Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals

BACKGROUND

Pain management in hospitalized children is often inadequate. The prevalence and main sources of pain in Danish university hospitals is unknown.

METHODS

This prospective mixed-method cross-sectional survey took place at four university hospitals in Denmark. We enrolled 570 pediatric patients who we asked to report their pain experience and its management during the previous 24 hours. For patients identified as having moderate to severe pain, patient characteristics and analgesia regimes were reviewed.

RESULTS

Two hundred and thirteen children (37%) responded that they had experienced pain in the previous 24 hours. One hundred and thirty four (24%) indicated moderate to severe pain and 43% would have preferred an intervention to alleviate the pain. In children hospitalized for more than 24 hours, the prevalence of moderate/severe pain was significantly higher compared to children admitted the same day. The single most common painful procedure named by the children was needle procedures, such as blood draw and intravenous cannulation.

CONCLUSION

This study reveals high pain prevalence in children across all age groups admitted to four Danish university hospitals. The majority of children in moderate to severe pain did not have a documented pain assessment, and evidence-based pharmacological and/or integrative ('non-pharmacological') measures were not systematically administered to prevent or treat pain. Thus, practice changes are needed.

The former preterm infant and risk of post-operative apnoea: recommendations for management

The preterm infant presenting for anaesthesia during the first 6 months of life is a major anaesthetic challenge. One of the most serious post-operative complications is apnoea with or without bradycardia. For this review, we conducted a search of the current literature in order to formulate a set of evidence-based clinical guidelines to help clinicians in the management of the former preterm infant to avoid post-operative apnoea. Only a small number of patients have been enrolled into prospective, randomized, controlled studies. Based on the current literature, regional anaesthesia is strongly recommended, preferably neuraxial block, but general anaesthesia is also used and in this setting, opioids and muscle relaxants should be avoided. Infants with a post-conceptual age of less than 46 weeks should be admitted for continuous monitoring for at least 12 h post-operatively. In infants with a post-conceptual age (PCA) between 46 and 60 weeks, a careful assessment of the child is mandatory and 12 h of respiratory monitoring is recommended if the patient's history reveals episodes of apnoea at home, chronic lung disease (CLD), neurological disease or anaemia. The otherwise healthy infant could be scheduled for theatre as the first patient on the list and subsequently monitored in the post-anaesthetic care unit for 6 h. The risk of apnoea in former preterm infants can be further reduced by the administration of intravenous caffeine (10 mg/kg). All of these patients should be referred to a tertiary centre for anaesthesia and surgery.

Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study

BACKGROUND

Clonidine is used increasingly in paediatric anaesthetic practice to prolong the duration of action of caudal block with a local anaesthetic agent. Which route of administration of clonidine is the most beneficial remains unknown. We compared the effects of caudal and i.v. clonidine on postoperative analgesia produced by caudal bupivacaine after hypospadias repair.

METHODS

Forty-six children (ASA I or II) aged 24-104 months received standardized premedication with midazolam, a general anaesthetic and a caudal block with bupivacaine 0.25%, 0.5 ml kg(-1). The children were randomized in a double-blind fashion to two groups: the i.v. group received clonidine 2 micro g kg(-1) i.v. and simultaneously the same volume of saline caudally. The caudal group received clonidine 2 micro g kg(-1) caudally and a similar volume of saline i.v. After surgery, all children received acetaminophen 20 mg kg(-1) rectally or orally 6-hourly and were given a patient-controlled or nurse-controlled analgesia (PCA/NCA) pump with i.v. morphine (bolus of 25 micro g kg(-1) and an 8-min lockout period with no background infusion). Monitoring of scores for pain, sedation, motor block, and postoperative nausea and vomiting was performed by nurses blinded to the study allocations. Time to first activation of the PCA/NCA pump and 0-24 h and 24-48 h morphine consumption were also recorded.

RESULTS

Forty-four children completed the study. Age, weight and duration of anaesthesia and surgery were similar in the two groups. The median (range) time to first activation of the PCA/NCA pump was similar in the two groups: 425 (150-1440) min in the i.v. group and 450 (130-1440) min in the caudal group. The number of children not requiring postoperative morphine was four and seven respectively. Morphine consumption during 0-24 h and 24-48 h was similar between groups.

CONCLUSIONS

The analgesic effect of clonidine 2 micro g kg(-1) as an adjunct to caudal block with bupivacaine 0.25%, 0.5 ml kg(-1) is similar whether administered i.v. or caudally.

Tetracaine gel vs EMLA cream for percutaneous anaesthesia in children

We have evaluated the anaesthetic effect of tetracaine gel 1 g, applied for 45 min, compared with EMLA cream 2 g, applied for 60 min, in a randomized, double-blind study in 60 children aged 3-15 yr. Venous cannulation was performed 15 min after removal of the EMLA cream (n = 20) and tetracaine gel (n = 20). Cannulation was performed up to 215 min after removal of the tetracaine gel in another 20 patients. Significantly lower pain scores were recorded by the children treated with tetracaine gel compared with EMLA cream (P < 0.02). Forty to 45% of children in the tetracaine groups reported no pain compared with only 10% in the EMLA group. Only minor adverse effects were observed. We conclude that tetracaine gel provided effective, rapid, long-lasting and safe local anaesthesia, and was significantly better than EMLA cream in reducing pain during venous cannulation in children using the recommended application periods for both formulations.

