- Email: [email protected]
Pain relief in children following outpatient surgery
Original Contributions Pain Relief in Children Following Outpatient Surgery Hamish M. Munro, MD, FRCA,* Shobha Malviya, MD,† Gillian R. Lauder, MD, FRCA,‡ Terri Voepel-Lewis, BSN, MS,§ Alan R. Tait, PhD㥋 Section of Pediatric Anesthesiology, University of Michigan Medical Center, Ann Arbor, MI
*Clinical Assistant Professor, Department of Anesthesiology †Assistant Professor, Department of Anesthesiology ‡Instructor, Department of Anesthesiology §Clinical Nurse Specialist, Department of Anesthesiology 㛳 Associate Professor, Department of Anesthesiology
Address correspondence to Dr. Munro at the Section of Pediatric Anesthesiology, University of Michigan Medical Center, F3900 Mott Hospital, Ann Arbor, MI 48109, USA. E-mail: [email protected] Presented in part at the American Society of Anesthesiologists meeting, San Diego, CA, October 17–21, 1997. Received for publication 10 September 1998; revised manuscript accepted for publication 2 February 1999
Study Objective: To evaluate perioperative analgesia, prescription patterns, pain relief, and parental care of children undergoing outpatient surgery. Design: Prospective data collection and parental interview. Setting: Large tertiary care, university-based medical center. Patients: 471 children aged between 10 months and 18 years who underwent an outpatient surgical procedure expected to be associated with pain. Measurements and Main Results: All perioperative data regarding analgesia, antiemetics, postoperative pain scores, and discharge prescriptions were recorded. Parents were telephoned 24 hours following surgery, and data concerning their child’s pain relief, analgesic and antiemetic usage, and their ability to care for their child were obtained. Of the 460 patients questioned, 97% were described by their parents as having adequate, good, or very good pain relief (acceptable) during the first 24 hours postoperatively, whereas only 15 (3%) had poor pain relief (unacceptable). All patients received some form of analgesia intraoperatively. The children with poor pain relief were more likely to have experienced postoperative nausea and vomiting (p ⫽ 0.01) and were more difficult to care for at home (p ⬍ 0.0001). In a subset of 185 patients who had genitourinary procedures, those who received regional analgesia reported better pain relief (p ⫽ 0.05). Conclusions: Despite a wide range of surgical procedures being performed on children on an ambulatory basis, current selection of patients for outpatient surgery is appropriate given the ability of the parents to manage their children’s pain and to care for their children at home. © 1999 by Elsevier Science Inc. Keywords: Pain; pediatrics; surgery, outpatient.
Introduction Current economic restraints within medicine have led to a review of postoperative admission policies with a view to decreasing length of stay and consequent hospital charges. This is especially true of pediatric surgery, wherein more children are now being discharged home following surgery. Many children who previously would have been admitted overnight for pain control are now being discharged home where their parents will manage their pain. To assure quality care and outcomes, it is important to ascertain whether pain in this population can be well managed at home. Whereas a recent study reviewed postoperative pain in adults following ambulatory surgery and reported a 5.3% incidence of
Journal of Clinical Anesthesia 11:187–191, 1999 © 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/99/$–see front matter PII S0952-8180(99)00022-7
Original Contributions
severe pain in the first 24 hours,1 there are, to our knowledge, no similar studies in the pediatric population. The current survey was undertaken to describe perioperative pain management, analgesic prescription patterns, and pain control in the first 24 hours following pediatric outpatient surgery.
Materials and Methods Intraoperative Data With approval from the Institutional Review Board at the University of Michigan, 471 consecutive children who underwent an outpatient surgical procedure expected to be associated with pain were enrolled in this study following verbal consent from parents. All surgical specialties with the exception of cardiothoracic and neurosurgery were included. Children were excluded if they were moderately to severely developmentally delayed, and if parents could not be reached following discharge. Pain management, antiemetic use, and fluid replacement in the postanesthesia care unit (PACU) were provided at the discretion of the anesthesiologist and the nurse who were responsible for the child’s care. The following data were prospectively obtained: patient demographics, intraoperative analgesics, types of regional blocks and local infiltration techniques employed, pain scores on admission and discharge from the PACU, as well as the highest recorded score, analgesics and antiemetics administered, analgesics prescribed for discharge, and the instructions given to parents. Pain scores were recorded by the PACU nurse every 15 to 30 minutes postoperatively until discharge. Pain was rated on a numerical scale from 0 to 10 (10 ⫽ worst pain) by children who were cognitively able to do so. Otherwise, the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale (scale ⫽ 0 to 10)2 was used by the nurse who rated the child’s pain. Patients were discharged home when they met standard discharge criteria, which include stable vital signs, minimal postoperative nausea and vomiting (PONV), and minimal pain (i.e., pain score ⬍3). Prior to their child’s discharge, parents were given the postoperative questionnaire that contained the information to be asked via the telephone the following day.
