Marilyn Savedra

Use of the Mcgill Pain Questionnaire To Measure Pain: A Meta-analysis

A meta-analysis of 51 studies was done to estimate normative mean McGill Pain Questionnaire (MPQ) scores and to assess pain quality and pain intensity as measured by the MPQ in 3,624 subjects with seven painful conditions. Across the painful conditions, all of the estimated normative mean scores were no more than 50% of the maximum score, suggesting that scores may be skewed to the left. Although the estimated normative mean scores were similar among the seven painful conditions, higher affective scores appeared to differentiate chronic painful conditions from acute painful conditions. Of the 78 MPQ words that describe pain quality, only 19 were selected by more than 20% of the subjects. Data reported in the majority of these studies were inadequate to test for differences in scores or word selection pattern by the seven painful conditions.

How do children describe pain? A tentative assessment

Abstract In a study to determine how children describe the experience of pain, we queried a convenience sample of 100 children in hospitals and 114 children in church and private schools who were between 9 and 12 years old. The questions were designed to seek correlations by age among boys and girls and between hospitalized and non‐hospitalized children that would aid health professionals in strategies that will identify and assist the child who is in pain. The preliminary results show that children clearly describe pain, that there are no appreciable differences by age groups, but that children who are hospitalized describe pain differently from children who are not.

Analgesic efficacy and safety of single-dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy.

&NA; The efficacy of ketorolac, a non‐steroidal anti‐inflammatory drug, in the management of moderate to severe pain in adults, has led us to conduct a trial of this analgesic in children following tonsillectomy. Children were randomized to receive intramuscular (i.m.) ketorolac (1 mg/kg, EXP group, n = 45) or saline (CTL group, n = 42) at the completion of surgery. Intravenous (i.v.) fentanyl (0.5 &mgr;g/kg/dose) was administered in repeated doses postoperatively. Pain intensity was measured using both the Oucher and the Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS) to allow for comparison between self‐report and behavioral measures of pain intensity. Severity of postoperative bleeding was measured using a 4‐point rating scale. The EXP group had a significant reduction in total fentanyl dose (mean: 35.9 &mgr;g) compared to the CTL group (mean: 48.3 &mgr;g, t = −2.21, P < 0.03). There was a statistically significant decrease in pre‐fentanyl CHEOPS scores in the Post‐Anesthesia Care Unit (PACU) in the ketorolac group (F (2,30) = 5.34, P < 0.01), but not in the saline group (F (2.24) = 2.46, P > 0.05). In the first hour postoperatively, the CHEOPS demonstrated significant decreases in pain intensity scores in response to opioids, in both groups. In the PACU, children were unable to provide a self‐report of pain intensity potentially due to a variety of factors (e.g., emergence delirium, agitation, excitement, sedation, and/or pain). However, during the remainder of the postoperative stay, the photographic scale of the Oucher was a more valid measure of pain intensity than the CHEOPS. There were no differences between the 2 groups in the severity of postoperative bleeding. Children in the EXP group were discharged significantly earlier (i.e., 30 min, t = −2.22, P < 0.03). Our data demonstrate that i.m. administration of ketorolac, at the end of surgery, significantly reduces opioid requirements and shortens length of stay without any evidence of increased bleeding. In addition, our data suggest that the patients altered level of consciousness and attention span may diminish the utility of self‐report measures of pain intensity in the immediate postoperative period.

Measuring pain quality: validity and reliability of children's and adolescents' pain language

&NA; Although considerable research has been conducted to identify childrens and adolescents language of pain, research is lacking regarding a method to quantify the pain quality described by this language. Three descriptive studies involving 1223 children, aged 8–17 years, were conducted in school and hospital settings. The aims were to develop and examine the validity and reliability of a word list for measuring pain quality that was free of age, gender, and ethnic biases. A word list with 43 words was developed and resulted in sensory, affective, evaluative, and total scores that correlated with pain location and pain intensity scores (r = 0.19−0.44; P ⩽ 0.01). Pain quality scores decreased over time in a postoperative pain model. Test‐retest reliability of the word list scores was high (r = 0.78–0.95; P < 0.001). This world list was revised and resulted in a word list with 56 words relatively free of gender, ethnic, and developmental biases. Additional research is needed to assess the psychometric properties of this world list in pediatric populations experiencing different pain syndromes.

