Behavioral Pain Scores Research Articles

Postoperative Sedation in Free Microvascular Tissue Transfer in Head and Neck Cancer: A Comparison of Fentanyl and Morphine

Background and Aims: Head-and-neck cancer surgeries with microvascular free flap reconstruction require endotracheal tube retention for 24–48 h postoperatively. Many regimes have been used for analgesia and sedation. The efficacy of fentanyl and morphine for post-operative analgosedation was compared by evaluating the need for additional sedatives to achieve optimum sedation scores. The secondary objective included analgesia, haemodynamic stability and a re-exploration rate. Methods: This was an open-label prospective study. A sample size of 36 was calculated in each group with α = 0.05 and a power of 80% to detect a 50% difference between the groups. Ninety adult patients were allocated to receive either fentanyl (Group F) or morphine (Group M). The Richmond agitation sedation score, Behavioural pain scale score, requirement of rescue hypnotic drug, pulse rate, systolic and diastolic blood pressures and re-explorations were recorded postoperatively. Haemodynamic parameters and sedation were analysed by two-way repeated measures of analysis variances. Pain scores were analysed using the Chi-square test. Results: When titrating to optimal sedation, in Group M, more patients needed intravenous midazolam boluses (n = 42, 93.3%) as compared to Group F (n = 33, 73.3%) (P = 0.011). More subjects in Group M required propofol infusion (n = 15, 33.3%) than in Group F (n = 4, 8.9%) (P = 0.009). Mean behavioural pain scores were significantly higher in Group M (score 1: P = 0.005 and score 2: P =0.001). The difference in the mean systolic, diastolic blood pressure, pulse rate, respiratory rate and re-exploration rate between the two groups was statistically insignificant. Conclusion: For analgesia-based sedation of spontaneously breathing intubated patients after head-and-neck cancer reconstructive surgeries, fentanyl is more effective than morphine in terms of ease of titration, sedation quality and analgesia. Both are safe for post-operative sedation regarding haemodynamic stability, tube retention and maintenance of spontaneous respiration.

Analgesic effectiveness of methoxyflurane inhaler during genicular nerve block in knee osteoarthritis: a randomized controlled trial

BackgroundUp to 30% of patients with knee osteoarthritis (KOA) have evidence of sensitization, with a similar proportion experiencing severe pain during procedures. Most patients with KOA are elderly and often...

The Effect of Breastfeeding on the Newborn’s Comfort and Pain Levels During Heel Blood Collection

ABSTRACT This research was planned to determine the effect of breastfeeding on newborns’ behavioral pain and comfort scores during heel blood collection. A pretest/posttest experimental-control group design was used. The research was conducted between August 2021 and June 2022. A total of 50 newborns, including 25 in each of the experimental and control groups, were included in the study. An Infant Descriptive Information Form, the COMFORTneo Behaviour Scale, the NIPS-Neonatal Infant Pain Scale, and the LATCH Breastfeeding Diagnosis and Assessment Tool were used in the study. The comfort behaviors and pain scores of infants in the experimental and control groups were evaluated during the heel blood collection process. The comparison of the comfort behaviors (comfort, pain, and distress), differences between pretest-posttest scores on the NIPPS pain score, and crying duration of the newborns in the experimental and control groups indicated a significant difference (p 0.05). The intra-group differences between the mean pretest and posttest scores of both the intervention and control groups were found to be statistically significant (p 0.05). Breastfeeding is an important nursing intervention for reducing procedural pain in newborns. The breastfeeding method reduces pain and distress and increases comfort for newborns during the heel blood collection process.

