Behavioral Pain Scores Research Articles

Attenuation of ischaemic injury in the equine jejunum by administration of systemic lidocaine

Absorption of endotoxin across ischaemic-injured mucosa is a major cause of mortality after colic surgery. Recent studies have shown that flunixin meglumine retards mucosal repair. Systemic lidocaine has been used to treat post operative ileus, but it also has novel anti-inflammatory effects that could improve mucosal recovery after ischaemic injury. Systemic lidocaine ameliorates the deleterious negative effects of flunixin meglumine on recovery of mucosal barrier function. Horses were treated i.v. immediately before anaesthesia with either 0.9% saline 1 ml/50 kg bwt, flunixin meglumine 1 mg/kg bwt every 12 h or lidocaine 1.3 mg/kg bwt loading dose followed by 0.05 mg/kg bwt/min constant rate infusion, or both flunixin meglumine and lidocaine, with 6 horses allocated randomly to each group. Two sections of jejunum were subjected to 2 h of ischaemia by temporary occlusion of the local blood supply, via a midline celiotomy. Horses were monitored with a behavioural pain score and were subjected to euthanasia 18 h after reversal of ischaemia. Ischaemic-injured and control jejunum was mounted in Ussing chambers for measurement of transepithelial electrical resistance (TER) and permeability to lipopolysaccharide (LPS). In ischaemic-injured jejunum TER was significantly higher in horses treated with saline, lidocaine or lidocaine and flunixin meglumine combined, compared to horses treated with flunixin meglumine. In ischaemic-injured jejunum LPS permeability was significantly increased in horses treated with flunixin meglumine alone. Behavioural pain scores did not increase significantly after surgery in horses treated with flunixin meglumine. Treatment with systemic lidocaine ameliorated the inhibitory effects of flunixin meglumine on recovery of the mucosal barrier from ischaemic injury, when the 2 treatments were combined. The mechanism of lidocaine in improving mucosal repair has not yet been elucidated.

EMLA Cream and Nitrous Oxide to Alleviate Pain Induced by Palivizumab (Synagis) Intramuscular Injections in Infants and Young Children

Palivizumab (Synagis [Abbot Laboratories, Kent, United Kingdom]) is recommended for the prevention of severe lower respiratory tract infections caused by respiratory syncytial virus in infants at high risk. These injections are very painful, and currently the use of analgesics is not systematic. The objective of this study was to compare the efficacy of EMLA with premixed 50% nitrous oxide/oxygen, used alone or combined with EMLA, for pain alleviation during palivizumab injections. This randomized, double-blind, multicenter study included children who were younger than 24 months. Each child randomly received during the first 3 monthly injections 3 different analgesic interventions: (1) EMLA: application of EMLA plus air inhalation; (2) nitrous oxide/oxygen: inhalation of 50/50 nitrous oxide/oxygen plus application of a placebo cream; and (3) nitrous oxide/oxygen plus EMLA: inhalation of 50/50 nitrous oxide/oxygen plus application of EMLA. Each child was his or her own control. Procedural pain was assessed through videotapes with the Modified Behavioral Pain Scale. The procedure itself was subdivided in 2 periods: (1) injection and (2) recovery (first 30 seconds after the removal of the needle). Modified Behavioral Pain Scale scores over time (injection and recovery periods) and among treatments were compared by repeated-measures analysis of variance. Fifty-five children were included. Mean +/- SD Modified Behavioral Pain Scale pain scores for EMLA, nitrous oxide/oxygen, and nitrous oxide/oxygen plus EMLA were, respectively, 9.3 +/- 1.0, 8.8 +/- 1.2, and 8.2 +/- 1.8 during the injection and 7.8 +/- 1.7, 7.4 +/- 1.9, and 6.9 +/- 2.4 during the recovery period. A significant time and treatment effect in favor of the combined nitrous oxide/oxygen plus EMLA was observed. The administration of 50/50 nitrous oxide/oxygen to infants and young children is effective in decreasing the pain associated with palivizumab intramuscular injections. The combined nitrous oxide/oxygen plus EMLA cream was more effective than either EMLA cream or nitrous oxide/oxygen alone.