A Randomized Clinical Trial of the Efficacy of Scheduled Dosing of Acetaminophen and Hydrocodone for the Management of Postoperative Pain in Children After Tonsillectomy

ObjectivesTo determine the effectiveness of around-the-clock (ATC) analgesic administration, with or without nurse coaching, compared with standard care with as needed (PRN) dosing in children undergoing outpatient tonsillectomy. MethodsChildren 6 to 15 years of age were randomized to receive acetaminophen and hydrocodone (167 mg/2.5 mg/5 mL) for 3 days after surgery: Group A (N=39)—every 4 hours PRN, with standard postoperative instructions; Group B (N=34)—every 4 hours ATC, with standard postoperative instructions, without nurse coaching; and Group C (N=40)—every 4 hours ATC, with standard postoperative instructions, with coaching. Parents completed a medication log, and recorded the presence and severity of opioid-related adverse effects and childrens reports of pain intensity using a 0 to 10 numeric rating scale. ResultsNo differences were found in analgesic administration or pain intensity scores between the 2 ATC groups. Therefore, they were combined for comparison with the PRN group. Children in the ATC group received more analgesic than those in the PRN group (P<0.0001). Children in the PRN group had higher pain intensity scores compared to children in the ATC group, both at rest (P=0.017) and with swallowing (P=0.017). Pain intensity scores for both groups were higher in the morning compared with the evening (P<0.0001). With the exception of constipation, scheduled analgesic dosing did not increase the frequency or severity of opioid-related adverse effects. DiscussionScheduled dosing of acetaminophen and hydrocodone is more effective than PRN dosing in reducing pain intensity in children after tonsillectomy. Nurse coaching does not impact parents adherence to ATC dosing.

The Pain Experience of Children With Leukemia During the First Year After Diagnosis

BackgroundChildren with cancer experience pain related to the disease process, the treatment, and the associated procedures. For children with leukemia, the pain experienced after diagnosis has received scant attention. ObjectiveTo examine the pain experience, management strategies, and outcomes during the first year after the diagnosis of acute leukemia. MethodsA longitudinal descriptive approach was used to collect data at seven data points from 95 English- and Spanish-speaking children, ages 4 to 17 years, receiving care in one of three southern California hospitals, and from their English- and Spanish-speaking parents. Age-appropriate instruments were used to examine the variables of pain intensity, location, pattern over time, and quality, as well as strategies for managing pain, perceived effectiveness of management strategies, and functional status. ResultsAll the children reported pain over the course of the year. Pain intensity scores incorporated the full range of possible responses. For the children 4 to 7 years old, the highest and lowest mean scores, respectively, were 2 and 1.6 (scale, 0–4). For the children 8 to 17 years old, the highest and lowest mean scores, respectively, were 50.1 and 39.5 (scale, 0–100). The most common location of pain was the legs (26.5%) in all seven interviews. Other frequently noted sites were the abdomen (16.6%), head/neck (16.6%), and back (14.2%). The words used most frequently by the older English- and Spanish-speaking children to describe pain were “uncomfortable” (incómodo) and “annoying” (molesto). According to the interviews, the most frequently used strategy for pain management was stressor modification (e.g., medication, sleep, hot/cold, and massage). The most common coping strategies according to a Likert scale rating were “watch TV” (n = 426), “lie down” (n = 421), “wish for it to go away” (n = 417), and “tell my mother or father” (n = 416). The pain intensity scores after pain management were significantly lower for the younger children in three of the seven interviews and for the older children in all seven interviews. For both the younger and older children, functional status (i.e., the ability to engage in routine activities) was above the median score at the seven interviews. ConclusionsChildren with leukemia experience pain throughout the first year of treatment. In this study, the pain was responsive to the management strategies used by the parents and children.

