pain scores, pre-dressing FLACC values were higher in Group B (p = 0.039); post-dressing VAS and FLACC values were significantly lower in group B (p 0.001; p 0.001). In terms of additional analgesia, we found more patients in Group S received analgesics (p 0.001).We believe that its effect on burn wound pain is superior to that of silver sulfadiazine.

The Clinical Suitability of an Artificial Intelligence-Enabled Pain Assessment Tool for Use in Infants: Feasibility and Usability Evaluation Study

BACKGROUND

Infants are unable to self-report their pain, which, therefore, often goes underrecognized and undertreated. Adequate assessment of pain, including procedural pain, which has short- and long-term consequences, is critical for its management. The introduction of mobile health-based (mHealth) pain assessment tools could address current challenges and is an area requiring further research.

OBJECTIVE

The purpose of this study is to evaluate the accuracy and feasibility aspects of PainChek Infant and, therefore, assess its applicability in the intended setting.

METHODS

By observing infants just before, during, and after immunization, we evaluated the accuracy and precision at different cutoff scores of PainChek Infant, which is a point-of-care mHealth-based solution that uses artificial intelligence to detect pain and intensity based solely on facial expression. We used receiver operator characteristic analysis to assess interpretability and establish a cutoff score. Clinician comprehensibility was evaluated using a standardized questionnaire. Other feasibility aspects were evaluated based on comparison with currently available observational pain assessment tools for use in infants with procedural pain.

RESULTS

Both PainChek Infant Standard and Adaptive modes demonstrated high accuracy (area under the curve 0.964 and 0.966, respectively). At a cutoff score of ≥2, accuracy and precision were 0.908 and 0.912 for Standard and 0.912 and 0.897 for Adaptive modes, respectively. Currently available data allowed evaluation of 16 of the 17 feasibility aspects, with only the cost of the outcome measurement instrument unable to be evaluated since it is yet to be determined. PainChek Infant performed well across feasibility aspects, including interpretability (cutoff score defined), ease of administration, completion time (3 seconds), and clinician comprehensibility.

CONCLUSIONS

This work provides information on the feasibility of using PainChek Infant in clinical practice for procedural pain assessment and monitoring, and demonstrates the accuracy and precision of the tool at the defined cutoff score.

Spanish version of the Pediatric Anesthesia Emergence Delirium scale: translation and cross-cultural adaptation

Background

Emergence delirium (ED) is a mental disturbance in children during recovery from general anaesthesia. The Pediatric Anesthesia Emergence Delirium (PAED) scale is the only validated scale that assesses ED in paediatric patients undergoing general anaesthesia. The aim of this study was the translation and cross-cultural adaptation of the PAED scale into Spanish (Chile). 

Methods

A five-stage translation and cross-cultural adaptation process was carried out. The reliability of the Spanish version of the PAED scale was evaluated in paediatric patients independently by a set of two raters (anaesthesiologists or postanaesthesia care unit nurses) in the postanaesthetic period after major outpatient surgery. ED was defined by a cut-off level of ≥ 10 points on the PAED scale. 

Results

The PAED scale was evaluated in 353 consecutive children. Patients had a mean age of 7.4 ± 3.22 years. The preoperative ASA Physical Status class was 62%, 37%, and 1% (ASA class I, II and III, respectively). The distribution of patients by service was as follows: 45% of patients underwent paediatric surgery; 33% underwent otorhinolaryngological surgery; 11% underwent orthopaedic surgery; 10% underwent ophthalmological surgery; and 1% underwent other types of surgery. The interrater agreement ranged from 96.9% to 97.9%, with Kappa values ranging from 0.59 to 0.79. The Cronbach’s alpha value was 0.91. The ED global incidence was 9.1% and was higher in the younger age groups (3–10 years).

Conclusions

The translated and cross-culturally adapted Spanish version of the PAED scale is a reliable instrument to measure ED in the postanaesthetic period in Chilean children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01893-1.

Bristol Rabbit Pain Scale (BRPS): clinical utility, validity and reliability

Background

The Bristol Rabbit Pain Scale (BRPS) was developed using a combination of methods, focus groups and behavioural observation, that led to a composite pain scale of six categories (Demeanour, Locomotion, Posture, Ears, Eyes and Grooming) with four intensities of pain (0, 1, 2, and 3), and a total score of 0–18. The aim of this study was to assess the clinical utility, validity and reliability of the BRPS.

