Sandra Merkel

Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations.

Individuals who are unable to communicate their pain are at greater risk for under recognition and undertreatment of pain. This position paper describes the magnitude of this issue, defines populations at risk and offers clinical practice recommendations for appropriate pain assessment using a hierarchical framework for assessing pain in those unable to self-report. Nurses have a moral, ethical, and professional obligation to advocate for all individuals in their care, particularly those who are vulnerable and unable to speak for themselves. Just like all other patients, these special populations require consistent, ongoing assessment, appropriate treatment, and evaluation of interventions to insure the best possible pain relief. Because of continued advances and new developments in strategies and tools for assessing pain in these populations, clinicians are encouraged to stay current through regular review of new research and practice recommendations.

The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment

Background:  Difficulty with pain assessment in individuals who cannot self‐report their pain poses a significant barrier to effective pain management. However, available assessment tools lack consistent reliability as pain measures in children with cognitive impairment (CI). This study evaluated the validity and reliability of the revised and individualized Face Legs Activity Cry and Consolability (FLACC) behavioral pain assessment tool in children with CI.

Reliability and Validity of the Face, Legs, Activity, Cry, Consolability Behavioral Tool in Assessing Acute Pain in Critically Ill Patients

BACKGROUND Few investigators have evaluated pain assessment tools in the critical care setting. OBJECTIVE To evaluate the reliability and validity of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain. METHODS Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the administration or procedure. Two nurses used the FLACC scale, the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children). RESULTS For 73 observations, FLACC scores correlated highly with the other 2 scores (rho = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P < .001). Exact agreement and kappa statistics, as well as intraclass correlation coefficients (0.67-0.95), support excellent interrater reliability of the tool. Internal consistency was excellent; the Cronbach alpha was 0.882 when all items were included. CONCLUSIONS Although similar in content to other behavioral pain scales, the FLACC can be used across populations of patients and settings, and the scores are comparable to those of the commonly used 0-to-10 number rating scale.

Pain management in children with and without cognitive impairment following spine fusion surgery

Background: We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery.

Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents

PurposeTo determine if low-dose ketorolac would improve analgesia while minimizing unwanted side effects in adolescents following posterior spinal fusion (PSF).MethodsA prospective randomized double-blind placebo-controlled trial assessed the analgesic effects of low-dose ketorolac following PSF. Thirty-five adolescents aged 11–17 yr were randomly assigned to receive placebo or 0.5 mg·kg−1 ketorolac (maximum of 15 mg) six hourly postoperatively for 36 hr in conjunction with standard morphine patient controlled analgesia (PCA). Pain and sedation were assessed twice daily for the first three postoperative days (POD). The incidence of side effects related to both non-steroidal anti-inflammatory agents and opioids were recorded.ResultsAdolescents in the ketorolac group received an average dose of 0.2 mg·kg−1 (average exposure 1.2 mg·kg−1), had lower pain scores on POD one and two (P < 0.05) and consumed less morphine in the postanesthesia care unit and on POD two. There was no difference in the incidence of pruritus, nausea, vomiting or constipation, but patients in the ketorolac group tolerated activity better on POD one (P < 0.05). There were no differences between groups with regard to postoperative blood loss or transfusion requirements. Fourteen patients were followed for two years and the incidence of curve progression, hardware failure or back pain at final follow-up was not different.ConclusionLow-dose ketorolac in conjunction with morphine PGA improved the quality of analgesia and reduced morphine requirements following PSF compared to placebo without increasing the incidence of non-steroidal anti-inflammatory side effects.RésuméObjectifDéterminer si une faible dose de kétorolac améliore l’analgésie tout en réduisant les effets secondaires chez des adolescents qui ont subi une spondylodèse postérieure (SDP).MéthodeUn essai à double insu, randomisé et contrôlé contre placebo a permis d’évaluer les effets analgésiques d’une faible dose de kétorolac administrée après une SDR Trente-cinq adolescents de 11–17 ans ont été répartis de manière aléatoire et ont reçu, soit un placebo, soit 0,5 mg·kg−1 de kétorolac (maximum de 15 mg) toutes les six heures après l’opération et ce, pendant 36 h en conjonction avec de la morphine normale en analgésie autocontrôlée (AAC). La douleur et la sédation ont été évaluées deux fois par jour pour les trois premiers jours postopératoires (JPO). L’incidence d’effets secondaires reliés aux anti-inflammatoires non stéroïdiens (AINS) et aux opioïdes a été notée.RésultatsLes sujets qui ont eu du kétorolac ont reçu une dose moyenne de 0,2 mg·kg−1 (exposition moyenne de 1,2 mg·kg−1), ont présenté des scores de douleur plus faibles aux JPO un et deux (P < 0,05) et ont pris moins de morphine à la salle de réveil et au deuxième JPO. Lincidence de prurit, nausées, vomissements ou constipation était comparable dans les deux groupes, mais les mouvements étaient mieux tolérés avec le kétorolac au premier JPO (P < 0,05). La perte sanguine postopératoire et les besoins de transfusion ont été comparables. Quatorze patients ont été suivis pendant deux ans et l’incidence de la progression de la courbe, de la défaillance du matériel ou de la douleur au dos n’était pas différente au dernier examen de suivi.ConclusionUne faible dose de kétorolac, administrée avec de la morphine en AAC, améliore la qualité de l’analgésie et réduit les besoins de morphine à la suite d’un SDP, en comparaison avec un placebo, et sans augmenter l’incidence d’effets secondaires des AINS.