A randomised controlled trial on effect of topical anaesthetics on injection pain during immunization in infants of 6 weeks to 6 months of age with pentavac vaccine

Background: Pain is a both a sensory and an emotional experience when untreated and unrecognized, it extracts a significant physiological, biochemical and psychological toll on both the children and family members. Vaccine injections are considered to be the most common cause of iatrogenic pain in childhood. Positive experience during vaccine injection like reducing injection pain with local anaesthetics can avoid pre procedural anxiety in future, needle phobias, healthcare avoidance behaviors and maintain trust in healthcare providers. Methods: This randomized controlled trial was done at immunization clinic of Rajah Muthiah Medical College Hospital over a period of 2 years.100 infants of age group 6 weeks to 6 months brought for Pentavac (DPT-Hib-Hepatitis B) combination vaccine were taken for study and allocated into control, intervention group (receiving local anaesthetic cream/lidocaine spray) and pain score was compared using modified behavioral pain score (MBPS). Results: Among the three groups studied, the mean pain scores after vaccine injection were minimum in group A (infants with topical occlusive EMLA cream), followed by group B (infants with topical LA spray), whereas control group of infants who did not receive any local anaesthesia exhibited higher pain scores values. Conclusions: Our study showing that topical occlusive EMLA cream significantly decreases injection pain in infants has applicability in clinical practice, where it can be routinely used in infants before administering intramuscular vaccine injections in settings where resources are not a constraint.

Oral Administration of Meloxicam and Flunixin Meglumine Have Similar Analgesic Effects After Lipopolysaccharide-Induced Inflammatory Response in Thoroughbred Horses.

Flunixin meglumine (FM), a nonselective cyclooxygenase (COX) inhibitor, is most frequently selected for the treatment of equine systemic inflammatory response syndrome (SIRS)/endotoxemia. However, FM has considerable adverse effects on gastrointestinal function. The aims of this study were to compare the effect of meloxicam (MX), a COX-2 selective inhibitor commonly used in equine clinical practice, with FM, and to investigate the potential for clinical application in horses with SIRS/endotoxemia. Fifteen horses were divided into three groups of five and orally administered MX (0.6 mg/kg), FM (1.1 mg/kg), or saline as placebo at 30 minutes after LPS challenge. Clinical parameters, including behavioral pain scores, were recorded and blood for clinical pathological data was collected at various times from 60 minutes before to 420 minutes after LPS infusion. The pain score were significantly lower in both the MX and FM groups than in the placebo group, with no significant difference between them. Body temperature was significantly lower in the MX and FM groups than in the placebo group. Heart rates and respiratory rates, hoof wall surface temperature, and leukocyte counts changed similarly between the MX and FM groups. TNF-α and cortisol were lower in the FM group than in the MX group. The results suggest that MX suppresses the inflammatory response after LPS infusion and has an analgesic effect similar to that of FM. Given the adverse effects of nonselective COX inhibitors, clinical application of MX may be beneficial in horses with SIRS/endotoxemia.

Systematic evaluation and meta-analysis of Chinese medicine in the treatment of centrally mediated abdominal pain syndrome.

Background:This study aimed to evaluate the clinical efficacy of Chinese medicine for the treatment of centrally mediated abdominal pain syndrome (CAPS) using a meta-analysis system.Methods:Six databases, including China National Knowledge Infrastructure, Vendor Information Pages, Chinese Biomedical Database, Wanfang, PubMed, and Embase were searched for randomized controlled trials related to the treatment of CAPS with traditional Chinese medicine. The bias risk assessment tool and RevMan5.3 software (Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration) were used to conduct quality assessment and meta-analysis, and the GRADE grading system was used to evaluate the quality of evidence for outcome indicators.Results:Fifteen articles were included in this study. Meta-analysis results showed that the treatment group was more effective in terms of the total effective rate (relative risk = 1.27; 95% confidence interval [CI], 1.19–1.34; P < .00001), Behavioral Rating Scale-6 pain score (mean difference [MD] = −0.79; 95% CI, −0.99 to −0.59; P < .00001), and traditional Chinese medicine (TCM) symptom score (MD = −1.74; 95% CI, −2.23 to −1.26; P < .00001) than the control group (P < .05). However, in terms of numerical rating scale pain score (MD = 0.79; 95% CI, −1.70 to 0.12; P = .09), the efficacy was comparable between the 2 groups, and the difference was not statistically significant (P > .05). In terms of verbal rating scale pain, depression, and anxiety scores, the data could not be combined due to inconsistent scoring criteria, and only descriptive analysis was performed. The results showed that the treatment group was slightly better than the control group in terms of relieving verbal rating scale pain and improving anxiety and depression (P < .05).Conclusion:Chinese medicine can effectively improve the pain and TCM clinical symptoms of patients with CAPS and relieve patients’ anxiety and depression with fewer adverse effects, which has certain therapeutic advantages. However, because of the low methodological quality assessment of the included literature, the quality of GRADE evidence for outcome indicators is of mostly low and very low quality, the strength of recommendation is weak, and the credibility of the conclusion is average. More rigorous, larger sample, and higher-quality clinical trials are required to provide a higher level of evidence-based medicine for the development of TCM treatment standards for CAPS.