Telephone Interview Parents were telephoned by a trained research assistant within 24 hours following surgery and were asked, using a standardized questionnaire, to describe the following: their child’s pain on discharge from hospital and on the trip home (none, mild, moderate, or severe), whether the parents had understood the discharge instructions given, use of analgesics at home, incidence of nausea and vomiting, whether the parents had contacted a health care worker about their child’s care and whether the advice given was helpful, and the use of other pain-relieving medicines or techniques not prescribed by the hospital. In addition, parents were asked to rate their child’s pain relief as poor (unacceptable), adequate, good, or very 188
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Table 1. Surgical Specialties and Common Procedures Type of Surgery (n) Genitourinary (185) Hernia/hydrocele repair Circumcision/chordee release Orchidopexy Hypospadius repair Umbilical hernia repair Other Otorhinolaryngology (81) Adenotonsillectomy Adenoidectomy alone Other General/plastic surgery (77) Excision cysts/lumps Other Ophthalmology (61) Strabismus correction Ptosis repair Other Orthopedic (38) Removal of hardware Hand surgery Other Oral surgery (18) Restorations/extractions Other
Patients (n)
79 30 33 17 12 14 32 28 21 55 22 42 7 12 15 15 8 11 7
good (acceptable), and their ability to care for their child (no difficulty, some difficulty, or extreme difficulty) during the 24 hours postoperatively. Patients whose parents could not be contacted by the third postoperative day were excluded from the study.
Statistical Analysis Categorical variables were analyzed using Chi-square analysis and Fisher’s exact test where appropriate. Data are expressed as means ⫾ standard deviation where applicable. Significance was accepted at the 5% level (p ⬍ 0.05).
Results Of the 471 children enrolled in the study, 11 were admitted unexpectedly after surgery and therefore were excluded. Two children were admitted for respiratory observation, three for surgical observation as a result of bleeding, and one patient for prolonged postoperative vomiting. Five children were admitted due to concerns regarding pain control as a result of having surgery more extensive than originally planned. Of these five children, three had undergone general surgical procedures, two orthopedic surgery, and all had received intraoperative and postoperative analgesics. The remaining 460 children (67% male, 33% female), aged 10 months to 18 years (mean 5.4 ⫾ 4.4 years), comprised the sample. Table 1 lists the subspecialties and the most common operations performed. For data analysis, genitourinary procedures (e.g.,
Pain relief in children: Munro et al.
Table 2. Intraoperative and PACU Analgesics and Doses Drug Intraoperative Morphine (mg/kg) Fentanyl (g/kg) Ketorolac (mg/kg) Acetaminophen (mg/kg)* Postoperative Morphine (mg/kg) Fentanyl (g/kg) Acetaminophen (mg/kg)* Codeine (mg/kg)
Dose (mean ⴞ SD)
n
0.09 ⫾ 0.05 1.6 ⫾ 0.99 0.6 ⫾ 0.6 19.8 ⫾ 5.4
124 130 126 317
0.05 ⫾ 0.03 0.3 ⫾ 0.2 15.2 ⫾ 6.8 0.6 ⫾ 0.3
141 2 75 14
PACU ⫽ postanesthesia care unit. * describes rectal administration with the exception of 15 patients in the postoperative group who received oral acetaminophen.
inguinal hernia repair, circumcision, orchidopexy) have been grouped together. All patients in the study had received some form of intraoperative analgesia (Table 2). Two hundred thirty-six children (51%) received a combination of analgesics intraoperatively, most often a combination of morphine sulphate and acetaminophen. One hundred nine patients (23.7%) received acetaminophen either alone or in combination with a regional technique. Of the patients undergoing a genitourinary procedure, a caudal block was used in 105 cases (57%), an ilioinguinal block or penile nerve block in 30 patients (16%), and local infiltration in 21 patients (11%). Three children had a combination of blocks. Of our sample, 33 children self-reported pain; the balance were scored by the PACU nurse. Three hundred forty-five children (75%) remained comfortable in PACU (pain score ⬍5) and did not require additional analgesia. For the remaining children, 79% received an opioid for pain control, and the rest received either ketorolac or acetaminophen. Over 98% of children were discharged from the PACU with minimal pain (i.e., score ⱕ3) as assessed by the PACU nurse. However 18% of parents rated their child’s pain at discharge as moderate or severe. Acetaminophen with or without codeine was prescribed in nearly 95% of cases, whereas 4% did not receive a prescription. Interestingly, in nearly half of the cases, the dose of acetaminophen prescribed by the primary service was less than 10 mg/kg, and the dose of codeine was less than
Figure 1. Pain relief in the first 24 hours by surgical subspecialty. GU ⫽ genitourinary; OTO ⫽ otorhinolaryngology; General ⫽ general/plastic surgery; Opthy ⫽ ophthalmology; Ortho ⫽ orthopedic surgery; Oral ⫽ oral/dental surgery.