Analgesic efficacy and safety of preoperative versus postoperative ketorolac in paediatric tonsillectomy

BACKGROUND

Tonsillectomy is a common procedure in childhood resulting in significant morbidity due to pain. The aim of this study was to evaluate the analgesic efficacy and safety of a single dose of ketorolac i.v. given before or after tonsillectomy, compared to placebo.

METHODS

A randomized, double-blind, placebo-controlled study was performed in 60 children, 5 to 15 years of age, admitted for tonsillectomy. Patients were allocated to receive ketorolac 1 mg.kg-1 i.v. or placebo. Postoperative pain was assessed by self-report 1.5, 3, 5, and 24 h after surgery.

RESULTS

Pain scores were significantly lower for both ketorolac groups compared to the placebo group 1.5, 3, and 5 h after surgery (P = 0.05). Pain scores were lowest in the preoperative ketorolac group 1.5 to 5 h after surgery, and significantly fewer children in this group had fentanyl 0 to 1.5 hr after surgery. But no significant differences were found between pain scores of the preoperative and postoperative ketorolac groups in the first 24 h after surgery. Acetaminophen consumption during the first 5 h after surgery was significantly less in patients receiving ketorolac (P < 0.05). Patients in the preoperative ketorolac group had a significantly lower incidence of postoperative vomiting (P < 0.05). There were no significant differences in the incidence of postoperative bleeding between groups. Three children in the preoperative, 5 children in the postoperative ketorolac group and 5 children in the placebo group experienced postoperative haemorrhage.

CONCLUSION

This study indicates that a single dose of ketorolac 1 mg.kg-1 i.v. administered either before or immediately after surgery improves postoperative analgesia in children after tonsillectomy without evidence of increased incidence of bleeding.

Peri-operative use of nonsteroidal anti-inflammatory drugs in children: analgesic efficacy and bleeding

Nonsteroidal anti-inflammatory drugs are effective in the management of mild to moderate postoperative pain in children. They can decrease or even eliminate the need for opioid analgesics, thus reducing or eliminating opioid-induced side-effects. The increasing peri-operative use of nonsteroidal anti-inflammatory drugs in children has, however, raised concerns about complications secondary to impaired haemostasis. To examine the extent of this unwanted side-effect, this paper reviews the published literature on analgesic efficacy and bleeding following the peri-operative use of nonsteroidal anti-inflammatory drugs in children. The reviewed literature confirms that haemorrhagic events in the postoperative period occur, but results remain inconclusive regarding the association between peri-operative use of nonsteroidal anti-inflammatory drugs and disordered haemostasis. In order to maximise the benefit of nonsteroidal anti-inflammatory drugs in children, the risks must be recognised and patients, clinical indications, the individual drug, timing and route of administration must be selected carefully. Nonsteroidal anti-inflammatory drugs appear to play a valuable role in the further improvement of postoperative pain management in children.

Comparison of continuous epidural infusion of fentanyl and bupivacaine with intermittent epidural administration of morphine for postoperative pain management in children

BACKGROUND

The aim of this study was to compare epidural infusion of bupivacaine and fentanyl and intermittent epidural morphine with regard to analgesic effect, and incidence and severity of side effects in children undergoing major abdominal or genito-urological surgery in order to improve the postoperative pain management of children.

METHODS

A double-blind, block-randomised study design was used. Thirty-one children aged 3 months to 6 years undergoing major abdominal or genito-urological surgery were studied. After induction of anaesthesia a lumbar epidural catheter was placed at L3-4 or L4-5. Postoperatively, the children received either 30 micrograms/kg of morphine every 8 h or a continuous infusion of fentanyl 2 micrograms/ml and bupivacaine 1.0 mg/ml at a rate of 0.25 ml.kg-1.h-1. All children additionally received rectal paracetamol in doses of 50-100 mg.kg-1.d-1 on a regular basis, and amol in doses of 50-100 mg.kg-1.d-1 on a regular basis, and if necessary supplementary intravenous morphine in doses of 50 micrograms/kg. Postoperatively, pain, administration of supplemental morphine and side effects were recorded 5 times by one observer during the day of surgery and the first postoperative day. All children had an epidural catheter throughout the study period.

RESULTS

Both regimens provided effective analgesia, but significantly better pain relief was obtained in children receiving the fentanyl/bupivacaine regimen. Sedation, pruritus, vomiting, and administration of antiemetics were seen in both treatment groups, and even though both the incidence and severity of side effects tended to be higher in children receiving morphine, no statistically significant difference was found. No episodes of respiratory depression or motor blockade were noticed.