Sensorial saturation improves infants’ procedure-related pain behaviour in the cardiac intensive care unit: A quasi-experimental study

BackgroundPainful procedures are unavoidable when providing critical care to infants in intensive care units. These adverse experiences during infancy can lead to later hyperalgesia and poor neurodevelopmental outcomes. Thus, appropriate interventions are required to relieve infant pain during these procedures. ObjectivesThis study evaluated the effectiveness of sensorial saturation in reducing pain for infants during jugular central venous catheter removal procedures in intensive care units. MethodsThis study involved a quasi-experimental, repeated-measures design. Data were collected from participants sequentially recruited from April to June 2019 (control period) and July to September 2019 (experimental period). Participants included 78 infants younger than 1 year with congenital heart disease. The control group (n = 38) received a general nursing intervention using swaddling, a common child-care practice that consists of wrapping infants to restrict movements, whereas the experimental group (n = 40) received sensorial saturation using oral sugar, body massage, and verbal interaction. Infants' physiological reactions to procedural pain were measured by changes in heart rate, oxygen saturation, and respiratory rate. Infants’ procedural pain and behavioural indicators were measured using the Modified Behavioural Pain Scale. Data were analysed using descriptive statistics, independent t-tests, χ2 tests, and repeated-measures analysis of variance. ResultsCompared with the control group, the experimental group had lower heart rates (F = 53.15, p < .001), respiratory rates (F = 15.19, p < .001), and behavioural pain scores (F = 45.21, p < .001), both during and after the procedure. ConclusionsSensorial saturation can be used as a nursing intervention in infants. Given the many invasive procedures that are part of infant clinical care, sensorial saturation may be a safe analgesic alternative. The findings of this study could lead to the development of evidence-based clinical practice guidelines for the nonpharmacological management of acute pain in infants.

Effect of erector spinae plane block on postoperative analgesia after pediatric hip surgery: Randomized controlled study.

Erector spinae plane block (ESPB) in pediatric patients presenting for hip surgery may improve the postoperative analgesia. The study aimed to investigate the effect of ultrasound-guided ESPB on postoperative analgesia after a pediatric hip surgery. Forty children scheduled for hip surgeries were included in this trial and randomly distributed into; Control group, patients received sham ultrasound-guided ESPB at the level of L3 or ESPB group, patients received real ultrasound-guided ESPB at the level of L3 with an injection of 0.4ml/kg of plain bupivacaine 0.25%. The time for the first call of rescue analgesia, intraoperative fentanyl consumption, postoperative morphine consumption, Children's Hospital Eastern Ontario Pain Scale (CHEOPS), and Objective Behavioral Pain score (OPS) were recorded. As compared to the control group, the use of ESPB significantly prolonged the time for first request of rescue analgesia from 170.50±44.066 to 256.50±66.434min (p<0.0001), decreased the intraoperative fentanyl consumption from 1.025±0.379 to 0.775±0.343μg/kg (p=0.035), decreased the postoperative morphine consumption from 0.105±0.036 to 0.065±0.023mg/kg (p=0.0002). Also, it significantly decreased postoperative CHEOPS and OPS scores 2, 4, and 6h after the surgery (p<0.05) with an insignificant difference between the two groups at all other time intervals (p˃0.05). The use of ESPB in pediatric patients undergoing hip surgery prolonged the time for the first call of analgesia, decreased the intraoperative and postoperative opioid consumption, and decreased the postoperative pain.

Trajectories of distress regulation during preschool vaccinations: child and caregiver predictors.