(354) Development of a pain assessment scale for patients with moderate to severe brain injury: A pilot study

Evaluation of pain in traumatic brain injury (TBI) patients with impaired cognition and communicative ability is confounded by the absence of reliable self-reporting of symptoms. Many studies have looked at pain behaviors in the confused elderly, cognitively impaired, neonatal and mild TBI (mTBI) populations, yet there have been no formal validation of methods to assess pain behavior in the moderate to severe TBI (sTBI) population. We sought to develop a method of quantifying pain levels (Behavioral Pain Scale, BPS) based on pain behaviors observed in patients with brain injuries. The study took place at an urban academic rehabilitation hospital. There were 18 nonverbal patients with varying degrees of TBI brain injury: Rancho los Amigos Scale (RAS) and Reverse Wong Baker (RWB) scale scores ranged between II-IV and 0-6, respectively. Patients were monitored for fifteen minutes by blinded and unblinded observers who rated specific behaviors. Pain behaviors were grouped into three categories: vocalization, facial behaviors, and body behaviors, all contributing to the patient’s total BPS score. The most frequently observed behaviors were limb movement (83%), facial grimacing (67%), spasms/contractures (50%), and extended eye closing (37.5%). The BPS scores correlated significantly with the RWB (rs = .590 , p = .01), but not with the RAS (p = .877) or the Glasgow scores (p = .193). Injury etiology and pain behaviors do not appear to be associated; however statistical examination with a larger sample size may prove otherwise. Preliminary development of a Behavioral Pain Score in nonverbal TBI patients shows a correlation with RWB, but not with the RAS or Glasgow scores. Further validation is warranted. Evaluation of pain in traumatic brain injury (TBI) patients with impaired cognition and communicative ability is confounded by the absence of reliable self-reporting of symptoms. Many studies have looked at pain behaviors in the confused elderly, cognitively impaired, neonatal and mild TBI (mTBI) populations, yet there have been no formal validation of methods to assess pain behavior in the moderate to severe TBI (sTBI) population. We sought to develop a method of quantifying pain levels (Behavioral Pain Scale, BPS) based on pain behaviors observed in patients with brain injuries. The study took place at an urban academic rehabilitation hospital. There were 18 nonverbal patients with varying degrees of TBI brain injury: Rancho los Amigos Scale (RAS) and Reverse Wong Baker (RWB) scale scores ranged between II-IV and 0-6, respectively. Patients were monitored for fifteen minutes by blinded and unblinded observers who rated specific behaviors. Pain behaviors were grouped into three categories: vocalization, facial behaviors, and body behaviors, all contributing to the patient’s total BPS score. The most frequently observed behaviors were limb movement (83%), facial grimacing (67%), spasms/contractures (50%), and extended eye closing (37.5%). The BPS scores correlated significantly with the RWB (rs = .590 , p = .01), but not with the RAS (p = .877) or the Glasgow scores (p = .193). Injury etiology and pain behaviors do not appear to be associated; however statistical examination with a larger sample size may prove otherwise. Preliminary development of a Behavioral Pain Score in nonverbal TBI patients shows a correlation with RWB, but not with the RAS or Glasgow scores. Further validation is warranted.

Safety and efficacy of two protocols for sedation in pediatric oncology procedures

Abstract Invasive procedures, such as the lumbar puncture, can cause anxiety and pain in children undergoing treatment for acute lymphoblastic leukemia (ALL). We investigated the safety and efficacy of two different protocols for pain relief in 20 children with ALL undergoing lumbar puncture. Protocol A was composed of an association between propofol and alfentanil. Protocol B consisted in the combination of propofol and ketamine. Vital and behavioural parameters, sedation and pain scores were recorded at different times during and after the procedure. All patients showed a satisfactory sedation and analgesia. We found a statistically significant difference of vital parameters between protocol A and protocol B, while there were no significative differences between sedation scores and the other parameters evaluated. Patients in protocol A showed a higher incidence of major side effects, such as respiratory depression. Our results show that both protocols are effective to obtain a good sedation and analgesia in children with ALL undergoing lumbar puncture, but the association between propofol and ketamine appears more safe due to the lower incidence of side effects.

