Janice Lander

Pain progression, intensity and outcomes following tonsillectomy.

&NA; The objective of this study was to assess outcomes of pediatric day surgery tonsillectomy. A total of 129 children, aged 5–16 years, and their parents were recruited from three urban hospitals which provided pediatric day surgery. Children reported pain on a visual analogue scale (VAS) in day surgery and then daily at home for 7 days. Parents reported outcomes of surgery, including fluid intake, nausea, vomiting and sleep disturbances. They also recorded analgesic administration. Three main results related to extent and duration of pain, quality of management of pain, and effect of pain on utilization of health services. Tonsillectomy caused considerable pain which lasted more than 7 days. Pain followed a trajectory of intense or moderately intense pain for the first 3 days followed by a gradual decline over the next 4 days. In general, post‐tonsillectomy pain was poorly managed by health professionals and parents. An unexpected observation was that children who had a bupivacaine infiltration of the tonsil fossa during surgery had significantly more pain in the evening of surgery than children who did not have an infiltration. The increase in postoperative pain experienced by those who had the infiltration was attributed to quality of pain management. Children with persistent pain (those who did not follow the typical trajectory) were likely to be taken to a medical practitioner. One‐third of the sample made unscheduled visits to practitioners with most occurring from Day 4 to Day 7 of the follow‐up.

Cognitive status and postoperative pain: Older adults

The purpose of this study was to assess older adults to determine (a) the course of postoperative pain, (b) influences of pain and analgesics on mental status, and (c) relationships among age, mental status and pain. Sixty adults, aged 50-80 yr, who had total hip replacement surgery were included in this study. All subjects had met a preoperative criterion for mental status. Data collection took place over 5 days following surgery. Pain intensity and distress were assessed three times a day for 5 days. Recalled night pain intensity, pain distress, and sleep disturbance from pain were assessed daily in the early morning prior to assessment of mental status. Although no within day or day-to-day pain patterns were observed, the greatest decreases in pain occurred during the first 2 days. Night pain also improved after the third day. One-third of subjects recorded one or more episodes where mental status declined below criterion after surgery. Multivariate analysis indicated that pain, not analgesic intake, predicted mental status decline. Age was not related to pain or mental status. In general, pain was poorly managed in this group of subjects. The results suggest an explanation for acute confusion in older patients after surgery and recommend improved pain management.

Determinants of success and failure of EMLA.

&NA; Although EMLA is known to be an effective topical anesthetic, its rate of success is unknown. Indeed, researchers have suggested that EMLA may fail with young and apprehensive children. Therefore, the objectives of this study were to assess EMLAs rate of success as well as factors which predict success. A double‐blind, placebo‐controlled design was utilized. The sample included 258 children and adolescents aged 5–18 years who were having venipuncture or intravenous (i.v.) cannulation. After having their anxiety assessed, subjects were randomly assigned to have EMLA or placebo applied over the procedure site for 90 min. The visual analogue scale was used to assess pain caused by removal of the semi‐permeable dressing and by the procedure. Other information that was collected included: duration of drug application, interval between drug removal and procedure, skin changes at bandage and drug sites and rated difficulty of the procedure. EMLA was successful 84% of the time for venipuncture and 51% of the time for i.v. cannulation. Factors which predicted success of EMLA included type of procedure, duration of drug application and anxiety. EMLA was less successful for i.v. cannulation compared to venipuncture even with duration of drug application controlled. Those who had a poor outcome were more anxious than those with a good outcome. Age of child was not a factor. Strategies for improving efficient use of EMLA were recommended.

AGE DIFFERENCES IN CHILDREN'S PAIN

A cross-sectional study of venipuncture pain and anxiety was conducted with 180 consecutively referred children and their parents. Analysis indicated that younger children report more venipuncture pain than older children. Anxiety was related to both age and pain. As well, anxiety was lowest among children with no previous venipuncture experience and among those with the greatest experience.

TENS for children's procedural pain.