Recent research has highlighted the need for a deeper understanding of the heterogeneity in trajectories of children's distress after acute pain exposure, moving beyond the group means of behavioural pain scores at a single timepoint. During preschool vaccinations, 3 distinct trajectories of postvaccination pain regulation have been elucidated, with approximately 75% of children displaying trajectories characterized by downregulation to no distress by 2 minutes postneedle and 25% concerningly failing to downregulate by 2 minutes. The objective of this study was to examine child and caregiver predictors of preschool children's postvaccination regulatory patterns. Our results indicated that higher child baseline distress, more caregiver coping-promoting verbalizations in the first minute after the needle, less coping-promoting verbalizations in the second minute, and more caregiver distress-promoting verbalizations in the second minute after the needle were associated with membership in the trajectories characterized by high distress. Furthermore, although all children's pain-related distress at various timepoints throughout the appointment was most strongly predicted by previous pain scores, different patterns of associations emerged depending on the trajectory exhibited. This research highlights both the need to minimize distress before the needle to avoid the highly distressed trajectory and the importance of considering the heterogeneity of trajectories of preschool pain responding when examining the factors that are associated with children's pain-related distress.

Effect of Active Distraction on Children’s Pain and Behavioral Response during Intravenous Catheter Insertion

ABSTRACT Background Relief of pain and suffering is an important responsibility of nurses caring for children, and intravenous cannula insertions is the most common sources of pain in hospitalized children. Distraction is recommended to help in minimizing the discomfort of painful procedures. The aim of the study is to examine the effects of pressing a soft ball on children’s behavioral response and pain level during and after intravenous catheter insertion. Methods: Research design Quasi-experimental design was used. Setting: The study was conducted at surgical ward at pediatric hospital, Zagazig university hospitals. Sample: A convenient sample of 100 children aged 4–10 years. Tools: Four tools were used to collect the study data: (I): Demographic data (child’s age, gender, birth order and cause of surgery). (II): Vital signs sheet (heart rate and respiratory rate) measured before and after intravenous cannula insertion in both intervention and control groups. (III): Behavioral response scale “FLACC” included five criteria (Face, Legs, Activity, Cry, Consolability). (IV): Wong–Baker FACES Pain Rating Scale (WBFPS) to assess children’s pain. Findings: After performing the procedure 46% of intervention group experienced moderate pain, compared to 56% of the control group. Statistically significant correlation between children behavioral response and pain score in both intervention and control groups (P = 0.001, P = 0.01) respectively. Highly statistically significant correlation between respiratory rate after intervention and children face rating scale in intervention group (P < 0.001). Conclusion: the study concluded that pressing a soft ball is an effective and easily accessible technique to decrease pain during IVCI in children between 4 years and 10 years. Practice implication: The results have implication for how health care professionals should implement distraction techniques to relieve children’s pain during painful invasive procedures such as IVCI.

Postoperative pain course after paediatric tonsillectomy: A prospective observational study comparing one behavioural and one numerical pain assessment tool

IntroductionPaediatric tonsillectomy is often performed as outpatient surgery, although postoperative pain may be severe and protracted. This prospective observational study evaluated two paediatric pain assessment tools for use in telephone interviews with parents. MethodsASA I-II children, ≥1 and < 13 years, undergoing outpatient tonsillectomy were recruited. Anaesthesia (propofol-remifentanil) and intraoperative analgesia were standardized. Sedating premedication was not given.Before discharge, a “smiley face” numerical pain assessment tool was introduced to parents. In telephone interviews on postoperative days 1, 3, 7 and 14, parents scored their childrens pain numerically (0–10) and on the behavioural Postoperative Pain Measure for Parents (PPMP, 0-15). Number of analgesic doses (paracetamol/ibuprofen) per 24 h was noted. Values are median (quartiles). Results22 consecutive children were included, age 4 (3–6) years. Parents had administered analgesics to 100%, 95%, 80%, and 5% of children at the four interview times. Numerical pain scores were 3.5 (1–7) at hospital discharge, and 5.5 (3–7), 3 (2–6), 3.5 (0–6), and 0 (0-0) on postoperative days 1, 3, 7, and 14, respectively. In 12/22 children, pain declined to a value of 1 (0–2) on day 7. In 6/22 children pain initially declined, but surged to 5.5 (4–7) on day 7. Significant, protracted pain (9 (6–10) on day 7) was reported in 3/22 children. Behavioural (PPMP) scores were positively correlated to numerical pain scores (day 3: R2 = 0.48, day 7: R2 = 0.31, day 14: R2 = 0.85). With increasing age, children systematically had lower behavioural pain scores for the same numerical pain score (0.61 per years age; p < 0.023). ConclusionIn structured telephone interviews, parents effectively pain scored their children after outpatient tonsillectomy. Numerical and behavioural pain scores correlated well, however age-dependent. Pain courses varied considerably, and a majority of children had significant pain. Pain after paediatric tonsillectomy should be assessed and treatment individualised.