Recurrent Hypoxemia in Children Is Associated with Increased Analgesic Sensitivity to Opiates

Postsurgical administration of opiates in patients with obstructive sleep apnea (OSA) has recently been linked to an increased risk for respiratory complications. The authors have attributed this association to an effect of recurrent oxygen desaturation accompanying OSA on endogenous opioid mechanisms that, in turn, alter responsiveness to subsequent administration of exogenous opiates. In a retrospective study, the authors have shown that oxygen desaturation and young age in children with OSA are correlated with a reduced opiate requirement for postoperative analgesia. The current study was designed to test that conclusion prospectively in 22 children with OSA scheduled to undergo adenotonsillectomy. The children were stratified to those having displayed < 85% or > or = 85% oxygen saturation nadir during sleep preoperatively. Using a blinded design, the children were given morphine postoperatively to achieve an identical behavioral pain score. As compared with children in the > or = 85% group, the < 85% oxygen saturation nadir group required one half the total analgesic morphine dose postoperatively, indicating heightened analgesic sensitivity to morphine after recurrent hypoxemia. Previous recurrent hypoxemia in OSA is associated with increased analgesic sensitivity to subsequent morphine administration. Therefore, opiate dosing in children with OSA must take into account a history of recurrent hypoxemia.

Efficacy and Safety of Preoperative Etodolac and Butorphanol Administration in Dogs Undergoing Ovariohysterectomy

Eighteen dogs undergoing ovariohysterectomy were premedicated with etodolac, butorphanol, or their combination. Various parameters, such as blood pressure, isoflurane requirements, behavioral pain scores, plasma cortisol concentration, plasma glucose concentration, and mucosal bleeding time, were assessed. The integrated plasma cortisol values were significantly lower in the etodolac and etodolac with butorphanol groups. Dogs receiving etodolac and butorphanol had the lowest behavioral pain scores from extubation until the end of monitoring. Isoflurane concentration over time (area under the curve), buccal mucosal bleeding time, and indices of renal function were not significantly different among the treatment groups.

Validation of Visual Analog Scale (VAS) Pain Scores in Children Less than 3 Months of Age: Comparison of VAS versus the Behavioral DAN Pain Scores in the Emergency Department

Validation of Visual Analog Scale (VAS) Pain Scores in Children Less than 3 Months of Age: Comparison of VAS versus the Behavioral DAN Pain Scores in the Emergency Department

Clinical, Physiologic, and Biologic Impact of Environmental and Behavioral Interventions in Neonates During a Routine Nursing Procedure

The aim of this randomized crossover study was to evaluate the impact of environmental and behavioral interventions (EBI) on behavioral, physiologic, and biologic stress response during a weighing procedure in neonates. Three groups of 15 neonates included (A) gestational age (GA), ≤32 weeks; (B) GA, 32 weeks, 1 day to 36 weeks, 6 days; and (C) GA, ≥37 weeks. Each neonate experienced 2 weighing procedures with and without EBI. Pain was evaluated by using the Neonatal Infant Pain Scale (NIPS) and the Neonatal Pain and Discomfort Scale (EDIN). Heart rate and oxygen saturation were recorded. Salivary samples were obtained for cortisol assay. Cerebral tissue oxygenation index (TOI) was recorded with near-infrared spectroscopy. A significant decrease of NIPS and EDIN was observed with EBI versus control. Mean heart rate was lower with EBI. No difference in cortisol level changes was observed. For groups A and B, a trend of increased TOI was observed with EBI. We concluded that EBI during a nursing procedure provides a decrease in pain scores in preterm and term neonates with changes in heart rate. Perspective This study evaluates the impact of combined environmental and behavioral interventions on pain responses in neonates during a weighing procedure. The results indicate a decrease in behavioral pain scores and in heart rate for preterm and term neonates and a trend in increased brain oxygenation depending on gestational age.