&NA; A 3 × 6 factorial design with a double blind and placebo control was employed to investigate the effect of TENS treatment on pain produced by venipuncture. The three treatment groups consisted of TENS, placebo‐TENS and control. Subjects were blocked into six 2‐year age groups (ages: 5–17 years). During the period of the study, 896 children attending the outpatient laboratory of a general hospital were screened and 514 children completed the study. The data which were collected before venipuncture included expected pain and state anxiety. Following venipuncture, pain intensity was measured with a vertical visual analogue scale (VAS) and pain affect was assessed with McGraths faces scale. Significant main effects for treatment and age groups were obtained. Pain intensity and affect were lowest for the TENS group and highest for the control group. The pain scores were greatest for lower age groups and lowest for higher age groups. The results of this study support the use of TENS for childrens pain and the need for interventions for childrens procedural pain.

Children's pain predictions and memories

A cross-sectional descriptive design was utilized to explore expected, experienced and recalled pain, and anxiety. Subjects were 138 children (5-17 yr) who were attending an outpatient laboratory for venipuncture. They reported state anxiety and expected visual analogue scale pain prior to having venipuncture. Following venipuncture, they reported sensory and affective pain. Two months afterward, subjects were contacted and asked to recall sensory and affective pain from the venipuncture. Analysis of data determined that childrens recall of pain was quite good although better for affective pain than sensory pain. Prediction accuracy for pain was not good. From analysis it was determined that overestimation of pain was related to anxiety but not to greater experienced pain. Four patterns of responses were identified when prediction and recall accuracy were further examined. These patterns were designated as realism, irrelevance, over-reaction and denial. It was suggested that these patterns of response may provide clues about avoidance and coping behavior for childrens pain. In general, the results of this study did not support previous research. It was demonstrated that various statistical techniques which have been employed in research on this topic have influenced the interpretation of pain prediction and recall data.

Children's coping with venipuncture

Childrens strategies for coping with the pain and distress of venipuncture were examined in this descriptive study. Eighty-five children (aged 5-13 years) were interviewed prior to and following blood collection. Prior to the procedure, children reported pain expectations and coping strategies that might be used. Self-reports of the pain experienced and coping strategies used were obtained immediately after the procedure. Twenty-seven different strategies were identified from the childrens responses. These strategies were subsequently grouped into 11 coping categories: Active Involvement in Procedure, Behavior-Regulating Cognitions, Cognitive Reappraisal, Direct Efforts to Maintain Control, Diversionary Thinking, Emotion-Regulating Cognitions, Information Seeking, Reality-Oriented Working Through, Reliance on Health-Care Interventions, Support Seeking, and Avoidance and Catastrophizing. Direct Efforts to Maintain Control was the most frequently used category. Age and gender differences were observed in both number and type of strategies reported by the children. Further research is needed to examine the observed relationship between the type of coping strategies generated and the childrens pain experience.

Gender Effects in Pain Perception

Studies have shown that women report more pain than men when pain is induced in the laboratory. As sex differences in perceived pain have not been established with clinical or endogenous pain, research was undertaken to compare reported pain of males and females arising from one of three sources. Two groups of adults and one group of children were studied. Analyses indicated no sex differences in reported clinical or endogenous pain for children or adults.

Assessing Children’s State Anxiety

Anxiety is an important component of childrens pain and is routinely assessed in pain research. Two forms of the State-Trait Anxiety Inventory have been used frequently by researchers investigating childrens pain and state anxiety (form C-1 and Y-1). We were unable to find psychometric information about this tool when used with a population of hospitalized children. Therefore, we undertook to assess reliability and validity, and identify problem items using data from 881 hospitalized children (aged 5-18 years) whom we had tested. Considering results of all analyses together, we concluded that the tools lack validity and reliability, and contain many problem items that are in need of revision.

Patient-Controlled Analgesia for Older Adults:

Use of patient-controlled analgesia (PCA) was compared with nurse-administered intermittent intramuscular (NM) Injections of morphine in older adults during their postoperative recovery. Data analyses indicated that the PCA and IM groups did not dyfer in pain intensity, pain distress, and satisfaction. The PCA group had significantly less sleep disturbance from pain than the IM group. Neither group was considered to have acceptable pain management.