1.0 mg/kg. Table 3 presents the analgesics prescribed by each subspecialty. The majority (72%) of parents gave the postoperative analgesics as prescribed, whereas 23% gave less than, and 5% gave more than recommended (in each case, the dose given did not exceed the recommended maximum). Sixteen parents (3.5%) administered analgesics that were not prescribed. In four cases, a nonsteroidal antiinflammatory drug was administered, in five an opioid that had been prescribed for a previous visit, and for the balance it could not be determined what medication was given. In each of these cases, with the exception of one, the supplemental medication given by the parent was helpful. Figure 1 shows the description of pain relief by surgical subspecialty. The majority of children in each subspecialty had acceptable pain relief. Overall, 445 children (97%) experienced adequate, good, or very good pain relief in the first 24 hours. Only 15 children were described by their parents as having poor pain relief. There were no differences in the use of intraoperative and postoperative analgesics, or in the analgesics administered by parents at home, between children who had acceptable analgesia and those who had unacceptable analgesia. In the subset
Table 3. Postoperative Prescription Pattern for Various Surgical Specialties
Type of Surgery (n) Genitourinary (185) Otorhinolaryngology (81) General/plastic surgery (77) Ophthalmology (61) Orthopedic (38) Oral surgery (18)
Acetaminophen ⴙ Codeine
Acetaminophen Alone
Other
None
120(65%) 69(85%) 43(56%) 9(15%) 28(74%) 11(61%)
58(31%) 11(14%) 32(42%) 43(71%) 3(8%) 5(28%)
7(4%) 1(1%) 2(2%) 2(3%) 7(18%) 2(11%)
0(0%) 0(0%) 0(0%) 7(11%) 0(0%) 0(0%)
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Original Contributions
of 185 children who had genitourinary surgery, the use of a caudal or regional block for the procedure was associated with better analgesia in the first 24 hours (p ⫽ 0.05). Interestingly, 9 of the 15 (60%) children with poor pain relief had undergone genitourinary surgery. The incidence of PONV was 22% (101/460) in the PACU, and 49% of the children who vomited had received an intraoperative antiemetic. Furthermore, 77 children (17%) experienced PONV over the first 24 hours. Of the children described as having poor pain relief in the first 24 hours, 6 of 15 (40%) experienced PONV compared to 70 of 445 (16%) who had acceptable pain relief (p ⫽ 0.01). Fewer of the parents who described pain relief as adequate, good, or very good contacted a health care worker for advice after discharge compared to those who described pain relief as poor (4% vs. 10% respectively; p ⫽ 0.01). Of the 22 parents (5%) who did contact someone, six did so because of inadequate pain control. For these patients, an increased dose or alternative analgesic was suggested, which was deemed helpful in four instances. Although 90% of parents reported no difficulty in caring for their child at home, 54% whose children had unacceptable pain relief reported greater difficulty in caring for their child compared to only 10% of those whose children had acceptable pain relief (p ⬍ 0.0001). Additionally, 26% of parents whose children experienced PONV reported difficulty caring for their child compared to only 8% of those without PONV (p ⬍ 0.0001). No child in this study returned to the hospital for inadequate pain control following discharge.