Graphical Display of Data Could Reveal Errors in Statistical Tests

Hôpital Ambroise Paré, Boulogne Billancourt, France. bruno.guignard@apr.aphp.frI read with interest the article about intraoperative remifentanil infusion by Lee et al. I have major concerns regarding the nonsignificance of chi-square tests for the behavioral pain score during the first 15 min in the recovery room. The bar representation in their figure 1 is appropriate for expressing these results and clearly shows a different comportment of patients in the two groups. After redoing the analysis by extrapolated number of patients according to bar height, it seems that, as expected, significant activity for chi-square tests is very high at all times studied (). Calculations were made with JMP 5.1 (SAS Institute, Cary, NC). The comment in the text says that 60% of patients in the remifentanil group versus 40% in the nitrous oxide group have a behavioral pain score of 0. That does not match the figure in the article. Furthermore, the percentage of total patients exceeds 100% at T5 for the remifentanil group.If these results are not type errors, we could have question about the morphine titration. In our study, the morphine titration was based essentially on behavioral scale during the first 15 min after extubation, because of the difficulty to have correct pain assessment just based only on the visual analog pain scale score at this moment. Another difference with our study is the use of fentanyl at induction and morphine at skin incision. The time to first dose of morphine does not appear in the results. The authors' conclusion could be right, but the discrepancies in the presented data may alter this finding. Opioid tolerance is not always clinically significant because of patient variability, surgery duration, opioid dosage, or concomitant medication. Graphics can help us to show clinical evidence, and statistical tests are used to confirm and valid ideas revealed by data. The high publication pressure should not deserve statistical review. Analysis and criticism are the guaranties of medical research.Hôpital Ambroise Paré, Boulogne Billancourt, France. bruno.guignard@apr.aphp.fr

HIP FUNCTION IN ADULTS WITH SEVERE CEREBRAL PALSY

The reported prevalence of hip pain in patients with severe cerebral palsy has varied widely. It is unclear whether surgical treatment is indicated for progressive hip subluxation in immature patients with severe involvement. In the present study, we evaluated seventy-seven adults who were profoundly affected with cerebral palsy to determine if either spastic hip displacement (subluxation or dislocation) or osteoarthritis was associated with hip pain and/or diminished function. Data regarding the medical history, level of function, pain, and use of analgesics were obtained from a review of medical records and from caregiver interviews. The range of motion of the hip, the degree of spasticity, the presence of pressure ulcers, and changes in vital signs as well as in the Face, Legs, Activity, Cry, and Consolability behavioral pain score were documented. Radiographs of the pelvis and spine were blindly evaluated for evidence of osteoarthritis and subluxation or dislocation. Statistical analysis was performed in order to identify associations between the medical history, the physical examination findings, and the radiographic measurements. The study group included seventy-seven adult subjects (thirty-eight men and thirty-nine women) with a mean age of forty years. Twenty-three (15%) of the 154 hips in these subjects were dislocated, eighteen (12%) were subluxated, and thirty-five (23%) had radiographic evidence of osteoarthritis. Twenty-eight (18%) of the 154 hips were definitely painful, and sixty-nine (45%) were definitely not painful. Increased hip pain and problems with perineal care were noted in patients with decreased hip abduction (<30 degrees ) (p = 0.01), windswept hip deformities (p = 0.02), and flexion contractures of >30 degrees (p = 0.07). Increased spasticity was associated with higher rates of osteoarthritis, dislocation, pain, and pressure ulcers. Spastic hip subluxation or dislocation was significantly associated with osteoarthritis (p = 0.0001), but not with hip pain. There was no association between radiographic evidence of osteoarthritis and hip pain. Neither hip displacement (i.e., subluxation or dislocation) nor osteoarthritis was found to be associated with hip pain or diminished function. Because the prevalence of hip pain is low and is not associated with hip displacement or osteoarthritis, we suggest that surgical treatment of the hip in severely affected patients be based on the presence of pain or contractures and not on radiographic signs of hip displacement or osteoarthritis. Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Analgesic effect of pre-operative etodolac and butorphanol administration in dogs undergoing ovariohysterectomy