CONCLUSIONS

Continuous epidural infusion of fentanyl and bupivacaine was found to be superior to intermittent epidural morphine. The initial regimen should be fentanyl 2 micrograms/ml and bupivacaine 1.0 mg/ml infused at a rate of 0.25 ml.kg-1.h-1.

[Parents' expectations and evaluation of their children's postoperative pain treatment]

In order to improve postoperative pain management in children, the parents of 31 elective surgical children, three months to 15 years of age, were asked preoperatively about their expectations regarding their children's postoperative pain and pain relief. At 24 hours after surgery, the parents were asked about their perceptions of their children's pain and pain control. The survey indicates that the parents had high expectations of good pain relief. Eighty percent wanted effective analgesia administered promptly when the children had some pain. On the whole the parents' perceptions corresponded to their expectations. However, current practice in controlling pain after surgery is still not optimal. Twenty-nine percent (9) of the children experienced severe or unbearable pain or experienced pain for all of the 24 h after surgery. An approach to improve pain management in children could be for the hospital staff to reorganize and to develop an "acute pain service". A pain service may not require new technology, but could instead be based on more effective communication and skill in utilizing the traditional systems.

Postoperative pain in children: a survey of parents' expectations and perceptions of their children's experiences

Parental expectation and participation in postoperative analgesia is very important in paediatric practice. In order to improve postoperative pain management in children, the parents of 31 elective surgical children, three months to 15 years of age, were asked preoperatively about their expectations regarding their children's postoperative pain and pain relief. At 24 h after surgery, the parents were asked about their perceptions of their children's pain and pain control. The survey indicates that the parents had high expectations of good pain relief. They wanted effective analgesia administered promptly when the children had some pain. However, current practice in controlling pain after surgery is still not optimal. Nine (29%) of the children experienced severe or unbearable pain or experienced pain for the whole of the 24 h after surgery. An approach to improve pain management in children could be for the hospital staff to reorganize and to develop an 'acute pain service'. A pain service may not require new technology, but instead be based on more effective communication and skill in utilizing the traditional systems.

Arterial desaturation in healthy children during and after minor surgery

Pulse oximetry (PO) was applied to 79 otherwise healthy children during and after minor ENT surgery under general anaesthesia in private practice. The PO data were not available to the anaesthetist unless desaturation to less than or equal to 85% was present for greater than or equal to 30 s. This occurred in 12 and 9 cases during anaesthesia and recovery, respectively, only 8 and 5 cases, respectively, being diagnosed clinically. Desaturation during and after anaesthesia was more common in children undergoing adenoidectomy than during procedures for which endotracheal intubation was not performed. During recovery, desaturation was more likely to occur in the same patients again. Lower values of SaO2 were found in younger children and in children resisting or crying at induction. There was a (weak) negative correlation between SaO2 and HR. As clinically undiagnosed desaturation occurs even in healthy children undergoing minor surgical procedures, a more widespread use of PO during and after anaesthesia may be advisable.

Measurement of central venous pressure after open heart surgery and effect of positive end expiratory pressure

Central venous pressure (CVP) recorded on electronic equipment (E-CVP) is compared with CVP measured by water column (W-CVP) in 50 patients after coronary bypass surgery without prior pulmonary symptoms. We find a statistically significant, but clinically insignificant, difference between E-CVP and W-CVP. Treatment with 10 cm H2O positive end expiratory pressure (PEEP) causes a significant rise in CVP by increasing intrathoracic pressure, but as changes in CVP rather than a given value are of greater importance in the daily clinical situation, we do not consider it clinically important to interrupt treatment with PEEP in as much as only small changes in CVP are induced after application of PEEP.

Misplacement of subclavian venous catheters: importance of head position and choice of puncture site

We have investigated the frequency of misplacement of subclavian catheters in 200 consecutive patients admitted to the Intensive Care Unit. The patients were allocated randomly to an attempt at infraclavicular cannulation of the right or left subclavian vein with the head turned either towards or away from the selected side, giving four groups. Catheterization was successful in 185 (92.5%) patients. Misplacement into the internal jugular vein occurred in 10 (5.4%) patients. No statistically significant difference (P less than 0.05) was demonstrated between the four groups.

Occlusive dressing versus petroleum gauze on drainage wounds

Two different wound dressings were tested on human drainage wounds. Improved healing was observed under an occlusive, oxygen-impermeable hydrocolloid dressing compared with petroleum gauze. Infection tendency was not increased under the occlusive dressing.

A quantitative Allen's test

Allen's test has been performed quantitatively by measuring digital systolic pressure during compression of the radial or ulnar artery at the wrist. The reduction of pressure in normal subjects was less than 25 per cent. Insufficiency of the arterial supply to the hand from the radial artery, the ulnar artery or the palmar arcades can easily be diagnosed from an abnormal reduction in digital systolic pressure during arterial compression.