Discussion Parents have high expectations of good pain relief for their children following surgery.3 With an increasing number of procedures being performed on an outpatient basis, it is important that the selection of surgical procedures for outpatient care be appropriate, and that parents are able to manage their child’s analgesia at home. At our institution, there has been a 20% increase in the number of ambulatory cases over the past 5 years, which now comprise over 60% of the total surgical caseload. This survey showed that, despite a wide variation in prescription patterns and compliance, 97% of children had acceptable (adequate, good, or very good) pain control in the first 24 hours following outpatient surgery. Recently, Chung et al.1 conducted a large study of postoperative pain in adults following ambulatory surgery and reported a 5.3% incidence of severe pain in the first 24 hours postoperatively. Similar to our findings, Chung et al. reported a very low incidence of unexpected admission due to pain. These authors found that larger body mass, longer duration of anesthesia, and certain types of surgery were most predictive of PACU pain. Furthermore, Chung et al. reported that patients who had orthopedic surgery had the highest incidence of pain at home; however, other factors that may have contributed to pain at home were not discussed. In contrast, our study found that although slightly more children undergoing genitourinary procedures experienced poor pain relief compared to other 190
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subspecialties, this finding was not statistically significant. Similar to a previous report,4 the use of regional techniques, such as caudal or local nerve block for urologic surgery, was associated with better pain relief in this subset of patients. The overall incidence of PONV in the first 24 hours was 18%, which is comparable to rates previously reported by Baines.5 Not surprisingly, PONV was associated with poorer pain control and contributed to parent’s difficulty in caring for the child at home. In several instances, PONV led to poor tolerance of orally administered analgesics. In some cases, a call to the health care worker was necessary to obtain an antiemetic. In an earlier study of outpatient tonsillectomy patients, Bartley et al.6 found that parents who had difficulty caring for their child reported difficulty with oral fluid intake and managing pain with oral analgesics the following morning. Similar to our findings, Bartley et al. reported that most parents (84%) were comfortable caring for their children at home. These similarities lend some external validity to our results. An interesting finding in this study was a discrepancy between nurse and parental perceptions of pain relief on discharge. Whereas the majority of children were discharged from PACU with minimal pain, the parents described their child’s pain on discharge as moderate to severe in 18% of cases. Such discrepancies have been described by other authors.7,8 Although parents use verbal and nonverbal cues to assess their child’s pain,9 these cues may be misinterpreted by health care workers. The parents’ perception of their child’s pain at discharge may be important in prescribing analgesics postoperatively. Only a small number (⬍5%) of parents contacted a health care worker for advice following discharge, most commonly due to questions about pain medication, vomiting, and surgical concerns. A survey by Ghosh et al.10 found that 2.5% of patients contacted the hospital within 24 hours of discharge, and 4.3% contacted their family practitioner within 48 hours. They found that the most common reason for such contact was problems with postoperative pain control. Furthermore, overall patient satisfaction in their study was related to good preoperative and postoperative information and effective analgesia. Given these observations, as well as our findings, it is important that parents be well educated prior to their child’s discharge, with additional emphasis placed on the potential for pain, nausea, and vomiting, and how to manage these problems.11 Of equal importance is the provision of information on how to contact a health care worker for advice postoperatively. In summary, this survey suggests that despite the rapid growth in ambulatory surgery, the current selection of patients and procedures for outpatient surgery remains appropriate given the ability of parents to provide care for their children at home. Most children experienced acceptable pain relief in the first 24 hours following discharge. The presence of pain on discharge and PONV contributed to poor pain relief at home in a small percentage of children. Alternative analgesics and antiemetics should be recommended or prescribed to treat those children with poor pain control and PONV.
Pain relief in children: Munro et al.
Acknowledgment The authors wish to thank Monica Siewert for her assistance in patient recruitment and data collection.
References 1. Chung F, Ritchie E, Su J: Postoperative pain in ambulatory surgery. Anesth Analg 1997;85:808 –16. 2. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S: The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293–97. 3. Romsing J, Walther-Larsen S: Postoperative pain in children: a survey of parents’ expectations and perceptions of their children’s experiences. Paediatr Anaesth 1996;6:215–18. 4. Londergan TA, Hochman HI, Goldberger N: Postoperative pain following outpatient pediatric urologic surgery: a comparison of anesthetic techniques. Urology 1994;44:572– 6.
5. Baines D: Postoperative nausea and vomiting in children. Paediatr Anaesth 1996;6:7–14. 6. Bartley JR, Connew AM: Parental attitudes and postoperative problems related to paediatric day stay tonsillectomy. N Z Med J 1994;107:451–2. 7. Rømsing J, Møller-Sonnergaard J, Hertel S, Rasmussen M: Postoperative pain in children: comparison between ratings of children and nurses. J Pain Symptom Manage 1996;11:42– 6. 8. Miller D: Comparisons of pain ratings from postoperative children, their mothers, and their nurses. Pediatr Nurs 1996;22:145–9. 9. Reid GJ, Hebb JPO, McGrath PJ, Finley GA, Forward SP: Cues parents use to assess postoperative pain in their children. Clin J Pain 1995;11:229 –35. 10. Ghosh S, Sallam S: Patient satisfaction and postoperative demands on hospital and community services after day surgery. Br J Surg 1994;81,1635– 8. 11. Voepel-Lewis T, Andrea CM, Magee SS: Parent perceptions of pediatric ambulatory surgery: using family feedback for program evaluation. J Post Anesth Nurs 1992;7:106 –114.