The analgesic, bleeding, and renal effects of dogs pre-medicated with etodolac with and without butorphanol were evaluated. Twenty-four 1-year-old healthy dogs, weighing 19 ± 3 kg (mean ± SD) were randomly assigned to four treatment groups (n = 6): control (C), etodolac (E), butorphanol (B), and etodolac with butorphanol (EB). Etodolac (12–14 mg kg−1 PO) was given 1 hour before propofol induction and isoflurane maintenance anesthesia. Butorphanol (0.4 mg kg−1 IV) was given immediately following endotracheal intubation. Control dogs received only propofol (8 mg kg−1 to effect) and isoflurane anesthesia. All dogs were mechanically ventilated to maintain Pe′CO2 between 35 and 45 mm Hg (4.7–6.0 kPa). Lactated Ringer's solution was given at 10 mL kg−1 hour−1 during anesthesia. Plasma cortisol concentrations were assessed 1 day prior to surgery (baseline), immediately prior to anesthesia induction, and every 30 minutes until 5 hours following extubation, and 1 day after surgery. Total duration of anesthesia was 50 minutes and total surgery duration was 30 minutes. Isoflurane concentration area under the curve (AUC) over time during the anesthesia was compared among treatment groups. Buccal mucosal bleeding time (BMBT) was assessed 1 day before E administration and during surgery. Urine GGT to urine creatinine ratio, BUN, and plasma creatinine were taken daily from 1 day before to 3 days after surgery. Behavioral pain scores (numerical rating scale) were assessed by two observers blinded to the treatment during the 5-hour recovery period at 30 minute intervals until 3 hours, and again at 5 hours after extubation. All data were analyzed using anova. Multiple comparisons were performed if the anova was significant. Alpha value was set at 0.05. Plasma cortisol concentrations significantly increased from time of extubation in all the treatment groups. They did not return to the baseline until 5, 2.5, 1.5, and 1.5 hours after extubation in the C, B, E, and EB groups, respectively. Isoflurane AUC was not significantly different among treatment groups. Dogs treated with EB had significantly less behavioral pain than all other groups throughout the 5-hour recovery period. No significant difference was found between treatment groups or within treatment groups over time in BMBT, or any renal variables. This study demonstrated that (i) pre-operative administration of E provides profound analgesia during the post-operative period without renal or bleeding side-effects in dogs undergoing OHE; and (ii) a combination of butorphanol–etodolac provides the best analgesic effect during the post-operative period based on the behavioral pain score.

Observer-blinded comparison of two nonopioid analgesics for postoperative pain in piglets

Piglets are popular for studies of respiratory and cardiovascular function, but opioid analgesics are contraindicated in these studies because of central nervous system depression. We evaluated two nonopioid analgesics for postoperative pain relief following implantation of a central arterial catheter via an inguinal incision. Animals were randomly assigned to paracetamol-treated ( n=8, rectal suppositories, 100 mg/kg) meloxicam-treated ( n=8, 1 mg/kg meloxicam via the catheter) or untreated control group ( n=8, placebo suppositories and normal saline). Additional controls received paracetamol or meloxicam, without pain ( n=6 for both groups). Behavioral and physiological assessments, and blood sampling were undertaken at nine timed intervals until 24 h after surgery. Multifactorial numerical rating scale (NRS), behavioral and physiological pain scores (PPS) decreased over time for all groups ( P<.001). On NRS and behavioral criteria, meloxicam was significantly better than paracetamol ( P<.001), and both were better than control ( p<.001 for each). Physiological parameters discriminated between the control and analgesia-treated groups, but not between paracetamol and meloxicam. Preliminary pharmacokinetics, determined by isocratic high-performance liquid chromatography (HPLC), revealed no difference in the half-life of paracetamol (2.5±0.3 h) vs. meloxicam (3.4±0.4 h). Paracetamol and meloxicam provided effective postoperative analgesia in piglets, with meloxicam superior to paracetamol on behavioral criteria.