A Comparison of the Clinical Utility of Pain Assessment Tools for Children with Cognitive Impairment

BACKGROUND:Difficulty assessing pain has been cited as one of the primary reasons for infrequent and inadequate assessment and analgesia for children with cognitive impairment (CI). Several behavioral observational pain tools have been shown to have good psychometric properties for pain assessment in this population; however, routine clinical use may depend largely on their pragmatic qualities. We designed this study to evaluate pragmatic attributes or clinical utility properties of three recently developed pain assessment tools for children with CI. METHODS:A sample of clinicians from three medical centers were asked to review 15 videotaped observations of children with CI, recorded during their first three postoperative days during participation in a previous study. Participants scored pain using the revised-Face, Legs, Activity, Cry, Consolability (r-FLACC) tool (individualized for the child during the previous study) for five observations, the noncommunicative Non-Communicating Children’s Pain Checklist-Postoperative Version (NCCPC-PV) for five, and the Nursing Assessment of Pain Intensity (NAPI) for five observations. After their review of all segments, participants completed the Clinical Utility Attributes Questionnaire (CUAQ) ranking three attributes of clinical utility; complexity, compatibility, and relative advantage. RESULTS:Five physicians and 15 nurses comprised the sample. There was excellent agreement between the coded pain scores (i.e., mild, moderate, severe pain) assigned using all tools and r-FLACC scores assigned by original observers (88%–98% exact agreement; &kgr; 0.71–0.96). The internal consistency or reliability of the CUAQ was supported by high &agr; values for each of the subscales (&agr; = 0.84–0.93). Subscale and total CUAQ scores were higher for the r-FLACC and NAPI compared with the NCCPC-PV. The r-FLACC had similar scores for complexity, but slightly higher scores for compatibility, relative advantage, and total utility compared with the NAPI. CONCLUSIONS:We found that clinicians rated the complexity, compatibility, relative advantage, and overall clinical utility higher for the r-FLACC and NAPI compared with the NCCPC-PV, suggesting that these tools may be more readily adopted into clinical practice.