Postoperative Pain in Children: A Survey of Parents’ Expectations and Perceptions of Their Children’s Experiences J. Romsing, S. Walther-Larsen Department of Pharmaceutics, Royal Danish School of Pharmacy, Copenhagen, Denmark Abstract Parental expectation and participation in postoperative analgesia is very important in paediatric practice. 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. Reprinted from Paediatric Anesthesiology 1996;6:215– 8.
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*Clinical Assistant Professor, Department of Anesthesiology †Assistant Professor, Department of Anesthesiology ‡Instructor, Department of Anesthesiology §Clinical Nurse Specialist, Department of Anesthesiology 㛳 Associate Professor, Department of Anesthesiology
Address correspondence to Dr. Munro at the Section of Pediatric Anesthesiology, University of Michigan Medical Center, F3900 Mott Hospital, Ann Arbor, MI 48109, USA. E-mail: [email protected] Presented in part at the American Society of Anesthesiologists meeting, San Diego, CA, October 17–21, 1997. Received for publication 10 September 1998; revised manuscript accepted for publication 2 February 1999
Study Objective: To evaluate perioperative analgesia, prescription patterns, pain relief, and parental care of children undergoing outpatient surgery. Design: Prospective data collection and parental interview. Setting: Large tertiary care, university-based medical center. Patients: 471 children aged between 10 months and 18 years who underwent an outpatient surgical procedure expected to be associated with pain. Measurements and Main Results: All perioperative data regarding analgesia, antiemetics, postoperative pain scores, and discharge prescriptions were recorded. Parents were telephoned 24 hours following surgery, and data concerning their child’s pain relief, analgesic and antiemetic usage, and their ability to care for their child were obtained. Of the 460 patients questioned, 97% were described by their parents as having adequate, good, or very good pain relief (acceptable) during the first 24 hours postoperatively, whereas only 15 (3%) had poor pain relief (unacceptable). All patients received some form of analgesia intraoperatively. The children with poor pain relief were more likely to have experienced postoperative nausea and vomiting (p ⫽ 0.01) and were more difficult to care for at home (p ⬍ 0.0001). In a subset of 185 patients who had genitourinary procedures, those who received regional analgesia reported better pain relief (p ⫽ 0.05). Conclusions: Despite a wide range of surgical procedures being performed on children on an ambulatory basis, current selection of patients for outpatient surgery is appropriate given the ability of the parents to manage their children’s pain and to care for their children at home. © 1999 by Elsevier Science Inc. Keywords: Pain; pediatrics; surgery, outpatient.
Introduction Current economic restraints within medicine have led to a review of postoperative admission policies with a view to decreasing length of stay and consequent hospital charges. This is especially true of pediatric surgery, wherein more children are now being discharged home following surgery. Many children who previously would have been admitted overnight for pain control are now being discharged home where their parents will manage their pain. To assure quality care and outcomes, it is important to ascertain whether pain in this population can be well managed at home. Whereas a recent study reviewed postoperative pain in adults following ambulatory surgery and reported a 5.3% incidence of
Journal of Clinical Anesthesia 11:187–191, 1999 © 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/99/$–see front matter PII S0952-8180(99)00022-7
Original Contributions
severe pain in the first 24 hours,1 there are, to our knowledge, no similar studies in the pediatric population. The current survey was undertaken to describe perioperative pain management, analgesic prescription patterns, and pain control in the first 24 hours following pediatric outpatient surgery.
Materials and Methods Intraoperative Data With approval from the Institutional Review Board at the University of Michigan, 471 consecutive children who underwent an outpatient surgical procedure expected to be associated with pain were enrolled in this study following verbal consent from parents. All surgical specialties with the exception of cardiothoracic and neurosurgery were included. Children were excluded if they were moderately to severely developmentally delayed, and if parents could not be reached following discharge. Pain management, antiemetic use, and fluid replacement in the postanesthesia care unit (PACU) were provided at the discretion of the anesthesiologist and the nurse who were responsible for the child’s care. The following data were prospectively obtained: patient demographics, intraoperative analgesics, types of regional blocks and local infiltration techniques employed, pain scores on admission and discharge from the PACU, as well as the highest recorded score, analgesics and antiemetics administered, analgesics prescribed for discharge, and the instructions given to parents. Pain scores were recorded by the PACU nurse every 15 to 30 minutes postoperatively until discharge. Pain was rated on a numerical scale from 0 to 10 (10 ⫽ worst pain) by children who were cognitively able to do so. Otherwise, the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale (scale ⫽ 0 to 10)2 was used by the nurse who rated the child’s pain. Patients were discharged home when they met standard discharge criteria, which include stable vital signs, minimal postoperative nausea and vomiting (PONV), and minimal pain (i.e., pain score ⬍3). Prior to their child’s discharge, parents were given the postoperative questionnaire that contained the information to be asked via the telephone the following day.