Acute pain measured with the modified Bernese Pain Scale for Neonates is influenced by individual contextual factors.

Individual contextual factors like gestational age (GA) or previous painful experiences have an influence on neonates' pain responses and may lead to inaccurate pain assessment when not appropriately considered. We set out to determine the influence of individual contextual factors on variability in pain response in neonates, measured with the modified Bernese Pain Scale for Neonates (BPSN), and, if necessary, to incorporate relevant individual factors into a revised version of the BPSN. We videotaped 154 full-term and preterm neonates of different GAs during 1-5 capillary heel sticks in their first 14days of life. For each heel stick, we produced three video sequences: baseline, heel stick, and recovery. The randomized sequences were rated on the BPSN by five blinded nurses. Individual contextual factors were retrospectively extracted from patient charts and from the video recordings. We analysed the data in single and multiple linear mixed models. Premature birth (b=-0.721), caffeine (b=-0.302), and the behavioural states quiet and awake (b=-0.283), active and asleep (b=-0.158), and quiet and asleep (b=-0.498) were associated with changes in behavioural pain scores. Premature birth (b=-0.232), mechanical ventilation (b=-0.196), and duration of the heel stick procedure (b=0.0004) were associated with changes in physiological pain scores. Premature birth (b=-0.907), Caffeine (b=-0.402), the behavioural states quiet and awake (b=-0.274), and quiet and asleep (b=-0.459), and duration of the heel stick procedure (b=0.001) were associated with changes in the modified BPSN total scores. Postmenstrual age, behavioural state, caffeine, and ventilation status have an influence on neonates' pain response and should be incorporated in the revised BPSN to enhance clinical pain assessment in neonates with different GAs. We identified individual contextual factors associated with dampened pain response in neonates and will incorporate them into a revised version of the Bernese Pain Scale for Neonates to provide clinicians with a tool they can use to more accurately assess and manage pain in this vulnerable population.

The Influence of Local Anesthesia Depth on Procedural Pain During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial.

The aim of the study was to evaluate the influence of the depth of local anesthesia application on procedural pain during lumbar transforaminal epidural steroid injection. Sixty-eight patients were enrolled who were scheduled for single-level, unilateral fluoroscopically guided lumbar transforaminal epidural steroid injection. Patients were randomly allocated to receive either subcutaneous local anesthesia (group S) or deep local anesthesia (group D) for transforaminal epidural steroid injection. The data related to pain and technical performance during the procedure was compared. In addition, the incidence of injection site soreness was assessed 2 wks after transforaminal epidural steroid injection. Sixty-seven patients completed all assessments (group S, n = 33; group D, n = 34). There was no significant difference in procedural pain and discomfort level between the groups (P = 0.151, P = 0.183, respectively). Patients in group D showed lower behavioral pain scores (P = 0.017). There was no significant difference in the numbers of needle manipulations, fluoroscopy time, and radiation dose during the procedure between the groups. Two patients in group S and three in group D complained of injection site soreness after transforaminal epidural steroid injection for a few days, but there was no significant difference in its incidence (P = 0.667). Deep local anesthesia to reduce procedural pain during transforaminal epidural steroid injection seems to have no significant clinical benefit compared with conventional subcutaneous local anesthesia. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Reduce procedural pain by considering clinical factors of the patient during fluoroscopically guided lumbar transforaminal epidural injections.Upon completion of this article, the reader should be able to: (1) Understand the potential impact of procedural pain on the performance of transforaminal epidural steroid injections; (2) Distinguish cutaneous nociceptive afferents from nociceptive afferents in muscle; and (3) Explain the factors to reduce procedural pain during fluoroscopically guided lumbar transforaminal epidural injections. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Oral Administration of Meloxicam Suppresses Low-Dose Endotoxin Challenge–Induced Pain in Thoroughbred Horses