Prévention de la douleur à l’injection du propofol chez l’enfant : comparaison de l’inhalation de protoxyde d’azote à l’injection de lidocaïne

Introduction: Injection pain caused by propofol is an important disadvantage, especially in children, incompletely reduced by adding lidocaine intravenously. Nitrous oxide’s analgesic effects, well known, have never been evaluated on pain due to propofol. Objective: To compare the effects of nitrous oxide with lidocaine on pain on injection caused by propofol in children. Study design: Double blind, randomised, prospective study. Patients and methods: 48 children aged more than 5 were randomly allocated to one of the 2 groups: N 2O group, breathed 50 %N 2O + 50 %O 2 than received propofol only and Lido group breathed 100% O 2 and received a mixture of propofol with lidocaine. The possible pain was scored during injection by a behavioural scale and once again in the recovery room by the child himself with a VAS. Results: There was no significant difference in behavioural pain scores among the 2 groups; pain was assessed as being moderate or severe in 6/24 patients in N 2O group and 10/24 in Lido group (behavioural scores > 1). Significantly more children in the N 2O group had low VAS scores compared with the Lido group (no child/24 scored a VAS > 4 and 7/23 in the Lido group) demonstrating that N 2O amnesic effects would omit the memory of pain caused by propofol. Conclusion: The use of nitrous oxide is an easy, cheap and efficient method to reduce the incidence of pain injection of propofol and his amnesic effects can provide real advantages in paediatric anaesthesia.

Acute Opioid Tolerance Manifested by Increased Postoperative Pain. Guignard et al. (page 409)

To assess the clinical consequences of acute tolerance to remifentanil, Guignard et al. recruited 50 adult patients scheduled for major abdominal surgery. On the evening before surgery, patients were instructed regarding the use of a 10-cm visual analog scale, a four-point verbal rating scale, and a patient-controlled analgesia system. After induction of anesthesia with use of thiopental and tracheal intubation, patients were randomized for administration of either remifentanil titrated to autonomic responses (with desflurane kept constant at 0.5 minimum alveolar concentration [MAC]) or desflurane titrated to autonomic responses (with remifentanil 0.1 mg · kg−1· min−1). All patients were administered a bolus of 0.15 mg/kg morphine approximately 40 min before completion of skin closure. The total dose of remifentanil administered to each patient was recorded, as were any complications, such as respiratory depression or shivering. Behavioral pain assessment (0 = calm, 2 = intensive manifestation of pain) was performed 5, 10, and 15 min after tracheal extubation.In the postanesthesia care unit and in the surgical unit, nurses blind to patient group assignment or intraoperative remifentanil dose assessed patient pain intensity using a visual analog scale and a verbal response scale, and they initially treated patient postoperative pain with morphine administered intravenously at a rate of 3 mg at 5-min intervals until the behavioral pain score was less than 1. Time to first request for postoperative morphine was also recorded, as were anesthetic-related complications, such as nausea, vomiting, or pruritus. Within 3 h after tracheal extubation, patients were connected to a patient-controlled analgesia device set to deliver 1 mg morphine as an intravenous bolus, with a lock-out interval of 5 min.Patients in the remifentanil group had higher verbal response scores for pain, and greater visual analog scale scores, at 30 min and 3 h and 4 h after extubation, than did those in the desflurane group. The cumulative dose of morphine administered intravenously by nurses in the postanesthetic care unit was significantly greater in the remifentanil group; by adding the cumulative patient-controlled analgesia morphine dosages, it can be seen that patients in the remifentanil group received almost double the amount of morphine.