Telephone Interview Parents were telephoned by a trained research assistant within 24 hours following surgery and were asked, using a standardized questionnaire, to describe the following: their child’s pain on discharge from hospital and on the trip home (none, mild, moderate, or severe), whether the parents had understood the discharge instructions given, use of analgesics at home, incidence of nausea and vomiting, whether the parents had contacted a health care worker about their child’s care and whether the advice given was helpful, and the use of other pain-relieving medicines or techniques not prescribed by the hospital. In addition, parents were asked to rate their child’s pain relief as poor (unacceptable), adequate, good, or very 188
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Table 1. Surgical Specialties and Common Procedures Type of Surgery (n) Genitourinary (185) Hernia/hydrocele repair Circumcision/chordee release Orchidopexy Hypospadius repair Umbilical hernia repair Other Otorhinolaryngology (81) Adenotonsillectomy Adenoidectomy alone Other General/plastic surgery (77) Excision cysts/lumps Other Ophthalmology (61) Strabismus correction Ptosis repair Other Orthopedic (38) Removal of hardware Hand surgery Other Oral surgery (18) Restorations/extractions Other
Patients (n)
79 30 33 17 12 14 32 28 21 55 22 42 7 12 15 15 8 11 7
good (acceptable), and their ability to care for their child (no difficulty, some difficulty, or extreme difficulty) during the 24 hours postoperatively. Patients whose parents could not be contacted by the third postoperative day were excluded from the study.
Statistical Analysis Categorical variables were analyzed using Chi-square analysis and Fisher’s exact test where appropriate. Data are expressed as means ⫾ standard deviation where applicable. Significance was accepted at the 5% level (p ⬍ 0.05).
Results Of the 471 children enrolled in the study, 11 were admitted unexpectedly after surgery and therefore were excluded. Two children were admitted for respiratory observation, three for surgical observation as a result of bleeding, and one patient for prolonged postoperative vomiting. Five children were admitted due to concerns regarding pain control as a result of having surgery more extensive than originally planned. Of these five children, three had undergone general surgical procedures, two orthopedic surgery, and all had received intraoperative and postoperative analgesics. The remaining 460 children (67% male, 33% female), aged 10 months to 18 years (mean 5.4 ⫾ 4.4 years), comprised the sample. Table 1 lists the subspecialties and the most common operations performed. For data analysis, genitourinary procedures (e.g.,
Pain relief in children: Munro et al.
Table 2. Intraoperative and PACU Analgesics and Doses Drug Intraoperative Morphine (mg/kg) Fentanyl (g/kg) Ketorolac (mg/kg) Acetaminophen (mg/kg)* Postoperative Morphine (mg/kg) Fentanyl (g/kg) Acetaminophen (mg/kg)* Codeine (mg/kg)
Dose (mean ⴞ SD)
n
0.09 ⫾ 0.05 1.6 ⫾ 0.99 0.6 ⫾ 0.6 19.8 ⫾ 5.4
124 130 126 317
0.05 ⫾ 0.03 0.3 ⫾ 0.2 15.2 ⫾ 6.8 0.6 ⫾ 0.3
141 2 75 14
PACU ⫽ postanesthesia care unit. * describes rectal administration with the exception of 15 patients in the postoperative group who received oral acetaminophen.
inguinal hernia repair, circumcision, orchidopexy) have been grouped together. All patients in the study had received some form of intraoperative analgesia (Table 2). Two hundred thirty-six children (51%) received a combination of analgesics intraoperatively, most often a combination of morphine sulphate and acetaminophen. One hundred nine patients (23.7%) received acetaminophen either alone or in combination with a regional technique. Of the patients undergoing a genitourinary procedure, a caudal block was used in 105 cases (57%), an ilioinguinal block or penile nerve block in 30 patients (16%), and local infiltration in 21 patients (11%). Three children had a combination of blocks. Of our sample, 33 children self-reported pain; the balance were scored by the PACU nurse. Three hundred forty-five children (75%) remained comfortable in PACU (pain score ⬍5) and did not require additional analgesia. For the remaining children, 79% received an opioid for pain control, and the rest received either ketorolac or acetaminophen. Over 98% of children were discharged from the PACU with minimal pain (i.e., score ⱕ3) as assessed by the PACU nurse. However 18% of parents rated their child’s pain at discharge as moderate or severe. Acetaminophen with or without codeine was prescribed in nearly 95% of cases, whereas 4% did not receive a prescription. Interestingly, in nearly half of the cases, the dose of acetaminophen prescribed by the primary service was less than 10 mg/kg, and the dose of codeine was less than
Figure 1. Pain relief in the first 24 hours by surgical subspecialty. GU ⫽ genitourinary; OTO ⫽ otorhinolaryngology; General ⫽ general/plastic surgery; Opthy ⫽ ophthalmology; Ortho ⫽ orthopedic surgery; Oral ⫽ oral/dental surgery.