Nonsteroidal anti-inflammatory drugs such as flunixin meglumine have been used to treat signs of systemic inflammatory conditions, but it is also known to have the side effect to small intestine mucosa. It may be considered to be due to inhibition of both cyclooxygenase (COX)-1 and COX-2. On the other hand, meloxicam is widely used in equine clinical practice and an effective nonsteroidal anti-inflammatory drug with the preferential inhibitory effect on COX-2. However, it has not yet been evaluated in equine systemic inflammation. The aim of this study was to evaluate the effect of meloxicam administered 60 minutes prior lipopolysaccharide (LPS)-induced inflammatory response in five Thoroughbred horses using a crossover test. Clinical parameters including body temperature, heart rate, respiratory rate, behavioral pain score, and hoof wall surface temperature were recorded, and plasma tumor necrosis factor-alpha, cortisol, and leukocyte counts were measured at various times before and after LPS infusion for 420 minutes. At time points 60, 90 (P < .01), 120, and 180 (P < .05) minutes, pain scores were significantly lower in meloxicam-treated horses. There was no significant difference in other parameters. In the present study, we revealed the analgesic effect of meloxicam using an equine low-dose endotoxin model.

Dexmedetomidine Versus Neostigmine in Addition to Bupivacaine for Caudal Analgesia in Pediatrics Undergoing Congenital Inguinal Hernia Repair

AbstractBackground: Post-operative pain management in children is a necessity for both medical and ethical reasons. Caudal block is one of the oldest and the most popular regional block in pediatric anesthesia. Dexmedetomidine is a specific a2 adrenergic receptor agonist with sedative, anxiolytic, and analgesic properties. Respiratory depression, sedation and pruritis ascribed to the use of caudal opioids are not encoun-tered with neostigmine.Aim of Study: Our aim is to compare the effect of dexme-detomidine versus neostigmine in addition to bupivacaine for caudal analgesia in pediatrics undergoing congenital inguinal hernia repair.Methods and Material: This study was carried out on 90 children, 1-6 years, ASA I-II, scheduled for congenital inguinal hernia repair. Patients were randomly classified into 3 equal groups, 30 patients each, caudal block with a total volume of 0.5ml/kg Group I: Bupivacaine 0.25%, Group II: 0.25% bupivacaine and dexmedetomidine 2mg/kg and Group III: 0.25% bupivacaine with neostigmine 2mg/kg in. HR, MAP and SpO2 were recorded at baseline & 15 (5 minutes after caudal), 25, 35, 45, 60min after induction of anesthesia & 5, 30, 60 & 120min after recovery. Pain score was recorded at 1, 2, 4, 6, 24hr after recovery using the FLACC Behavioral Scale, number of patients who needed rescue analgesia in the 1st 24hr' post-operative. Rescue analgesia was administered at FLACC score £4, total amount of acetaminophen within the 1st 24h, time till administration of first rescue analgesia & any undesirable side effects.Results: HR and MAP were statistically non-significant difference in the three groups, but it was statistically significant difference between the pre-operative HR and MAP and at 25min. FLACC behavioral pain score & total does of analgesia was significantly lower in group II than in group III than in group I. The time of first rescue analgesia was earlier in group I than in group III than in group II.Conclusions: Addition of dexmedetomidine or neostigmine to bupivacaine in a dose of 2mg/kg results in superior analgesia than bupivacaine alone. But dexmedetomidine had better analgesic effect than addition of neostigmine to bupivacaine.