Effect of pre-operative administration of ketoprofen on post-operative pain in dogs after elective ovariohysterectomy

Ketoprofen is a nonsteroidal anti-inflammatory drug used to manage post-operative pain in dogs. Pre-operative administration of ketoprofen may attenuate peripheral and central hypersensitization and reduce severity of post-operative pain. The purpose of our study was to determine the effect of pre-operative administration of ketoprofen on post-operative pain in dogs after elective ovariohysterectomy. Sixty minutes before induction of anesthesia, 11 dogs [22 ± 6 kg, 10 ± 4 months of age (mean ± SD)] were given saline solution (control) and another 11 dogs (21 ± 4 kg, 13 ± 9 months) were given ketoprofen (2 mg kg−1 IM). Thirty minutes before induction of anesthesia, glycopyrrolate (0.01 mg kg−1), acepromazine (0.05 mg kg−1) and butorphanol (0.2 mg kg−1) were given IM. Anesthesia was induced with thiopental (5–10 mg kg−1 IV) and maintained with isoflurane (1–3%) in oxygen. Ovariohysterectomy was performed by an experienced surgeon and butorphanol (0.1 mg kg−1 IV) was given 15 minutes before completion of the procedure. Behavioral and VAS pain scores, and physiological parameters were recorded before and immediately after surgery, and periodically for 24 hours after surgery. Similarly, blood samples for determination of serum cortisol and glucose were collected before and immediately after surgery, and at 4 hours intervals for 24 hours after surgery. Data were analyzed using analysis of variance for repeated measures and multiple comparison tests. VAS pain scores are expressed as median values. After pre-operative administration of ketoprofen, VAS pain scores (0–100) were significantly (p < 0.05) below control values at 8 [10 versus 25 (ketoprofen versus control)], 10 (10 versus 30), 12 (0 versus 20), and 16 (0 versus 15) hours after surgery. Significant differences between treatments over time were not observed for measured physiological indices or for serum cortisol or glucose. In dogs given butorphanol before and during elective ovariohysterectomy, pre-operative administration of ketoprofen reduces severity of post-operative pain, and does not alter serum cortisol or glucose.

Epidural Analgesia for Pain Relief After Scoliosis Surgery in a Patient with Rett's Syndrome

Epidural Analgesia for Pain Relief After Scoliosis Surgery in a Patient with Rett's Syndrome

A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates.