1.0 mg/kg. Table 3 presents the analgesics prescribed by each subspecialty. The majority (72%) of parents gave the postoperative analgesics as prescribed, whereas 23% gave less than, and 5% gave more than recommended (in each case, the dose given did not exceed the recommended maximum). Sixteen parents (3.5%) administered analgesics that were not prescribed. In four cases, a nonsteroidal antiinflammatory drug was administered, in five an opioid that had been prescribed for a previous visit, and for the balance it could not be determined what medication was given. In each of these cases, with the exception of one, the supplemental medication given by the parent was helpful. Figure 1 shows the description of pain relief by surgical subspecialty. The majority of children in each subspecialty had acceptable pain relief. Overall, 445 children (97%) experienced adequate, good, or very good pain relief in the first 24 hours. Only 15 children were described by their parents as having poor pain relief. There were no differences in the use of intraoperative and postoperative analgesics, or in the analgesics administered by parents at home, between children who had acceptable analgesia and those who had unacceptable analgesia. In the subset
Table 3. Postoperative Prescription Pattern for Various Surgical Specialties
Type of Surgery (n) Genitourinary (185) Otorhinolaryngology (81) General/plastic surgery (77) Ophthalmology (61) Orthopedic (38) Oral surgery (18)
Acetaminophen ⴙ Codeine
Acetaminophen Alone
Other
None
120(65%) 69(85%) 43(56%) 9(15%) 28(74%) 11(61%)
58(31%) 11(14%) 32(42%) 43(71%) 3(8%) 5(28%)
7(4%) 1(1%) 2(2%) 2(3%) 7(18%) 2(11%)
0(0%) 0(0%) 0(0%) 7(11%) 0(0%) 0(0%)
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of 185 children who had genitourinary surgery, the use of a caudal or regional block for the procedure was associated with better analgesia in the first 24 hours (p ⫽ 0.05). Interestingly, 9 of the 15 (60%) children with poor pain relief had undergone genitourinary surgery. The incidence of PONV was 22% (101/460) in the PACU, and 49% of the children who vomited had received an intraoperative antiemetic. Furthermore, 77 children (17%) experienced PONV over the first 24 hours. Of the children described as having poor pain relief in the first 24 hours, 6 of 15 (40%) experienced PONV compared to 70 of 445 (16%) who had acceptable pain relief (p ⫽ 0.01). Fewer of the parents who described pain relief as adequate, good, or very good contacted a health care worker for advice after discharge compared to those who described pain relief as poor (4% vs. 10% respectively; p ⫽ 0.01). Of the 22 parents (5%) who did contact someone, six did so because of inadequate pain control. For these patients, an increased dose or alternative analgesic was suggested, which was deemed helpful in four instances. Although 90% of parents reported no difficulty in caring for their child at home, 54% whose children had unacceptable pain relief reported greater difficulty in caring for their child compared to only 10% of those whose children had acceptable pain relief (p ⬍ 0.0001). Additionally, 26% of parents whose children experienced PONV reported difficulty caring for their child compared to only 8% of those without PONV (p ⬍ 0.0001). No child in this study returned to the hospital for inadequate pain control following discharge.