The influence of gestational age in the psychometric testing of the Bernese Pain Scale for Neonates

BackgroundAssessing pain in neonates is challenging because full-term and preterm neonates of different gestational ages (GAs) have widely varied reactions to pain. We validated the Bernese Pain Scale for Neonates (BPSN) by testing its use among a large sample of neonates that represented all GAs.MethodsIn this prospective multisite validation study, we assessed 154 neonates between 24 2/7 and 41 4/7 weeks GA, based on the results of 1–5 capillary heel sticks in their first 14 days of life. From each heel stick, we produced three video sequences: baseline; heel stick; and, recovery. Five blinded nurses rated neonates’ pain responses according to the BPSN. The underlying factor structure of the BPSN, interrater reliability, concurrent validity with the Premature Infant Pain Profile-Revised (PIPP-R), construct validity, sensitivity and specificity, and the relationship between behavioural and physiological indicators were explored. We considered GA and gender as individual contextual factors.ResultsThe factor analyses resulted in a model where the following behaviours best fit the data: crying; facial expression; and, posture. Pain scores for these behavioural items increased on average more than 1 point during the heel stick phases compared to the baseline and recovery phases (p < 0.001). Among physiological items, heart rate was more sensitive to pain than oxygen saturation. Heart rate averaged 0.646 points higher during the heel stick than the recovery phases (p < 0.001). GA increased along with pain scores: for every additional week of gestation, the average increase of behavioural pain score was 0.063 points (SE = 0.01, t = 5.49); average heart rate increased 0.042 points (SE = 0.01, t = 6.15). Sensitivity and specificity analyses indicated that the cut-off should increase with GA. Modified BPSN showed good concurrent validity with the PIPP-R (r = 0.600–0.758, p < 0.001). Correlations between the modified behavioural subscale and the item heart rate were low (r = 0.102–0.379).ConclusionsThe modified BPSN that includes facial expression, crying, posture, and heart rate is a reliable and valid tool for assessing acute pain in full-term and preterm neonates, but our results suggest that adding different cut-off points for different GA-groups will improve the BPSN’s clinical usefulness.Trial registrationThe study was retrospectively registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461. Registration date: 12 April 2016.

Quantitative sensory testing with Electronic von Frey Anesthesiometer and von Frey filaments in nonpainful cats: a pilot study

ObjectiveMeasurement of sensory thresholds could represent a complementary tool to behavioural pain scores in cats. The aim of this study was to investigate the feasibility of quantitative sensory testing (QST) with the Electronic von Frey Anesthesiometer (EVF) and von Frey filaments (VFF) in healthy cats, and to assess the limits of agreement (LOA) between the two devices. Study designProspective clinical study. AnimalsA total of 15 client-owned healthy cats. MethodsTwo investigators (A and B) carried out the measurements independently. The EVF and the VFF were applied on the upper lip and at the level of the medial aspect of the stifle. A 1-hour interval was allowed between the sets of measurements taken by investigators A and B; each investigator repeated the entire session of measurements after 24 hours. The LOA between the EVF and the VFF were analysed with the intraclass correlation coefficient (ICC), and with the Bland Altman method. ResultsQST with both the EVF and the VFF was feasible in healthy cats; however, the willingness of the cats to cooperate was negatively affected by the repetition of the measurements on the second day. The presence of the cat owners seemed to facilitate the trial. There was a fair agreement between the EVF and the VFF (ICC = 0.49; 95% confidence interval: 0.13–0.70). Conclusionsand clinical relevance Our findings indicate that both EVF and VFF may be used for QST in cats. Further trials will be needed to verify the usefulness of QST with EVF and VFF in feline patients suffering from actual chronic pain.

Randomized Clinical Trial of Lidocaine Analgesia for Transurethral Bladder Catheterization Delivered via Blunt Tipped Applicator in Young Children

Transurethral bladder catheterization (TUBC) is a painful, frequently performed procedure for collecting sterile urine. We sought to determine if administration of intraurethral lidocaine before TUBC using a blunt tipped syringe decreases procedural pain in young children in the pediatric emergency department. Randomized clinical trial of children 0 to 36 months old requiring TUBC for collection of urine in a pediatric emergency department was performed. Patients received intraurethral 2% lidocaine jelly or usual care (no analgesia). Randomization was stratified by sex. Intraurethral lidocaine jelly was administered via Uro-Jet, 5 minutes before TUBC. Baseline child state, lidocaine application, TUBC, and child state 1 minute post-TUBC were videotaped. Neither providers nor parents were blinded to study arm. Videos were scored by a trained, independent, blinded reviewer using the Faces, Legs, Arms, Cry, and Consolability (FLACC) and Modified Behavioral Pain Score scales. Pain scores were compared using the Wilcoxon rank sum test. Our primary outcome was difference in FLACC scores between groups. Eighty children were enrolled in the study, and 73 had analyzable data. No differences were detected in pain by mean FLACC score between intervention (8; 95% confidence interval, 7-9) and control (9; 95% confidence interval, 8-10) groups. There were no differences between groups in mean FLACC score when stratified by age or sex or in mean Modified Behavioral Pain Score. Intraurethral lidocaine for TUBC for urine collection using a blunt tipped applicator did not improve procedural pain scores. Pain scores were high across groups. Further study should be performed to improve analgesia for this highly painful procedure.