Materials and methods

The clinical utility of the BRPS was tested using a questionnaire composed of ten questions each on a five-point Likert scale ranging from one (strongly disagree) to five (strongly agree). The respondents, (veterinary surgeons and veterinary nurses), were asked to assess up to four rabbits in acute pain, using the novel pain. They then completed the questionnaire which asked whether the BRPS was easy and quick to use and whether it provided information that was clinically useful. The questionnaire was tested for internal reliability using the Cronbach’s alpha reliability coefficient. The construct validity (how well the tool measures the concept it was designed for) was measured by observers blindly rating 20 rabbits pre- and post-surgery whilst the criterion validity (the degree to which the tool correlates with a gold standard) was assessed by correlating BRPS scores with scores using a numerical rating scale (NRS) with a total score of 0–10. Inter-rater reliability was tested by quantifying the agreement in the pain scores given by nine participants when assessing the same 40 video clips. The intra-rater reliability was measured by testing how consistent the participants were when rating the same clips one month later.

Results

The median score of the ten questions of the clinical utility test was 4 (range 2–5). The Cronbach’s alpha reliability coefficient of the clinical utility test was good (α = 0.811) demonstrating good internal consistency. The median (range) pain score of the BRPS and the NRS were 3 (0–14) and 0 (0–8) before surgery and 12 (1–18) and 7 (0–10) after surgery respectively. The BRPS demonstrated high construct validity (Z = -11.452; p < 0.001) and there was a strong correlation between the BRPS and the NRS (Rho = 0.851; p < 0.001) indicating high criterion validity. The inter-rater and the intra-rater agreements were α = 0.863 and α = 0.861 respectively, which is considered good.

Conclusions

This study showed that the BRPS is a suitable tool for quantifying pain in rabbits in a clinically useful, valid and reliable way.

Safety and tolerance of Lacticaseibacillus paracasei N1115 in caesarean-born young children: a randomised, placebo-controlled trial

The administration of probiotics may help to improve dysbiosis and related health problems in children delivered by caesarean section. However, the effects are strain specific, and safety combined tolerance are considered a priority. The aim of this study was to evaluate the safety and tolerance of Lacticaseibacillus paracasei N1115 in caesarean-born children aged 6-24 months via a randomised, placebo-controlled intervention study. In total, 101 children were included and randomised to receive either a sachet of L. paracasei N1115 (2×1010 cfu/g, 2 g/day) or placebo (maltodextrin, 2 g/day) per day for 12 weeks. Anthropometric parameters were measured by trained nurses, and defecation characteristics, gastrointestinal symptoms, (serious) adverse events ((s)AEs), crying patterns and lifestyle behaviours were recorded by parents or guardians. Neurocognitive development was assessed by the Ages and Stages Questionnaires-3 (ASQ-3) before and after the intervention. The only difference between groups regarding defecation characteristics was a significant treatment × time effect on stool frequency (P=0.007), as the number of defecations was significantly higher in the probiotic group (around 1.2-1.3 times/day) than in the placebo group (around 1.0 times/day) in the later intervention period (P=0.035 at week 9; P=0.048 at week 10; P=0.026 at week 12). The use of L. paracasei N1115 also reduced the incidence rate of constipation (Incidence rate ratio (IRR): 0.120; 95% confidence interval (CI): 0.015, 0.967; P=0.046) and abdominal pain (IRR: 0.562; 95% CI: 0.358, 0.882; P=0.012). Changes in anthropometric parameters, including weight, height and head circumference, did not differ significantly between groups, nor did measures of crying, sleep, outdoor activity, temper, appetite or the ASQ-3 scores. No adverse events associated with consumption of the probiotic were reported. Thus, the administration of L. paracasei N1115 is safe and well-tolerated in caesarean-born children aged 6-24 months. Furthermore, it may ameliorate gastrointestinal function to some extent.