Lumbar epidural morphine infusions for children undergoing cardiac surgery

OBJECTIVE To determine whether outcomes and costs in children undergoing cardiac surgery are affected by the method of postoperative pain management. DESIGN Retrospective, case control. SETTING Tertiary care childrens hospital in a university setting. PARTICIPANTS Two groups of children undergoing cardiac surgery for palliation or repair of congenital heart disease oer a 21-month period between January 1993 and September 1994. INTERVENTIONS Lumbar epidural morphine infusions (LEM) in one group, and IV opioid (IVO) medication in the other for postoperative pain control. MEASUREMENTS AND MAIN RESULTS Hospital courses of 27 LEM patients and 27 IVO patients were analyzed. In LEM patients, epidural catheters were placed following anesthetic induction, but before anticoagulation. A bolus of 50 micrograms/kg of preservative-free morphine sulfate was administered through the catheter, followed by a continuous infusion at 3 to 4 micrograms/kg/h for 22 to 102 (median, 46) hours postoperatively. The IVO patients received 50 micrograms/kg, IV, of fentanyl before incision followed by a continuous infusion at 0.3 microgram/kg/min. The fentanyl infusion rate was decreased to 0.1 microgram/kg/min postoperatively and maintained for 24 hours. Although the LEM group was demographically similar to the IVO group, times to tracheal extubation, transfer from the intensive care unit, and resumption of regular diet were significantly shorter in LEM patients. LEM and IVO patients received similar amounts of fentanyl during surgery (10.4 +/- 19.3 micrograms/kg/h v 13.7 +/- 8.1 micrograms/kg/h, p = 0.4). However, during postoperative recovery, LEM patients who were extubated late received significantly less supplemental opioid medication than IVO patients extubated late during the first 5 postoperative days. No complications related to dural puncture, bleeding into the epidural space, or respiratory depression were encountered. Pruritus and nausea/vomiting were the most commonly reported morbidities in both groups. Fifty-six percent (15/27) of LEM patients and 41% of IVO patients reported pruritus (p = 0.4). There was no significant difference in the incidence of nausea and vomiting between the groups (34% v 30%, respectively). CONCLUSIONS Given the present methodologic limitations, the authors found improved outcomes only in LEM patients extubated late compared with IVO patients. Randomized, prospective studies to evaluate this conclusion and to determine the comparative efficacy and safety of LEM infusions are in progress.

A comparison of continuous epidural infusion and intermittent intravenous bolus doses of morphine in children undergoing selective dorsal rhizotomy

BACKGROUND AND OBJECTIVES Selective dorsal rhizotomy (SDR) is associated with moderale to severe postoperative pain. Although the efficacy of epidural analgesia in this population has been demonstrated, it has not been compared with conventional intravenous (i.v.) analgesia. This prospective study compared the effects of epidural and i.v. morphine regarding postoperative analgesia, side effects, and outcomes in children following SDR. METHODS Twenty-seven children were randomized to receive either epidural or i.v. analgesia. Children in the epidural group had a catheter placed by the neurosurgeon and received preservative-free morphine (Duramorph) 30 microg/kg, followed by an infusion of 3 microg/kg/h for 3 days. Children in the i.v. group received morphine 0.05-0.1 mg/kg intraoperatively, followed by 0.02 mg/kg doses postoperatively administered by nurses via a patient-controlled analgesia device. RESULTS The epidural group experienced lower pain scores (P = .04) and fewer muscle spasms (P < or = .04), and tolerated activity better (P < or = .02) during the early postoperative period than the i.v. group. Side effects were similar between groups, with no respiratory depression in either group. Parents of children in both groups perceived an adequate level of comfort and were very satisfied with the analgesic technique. Additionally, parents believed that their childs postoperative pain was less than anticipated (P < or = .01). CONCLUSIONS Both techniques provided effective postoperative analgesia with a similar incidence of side effects; however, our findings suggest that continuous infusions of epidural morphine improved overall comfort with lower pain scores, fewer muscle spasms, and improved tolerance of activity during the initial postoperative period.

Behavioral pain assessment and the Face, Legs, Activity, Cry and Consolability instrument

Difficulties assessing pain in individuals who cannot use self-report scales has led to their exclusion from clinical trials and rendered them vulnerable to undertreatment of pain. Although several observational pain scales are available for use in these populations, many lack the characteristics necessary for routine implementation into practice or research. The Face, Legs, Activity, Cry And Consolability pain scale was developed as a simple measure of pain intensity in young children. It has been validated in the postoperative setting in children 2–7 years of age and children aged 4–18 years with varying degrees of cognitive impairment. With minor revisions, the Face, Legs, Activity, Cry and Consolability pain scale may be useful to assess acute pain across populations of children and adults who are unable to self-report their pain.

Use of Transcutaneous Electrical Nerve Stimulation in a Young Child with Pain from Open Perineal Lesions

Transcutaneous electrical nerve stimulation (TENS) has been shown to be an effective treatment modality in adults experiencing pain associated with a variety of conditions. Therapeutic measures that are effective with adults can often be used with children. However, the benefit of TENS for children has not been well established since few research or clinical data have been published in the literature. This case report of a 4-year-old female with open perineal skin lesions who received TENS as an adjuvant therapy for painful dressing changes illustrates that TENS can be an effective treatment in children. In addition to the pain reduction seen in our patient, TENS therapy also had an opioid-sparing effect.