Comparison of Self-Reported and Behavioral Pain Assessment Tools in Critically Ill Patients.

Self-reported and behavioral pain assessment scales are often used interchangeably in critically ill patients due to fluctuations in mental status. The correlation between scales is not well elucidated. The purpose of this study was to describe the correlation between self-reported and behavioral pain scores in critically ill patients. Pain was assessed using behavioral and self-reported pain assessment tools. Behavioral pain tools included Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS). Self-reported pain tools included Numeric Rating Scale (NRS) and Wong-Baker Faces Pain Scales. Delirium was assessed using the confusion assessment method for the intensive care unit. Patient preference regarding pain assessment method was queried. Correlation between scores was evaluated. A total of 115 patients were included: 67 patients were nondelirious and 48 patients were delirious. The overall correlation between self-reported (NRS) and behavioral (CPOT) pain scales was poor (0.30, P = .018). In patients without delirium, a strong correlation was found between the 2 behavioral pain scales (0.94, P < .0001) and 2 self-reported pain scales (0.77, P < .0001). Self-reported pain scale (NRS) and behavioral pain scale (CPOT) were poorly correlated with each other (0.28, P = .021). In patients with delirium, there was a strong correlation between behavioral pain scales (0.86, P < .0001) and a moderate correlation between self-reported pain scales (0.69, P < .0001). There was no apparent correlation between self-reported (NRS) and behavioral pain scales (CPOT) in patients with delirium (0.23, P = .12). Most participants preferred self-reported pain assessment. Self-reported pain scales and behavioral pain scales cannot be used interchangeably. Current validated behavioral pain scales may not accurately reflect self-reported pain in critically ill patients.

Validation of two Chinese-version pain observation tools in conscious and unconscious critically ill patients

ObjectivesTo compare the construct validities of the Chinese-versions Critical-Care Pain Observation Tool and Behavioural Pain Scale as measures of critically ill patients’ pain by (a) discriminant validation of behavioural scales and vital signs (e.g. heart rate and mean arterial pressure) during a non-nociceptive procedure (noninvasive blood pressure] assessment) and a nociceptive procedure (endotracheal suctioning), (b) criterion validation of behavioural scales and vital signs with patients’ self-reported pain and (c) testing the interrater reliability of both scores. Research methodology/designIn this crossover, observational study, pain responses of 316 critically ill patients (213 conscious; 103 unconscious) were measured by both the Critical Care Pain Observation Tool and the Behavioural Pain Scale scores, vital signs and self-report (if conscious) during noninvasive blood pressure assessment and endotracheal suctioning procedures. Interrater reliability was tested in nociceptive procedures of a pilot study on 20 critically ill patients. Data were analysed by descriptive statistics, multiple logistic regression analysis and receiver-operating characteristic curves. SettingA medical intensive care unit in a regional teaching hospital in northern Taiwan. ResultsPatients’ self-reported pain was predicted by total Critical Care Pain Observation Toolscores (odds ratio=1.93, p<0.01) and total Behavioural Pain scores (odds ratio=1.83, p<0.01) but not by vital signs after controlling for patients’ demographic and clinical characteristics. Moreover, Chinese-versions had areas under the receiver-operating characteristic curve of 76.4% and 73.1%, respectively, indicating good ability to detect pain. ConclusionsThe Chinese-versions of the Critical care Pain Observation Toll and Behavioural Pain Score have good construct validity and can sensitively discriminate when critically ill patients experience pain or no pain.