The Psychometric Properties of the Visual Analogue Scale Applied by an Observer to Assess Procedural Pain in Infants and Young Children: An Observational Study

PURPOSE

The Visual Analogue Scale applied by an observer (VASobs) is widely used to quantify pain but the evidence to support validity is poor. The aim of this study was to evaluate the psychometric and practical properties of the VASobs used to assess procedural pain in infants and young children.

DESIGN AND METHODS

In an observational study, 26 clinicians applied the VASobs independently to video segments of 100 children aged six to 42 months undergoing a procedure to generate pain and distress scores. Each video segment was scored by four randomly selected reviewers.

RESULTS

Reliability for pain scores was poor to fair (ICC 0.35 to 0.55) but higher for distress scores (ICC 0.6 to 0.89). At a cut-off score of 3, sensitivity and specificity were 84.7% and 95.0%, respectively for pain and 91.5% and 77.5% respectively for distress. Linear mixed modelling confirmed responsiveness. An increase in pain scores (regression slope 4.95) and distress scores (regression slope 5.52) across phases (baseline to procedure) was seen for painful procedures. The correlation between VASobs pain and FLACC scores was good (r = 0.74) and correlations between VASobs distress and FLACC scores were excellent (r = 0.89).

CONCLUSION

VASobs was easily applied and preferred by clinicians. Despite evidence of sensitivity and responsiveness to pain, the reliability results were poor, and this scale cannot be recommended for use.

PRACTICE IMPLICATIONS

The results of this study prevent recommending the VASobs for assessing procedural pain in infants and young children for clinical or research purposes.

Comparison of the Psychometric Properties of the FLACC Scale, the MBPS and the Observer Applied Visual Analogue Scale Used to Assess Procedural Pain

Purpose

The purpose of this study was to compare the psychometric data and feasibility and clinical utility of the Face Legs, Activity, Cry and Consolability scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs) used to assess procedural pain in infants and young children.

Patients and Methods

Twenty-six clinicians assessed videorecorded segments of 100 infants and young children who underwent a painful and/or distressing procedure in the emergency department using the FLACC scale, the MBPS and the VASobs pain and VASobs distress.

Results

VASobs pain scores were lowest across all procedures and phases of procedures (p < 0.001). Inter-rater reliability was lowest for VASobs pain scores (ICC 0.55). Sensitivity and specificity were highest for FLACC scores (94.9% and 72.5%, respectively) at the lowest cut-off score (pain score two). Observers changed their MBPS scores more often than they changed FLACC or VASobs scores, but FLACC scores were more often incomplete. Reviewers did not consider any scale of use for procedural pain measurement.

Conclusion

The reliability and sensitivity of the FLACC and MBPS were supported by study data but concerns about the capacity of these scales to distinguish between pain- and non-pain-related distress were raised. The VASobs cannot be recommended. Despite its limitations, the FLACC scale may be better suited than other scales for procedural pain measurement.

Comparison of bupivacaine alone and in a combination with lidocaine for caudal block in patients undergoing circumcision: A historical cohort study

OBJECTIVE

Optimal analgesia following ambulatory surgery is an important matter in patient satisfaction, and it reduces unnecessary hospital admissions. This study investigated whether a caudal block with bupivacaine alone or in a combination with lidocaine can alter postoperative pain scores, complications, and peroperative and postoperative analgesic consumption.

MATERIAL AND METHODS

This is a retrospective study that included children who underwent elective circumcision surgery under general anesthesia and caudal analgesia between January and June 2018. Among the 103 children, 17 cases were not analyzed due to an unsuccessful caudal block and procedures simultaneously underwent another operation unrelated to circumcision. We divided the study participants into two groups according to the type of local anesthetic applied: 0.5 mL/kg 0.25% bupivacaine (Group B) and 0.5 mL/kg 0.25% bupivacaine + 3 mg/kg 1% lidocaine (Group BL) caudally.

RESULTS

Pain scores were similar between these groups and remained in the mild-to-moderate range throughout the hospitalization (p>0.05). There were significant differences regarding the rescue analgesic use, first micturition, and mobilization times (p<0.001). In addition, we applied the multivariable logistic regression for fentanyl consumption adjusted for first mobilization and micturition time, unlike mobilization, a significantly increased risk for postoperative delayed micturition (OR, 1.06; 95% CI, 1.0-1.12; p=0.038) was found with intra-operative intravenous fentanyl use.