Discussion Parents have high expectations of good pain relief for their children following surgery.3 With an increasing number of procedures being performed on an outpatient basis, it is important that the selection of surgical procedures for outpatient care be appropriate, and that parents are able to manage their child’s analgesia at home. At our institution, there has been a 20% increase in the number of ambulatory cases over the past 5 years, which now comprise over 60% of the total surgical caseload. This survey showed that, despite a wide variation in prescription patterns and compliance, 97% of children had acceptable (adequate, good, or very good) pain control in the first 24 hours following outpatient surgery. Recently, Chung et al.1 conducted a large study of postoperative pain in adults following ambulatory surgery and reported a 5.3% incidence of severe pain in the first 24 hours postoperatively. Similar to our findings, Chung et al. reported a very low incidence of unexpected admission due to pain. These authors found that larger body mass, longer duration of anesthesia, and certain types of surgery were most predictive of PACU pain. Furthermore, Chung et al. reported that patients who had orthopedic surgery had the highest incidence of pain at home; however, other factors that may have contributed to pain at home were not discussed. In contrast, our study found that although slightly more children undergoing genitourinary procedures experienced poor pain relief compared to other 190
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subspecialties, this finding was not statistically significant. Similar to a previous report,4 the use of regional techniques, such as caudal or local nerve block for urologic surgery, was associated with better pain relief in this subset of patients. The overall incidence of PONV in the first 24 hours was 18%, which is comparable to rates previously reported by Baines.5 Not surprisingly, PONV was associated with poorer pain control and contributed to parent’s difficulty in caring for the child at home. In several instances, PONV led to poor tolerance of orally administered analgesics. In some cases, a call to the health care worker was necessary to obtain an antiemetic. In an earlier study of outpatient tonsillectomy patients, Bartley et al.6 found that parents who had difficulty caring for their child reported difficulty with oral fluid intake and managing pain with oral analgesics the following morning. Similar to our findings, Bartley et al. reported that most parents (84%) were comfortable caring for their children at home. These similarities lend some external validity to our results. An interesting finding in this study was a discrepancy between nurse and parental perceptions of pain relief on discharge. Whereas the majority of children were discharged from PACU with minimal pain, the parents described their child’s pain on discharge as moderate to severe in 18% of cases. Such discrepancies have been described by other authors.7,8 Although parents use verbal and nonverbal cues to assess their child’s pain,9 these cues may be misinterpreted by health care workers. The parents’ perception of their child’s pain at discharge may be important in prescribing analgesics postoperatively. Only a small number (⬍5%) of parents contacted a health care worker for advice following discharge, most commonly due to questions about pain medication, vomiting, and surgical concerns. A survey by Ghosh et al.10 found that 2.5% of patients contacted the hospital within 24 hours of discharge, and 4.3% contacted their family practitioner within 48 hours. They found that the most common reason for such contact was problems with postoperative pain control. Furthermore, overall patient satisfaction in their study was related to good preoperative and postoperative information and effective analgesia. Given these observations, as well as our findings, it is important that parents be well educated prior to their child’s discharge, with additional emphasis placed on the potential for pain, nausea, and vomiting, and how to manage these problems.11 Of equal importance is the provision of information on how to contact a health care worker for advice postoperatively. In summary, this survey suggests that despite the rapid growth in ambulatory surgery, the current selection of patients and procedures for outpatient surgery remains appropriate given the ability of parents to provide care for their children at home. Most children experienced acceptable pain relief in the first 24 hours following discharge. The presence of pain on discharge and PONV contributed to poor pain relief at home in a small percentage of children. Alternative analgesics and antiemetics should be recommended or prescribed to treat those children with poor pain control and PONV.
Pain relief in children: Munro et al.
Acknowledgment The authors wish to thank Monica Siewert for her assistance in patient recruitment and data collection.
References 1. Chung F, Ritchie E, Su J: Postoperative pain in ambulatory surgery. Anesth Analg 1997;85:808 –16. 2. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S: The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293–97. 3. Romsing J, Walther-Larsen S: Postoperative pain in children: a survey of parents’ expectations and perceptions of their children’s experiences. Paediatr Anaesth 1996;6:215–18. 4. Londergan TA, Hochman HI, Goldberger N: Postoperative pain following outpatient pediatric urologic surgery: a comparison of anesthetic techniques. Urology 1994;44:572– 6.
5. Baines D: Postoperative nausea and vomiting in children. Paediatr Anaesth 1996;6:7–14. 6. Bartley JR, Connew AM: Parental attitudes and postoperative problems related to paediatric day stay tonsillectomy. N Z Med J 1994;107:451–2. 7. Rømsing J, Møller-Sonnergaard J, Hertel S, Rasmussen M: Postoperative pain in children: comparison between ratings of children and nurses. J Pain Symptom Manage 1996;11:42– 6. 8. Miller D: Comparisons of pain ratings from postoperative children, their mothers, and their nurses. Pediatr Nurs 1996;22:145–9. 9. Reid GJ, Hebb JPO, McGrath PJ, Finley GA, Forward SP: Cues parents use to assess postoperative pain in their children. Clin J Pain 1995;11:229 –35. 10. Ghosh S, Sallam S: Patient satisfaction and postoperative demands on hospital and community services after day surgery. Br J Surg 1994;81,1635– 8. 11. Voepel-Lewis T, Andrea CM, Magee SS: Parent perceptions of pediatric ambulatory surgery: using family feedback for program evaluation. J Post Anesth Nurs 1992;7:106 –114.
Postoperative Pain in Children: A Survey of Parents’ Expectations and Perceptions of Their Children’s Experiences J. Romsing, S. Walther-Larsen Department of Pharmaceutics, Royal Danish School of Pharmacy, Copenhagen, Denmark Abstract Parental expectation and participation in postoperative analgesia is very important in paediatric practice. 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. Reprinted from Paediatric Anesthesiology 1996;6:215– 8.
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