A randomized clinical trial of the effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in children following tonsillectomy

&NA; The purpose of this study was to determine whether around‐the‐clock (i.e. ATC) dosing of acetaminophen with codeine, with or without nurse coaching, compared to standard care with as needed (i.e. PRN) dosing: reduced childrens reports of pain intensity with and without swallowing; increased pain relief, and increased analgesic consumption. Eighty children, 6–15 years, undergoing tonsillectomy were randomized to one of three treatment groups to receive acetaminophen with codeine (120 mg/12 mg/5 ml) for 3 days after surgery: PRN group (N=28)—every 4 h PRN, with standard postoperative instructions, without nurse coaching; ATC group (N=26)—every 4 h ATC, with standard postoperative instructions, without nurse coaching; and ATC+coaching group (N=26)—every 4 h ATC, with standard postoperative instructions and nurse coaching. In all three groups, significant decreases were found over time in pain intensity scores at rest (P<0.0001) and with swallowing (P<0.0001). However, mean pain scores at rest and with swallowing were >3/10 until the fourth evening after tonsillectomy. Children in both ATC dosing groups received significantly greater amounts of acetaminophen and codeine than children in the PRN group (P<0.003). No significant differences were found in the amount of analgesic administered between the ATC dosing groups with and without nurse coaching. No significant differences were found in the amount of nausea and vomiting among the three groups. Scheduled dosing of acetaminophen with codeine did not provide adequate pain relief for children following tonsillectomy. Nurse coaching does not increase parents adherence with an ATC dosing schedule.

Postoperative analgesics for children and adolescents: Prescription and administration

Pain was measured and analgesic treatment examined in 131 children and adolescents, 8-17 years of age, for 5 days after surgery. Analgesic data were converted to 10 mg intramuscular morphine-equivalent doses (IMMSEQ) and were designated appropriate or inappropriate for body weight. Analgesic onset, peak, and duration were calculated in relation to administration routes and the time pain assessments were made. Children reported moderately severe pain in many body locations. Initially, all but two children were prescribed and ultimately all but one received analgesics. Prescribed and administered doses were frequently less than doses recommended for weight. Two-thirds of the children were beyond analgesic action when pain was assessed. Weak to moderately strong associations were noted between IMMSEQ doses and pain intensity scores on each of the 5 postoperative days. Unfortunately, findings indicate that children continue to be undertreated when they experience postoperative pain.

Changes in intensity, location, and quality of vaso-occlusive pain in children with sickle cell disease.

&NA; A descriptive, longitudinal design was used to examine changes in current, worst, and least pain intensity during hospitalization for a vaso‐occlusive episode in children with sickle cell disease. Other dimensions of the pain experience including location and quality were also evaluated. Children reported severe pain on the day of admission with 50% of the episodes showing a current pain intensity score of >70 and a worst pain intensity score of >80. Although both pain intensity scores demonstrated statistically significant decreases by approximately 5% over the course of the hospitalization, these decreases were not clinically significant based on the recommendations made in the American Pain Societys Guideline for the management of acute and chronic pain in sickle cell disease. In contrast to the pain intensity ratings, which did not decrease in 25% of the episodes, pain location surface area decreased in 100% of the episodes. Children described the quality of vaso‐occlusive pain using all categories of word descriptors from the adolescent pediatric pain tool. These findings suggest that pain associated with a vaso‐occlusive episode is inadequately assessed and managed during hospitalization.

Management of vaso-occlusive pain in children with sickle cell disease.

Purpose A descriptive, longitudinal design was used to evaluate the pain management strategies used in children with sickle cell disease who were experiencing pain during a vaso-occlusive episode. Methods A list of the medications (name, amount, mode of delivery, and frequency) prescribed and administered for pain management for each participant was recorded on the Medication Quantification Scale Worksheet, starting from day 1 of hospitalization to the day of discharge. Children were asked once each evening to provide three separate ratings of how much the pain medication helped them during the day, evening, and night using a 0-to-10 rating scale. Results Using patient-controlled analgesia (PCA), children self-administered only 35% of the analgesic medications that were prescribed and reported little pain relief. No significant relationships were found between changes in pain relief scores and the amount of analgesics administered. Conclusions Clinicians need to monitor the amount of analgesics delivered in relationship to pain relief and assist children to titrate PCA administration of analgesics to achieve optimal pain control, or to advocate for changes in the PCA regimen when children cannot assume control of pain management.