CONCLUSION

Our results suggest that the caudal block with a lidocaine+bupivacaine combination decreases rescue analgesic consumption at day-case surgery. In circumcision procedures, the caudal block is an effective and safe analgesic method for intraoperative and postoperative pain control with no side effects. This trial was registered at Clinicaltrals.gov, NCT03911648.

The Effect of Progressive Muscle Relaxation Exercises on Pain on Patients with Sickle Cell Disease: Randomized Controlled Study

PURPOSE

The study aimed to evaluate the effect of progressive muscle relaxation exercises on pain in patients with sickle cell disease.

MATERIALS-METHOD

This randomized controlled interventional study was conducted in a hospital in Mersin, Turkey between October 2017 and July 2018. The study sample comprised 58 patients who were aged >18 years, conscious, had sickle cell disease, reported pain, and were treated with non-opioid or weak opioid analgesic based on the physician's recommendation (treatment group = 29, control group = 29). Data were collected by the individual presentation form and visual analog scale. During the study, both groups were treated with analgesics prescribed by the physician for three days. In addition to the analgesics, the treatment group was performed progressive muscle relaxation exercises for 30 minutes whereas the control group was rested. Pain level of both groups was evaluated at three time points every day for three days. In the study, frequency distributions and descriptive statistics were presented for categorical and numerical variables, respectively. Chi-square analysis, independent samples t-test, Mann-Whitney U test, three-way ANOVA, and Sidak test were used to analyze the difference between the variables.

RESULTS

The mean age of the patients was 29.59 ± 6.94 years, and 53.4% of the patients were female and 69% were single. The mean pain score of the treatment group at the third time point on days 1, 2, and 3 was significantly lower than the control group (p < .05). There was no statistically significant difference between the two groups in terms of coping methods for pain, pain location, and complaints accompanying pain (p > .05).

CONCLUSION

Progressive muscle relaxation exercises were found to be effective in the pain management of patients with sickle cell anemia.

Pain experienced by infants and toddlers at urine collection bag removal: A randomized, controlled, clinical trial

BACKGROUND

In pre-continent children, collection bags are frequently used as a first-line option to obtain a urine specimen. This practice, acknowledged by several guidelines for the step of UTI screening, is driven by a perception of the technique as being more convenient and less painful. However, our own experience led us to consider bag removal as a painful experience.

OBJECTIVE

Our aim was to determine whether the use of an oleo-calcareous liniment to aid bag removal reduced the acute pain expressed by young children.

METHODS

This prospective, randomized, controlled, single blind study was carried out in two emergency pediatrics departments. Pre-continent children aged 0-36 months admitted with an indication for urine testing were eligible for the study. Urine for dipstick test screening was obtained using a collection bag. At micturition, the patients were randomized into bag removal with (intervention group) or without (control group) liniment. Bag removal was recorded on video in such a manner as to permit independent assessments of pain by two evaluators blinded to group allocation. Pain was assessed using the FLACC scale.

FINDINGS

135 patients were analyzed: 70 in the intervention group and 65 in the control group. The median FLACC scores [interquartile range] for the intervention and control groups, respectively 4.0 [2.0-7.0] and 4.0 [3.0-7.0], did not differ significantly (p = 0.5). A FLACC score ≥4 was obtained for 56% of the patients and a score ≥7 for 28%.

CONCLUSION

Removal of urine collection bags caused moderate to severe pain in half of the children included. The use of an oleo-calcareous liniment did not reduce this induced pain.

Combined nitrous oxide 70% with intranasal fentanyl for procedural analgosedation in children: a prospective, randomised, double-blind, placebo-controlled trial

OBJECTIVE

Nitrous oxide 70% (N₂O 70%) is an excellent medication for procedural analgosedation (PAS), yet the limit of its analgesic power remains uncertain; therefore, a combination with intranasal fentanyl (INF) was suggested. However, this combination seems to result in a higher rate of vomiting and deeper sedation. This study aimed at assessing the analgesic efficacy, sedation depth and rate of adverse events of PAS with N₂O 70% with and without INF.

METHODS

Patients aged 2-16 years who qualified for PAS with N₂O 70% were randomly assigned to receive either INF or placebo prior to N₂O inhalation in this randomised, double-blind study, which was performed in a tertiary children's hospital ED between September 2015 and October 2017. Behaviour during the procedure was evaluated using the Face, Leg, Activity, Cry and Consolability (FLACC) scale and the Modified Behavioural Pain Scale (MBPS); analgesic efficacy was assessed with a self-reported pain scale. Sedation depth using the validated University of Michigan Sedation Scale and adverse events in the ED and during the following 12 hours were documented.

RESULTS

A total of 402 patients were included; 3 did not tolerate N₂O and therefore had to be excluded. Overall, 399 patients were analysed, of whom 201 (50.4%) received INF. No significant group differences with regard to FLACC scale score, self-reported pain, MBPS score and sedation depth were found. In addition, the two groups did not differ with regard to all types of adverse events.

CONCLUSION

Combining N₂O 70% with INF resulted in no differences with regard to FLACC scale score, self-reported pain, MBPS score, patient and parental satisfaction rate, sedation depth, and adverse events.

TRIAL REGISTRATION NUMBER

NCT02533908.

Perioperative anesthetic management of children with congenital central hypoventilation syndrome and rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation

BACKGROUND

Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation are rare neurocristopathies characterized by autonomic dysregulation including bradyarrhythmias, abnormal temperature control, and most significantly, abnormal control of breathing leading to tracheostomy and ventilator dependence as life support. Surgical advancements have made phrenic nerve-diaphragm pacemakers available, to eliminate the tether to a mechanical ventilator for 12-15 hours each day. The thoracoscopic approach to implantation has allowed for a less invasive approach which may have implications for pain control and recovery time. However, thoracoscopic implantation of these devices presents several challenges to the anesthesiologist in these complex ventilator-dependent patients, including, but not limited to, sequential lung isolation, prevention of hypothermia, and management of arrhythmias. Postoperative challenges may also include strategies to treat hemodynamic instability, managing the ventilator following lung derecruitment, and providing adequate pain control.

AIMS

We aimed to describe the anesthetic management of Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation patients undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation and the nature and incidence of perioperative complications.

METHODS

A retrospective chart review was performed of 14 children with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation undergoing phrenic nerve-diaphragm pacemaker implantation at a single academic pediatric hospital between 2009 and 2017. Demographic information, intraoperative management, and perioperative complications were analyzed from patient records.

RESULTS

Twelve of 14 patients (86%) underwent an inhalational induction via tracheostomy. Lung isolation was achieved via fiberoptic guidance of a single lumen endotracheal tube sequentially into the right or left mainstem bronchi for 12 patients (86%). Double lumen endotracheal tubes were utilized in two patients (7%) and bronchial blockers in two patients (7%) for lung isolation. Anesthesia was maintained using a balanced technique of volatile agents (sevoflurane/isoflurane) and opioids (fentanyl). Bradyarrhythmias developed in six patients (43%) during surgery, 5 (36%) responded to anticholinergics and one patient (7%) required backup cardiac pacing using a previously implanted bipolar cardiac pacemaker. Intraoperative hypothermia (<35.5°C) was present in five patients (36%) despite the use of warming devices. Hypercarbia (>50 mm Hg) during lung isolation was present in eight patients (57%) and hemoglobin desaturation (<90%) in four patients (29%). Postoperatively, oxygen desaturation was a common complication with nine patients (64%) requiring supplemental oxygen administration via mechanical ventilator or manual bag ventilation. Opioids via patient-controlled analgesia devices (12 patients, 86%) or intermittent injection (two patients, 14%) were administered to all patients for postoperative pain control. Phrenic nerve-diaphragm pacemaker placement was successful thoracoscopically in all patients with no perioperative mortality.

CONCLUSION

The main anesthetic challenges in patients with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation include hemodynamic instability, the propensity to develop hypothermia, hypercarbia/hypoxemia, and the need to perform bilateral sequential lung isolation requisite to the thoracoscopic implantation technique. Most anesthetic agents can be used safely in these patients; however, adequate knowledge of the susceptibility to complications, coupled with adequate preparation and understanding of the innate disease characteristics, are necessary to treat anticipated complications.

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.