Neonates routinely undergo painful cutaneous procedures as part of their medical treatment. Lidocaine-prilocaine 5% cream (EMLA) is a topical anesthetic that may be useful for diminishing the pain from these procedures. EMLA is routinely used in children and adults. There is substantial apprehension about its use in neonates because of concerns that it may cause methemoglobinemia. The objective of this review was to determine the efficacy and safety of EMLA as an analgesic for procedural pain treatment in neonates and provide evidence-based recommendations for clinical practice. Systematic review techniques were used. Studies were identified using manual and computer-aided searches (Medline, EMBASE, Reference Update, personal files, scientific meeting proceedings). Behavioral (eg, facial action, crying) and physiologic (eg, heart rate, oxygen saturation, blood pressure, respiratory rate) outcome data from prospective nonrandomized controlled studies and randomized controlled trials in full-term and preterm neonates were accepted for inclusion to establish efficacy of EMLA. The risk of methemoglobinemia (defined as methemoglobin concentration >5% and requiring medical intervention) was estimated from all prospective studies. Eleven studies of the efficacy of EMLA were included in the analysis. Infant gestational age at the time of delivery ranged from 26 weeks to full-term. Two studies included data from both neonates and older infants. The following procedures were studied: circumcision (n = 3), heel lancing (n = 4), venipuncture (n = 1), venipuncture and arterial puncture (n = 1), lumbar puncture (n = 1), and percutaneous venous catheter placement (n = 1). Nine studies were randomized controlled trials. The total sample size for each study ranged from 13 to 110 neonates. The dose of EMLA used was 0.5 g to 2 g in 9 studies, and was not specified in the others. The duration of application ranged from 10 minutes to 3 hours. The three studies that investigated the efficacy of EMLA for decreasing the pain of circumcision used a randomized controlled trial design. All of them demonstrated significantly reduced crying time during the procedure in the infants in the EMLA group compared with the infants in the control group. Facial grimacing, assessed in two of the studies, was also significantly lower in the EMLA group. Using meta-analytic techniques, the heart rate outcome data for two studies was summarized. Increases in heart rate compared with baseline values were 12 to 27 beats per minute less for the EMLA group than in the placebo group during various stages of the surgical procedure. Three studies that investigated the pain from heel lancing were randomized controlled trials; the other was a nonrandomized controlled study. None demonstrated a significant benefit of EMLA for any of the outcome measures used to assess pain (ie, behavioral pain scores, infant crying, heart rate, blood pressure, respiratory rate, oxygenation parameters). One randomized controlled study of the pain from venipuncture showed that infants treated with EMLA had significantly lower heart rates and cry duration compared with infants treated with a placebo. In one nonrandomized study, a significantly lower behavioral pain score was observed for infants treated with EMLA compared with the control group. Infant heart rate, however, did not differ between the groups. In one randomized controlled study of pain from percutaneous venous catheter placement, EMLA resulted in a significantly lower increase in heart rate and respiratory rate. Behavioral pain scores were significantly lower during arterial puncture in one nonrandomized controlled study. EMLA did not reduce physiologic changes or behavioral pain scores in one randomized controlled trial in infants undergoing lumbar puncture. Meta-analytic techniques revealed that methemoglobin concentrations did not differ between EMLA-treated and placebo-treated infants (weighted mean di

Effect of neonatal circumcision on pain responses during vaccination in boys

Using data from one of our randomised trials, we investigated post-hoc whether male neonatal circumcision is associated with a greater pain response to routine vaccination at 4 or 6 months. Pain response during routine vaccination with diphtheria-pertussis-tetanus (DPT) alone or DPT followed by Haemophilus influenzae type b conjugate (HIB) was scored blind. 42 boys received DPT and 18 also received HIB. After DPT, median visual analogue scores by an observer were higher in the circumcised group (40 vs 26 mm, p=0·03) After HIB, circumcised infants had higher behavioural pain scores (8 vs 6, p=0·01) and cried longer (53 vs 19 s, p=0·02). Thus neonatal circumcision may affect pain response several months after the event.

Nerveblocks by local anaesthesia also change body-mind interdependencies and effect structural reactions of mind

Skin conductance (SC) has been previously used to measure acute post-operative pain in adults and older children (> 1 year old).We have investigated the ability of SC to predict the severity of post-operative pain scores in the exclusively infant population.Infants (ages 6–12 months) scheduled for elective surgery were recruited for the study. Data for behavioral pain scores and SC values — frequency of electrodermal responses per second (EDR/s), peak and basal levels, were recorded in the post-anesthesia care unit (PACU). Blood samples were collected for genomic studies, including single nucleotide polymorphisms (SNP) in morphine opioid receptor (MOR) A118G and the catechol-O-methyltransferase (COMT) G1947A genes.31 infants, mean age 8.9 months (± 1.9); mean weight 8.5 kg (± 1.1) were included in the final study analysis. With every 0.1 unit increase in peak values noted on SC, the odds of higher pain scores were found to be 5% greater (p = 0.03). For predictability of moderate to severe pain, the area under the curve, sensitivity and specificity were 0.64, 90.9% and 51.4% respectively for peak values and 0.66, 54.5% and 79.4% respectively for EDR/s values. Genotyping performed in 16 out of 31 infants demonstrated that the carriers of MOR 118G allele had consistently higher basal SC values in the PACU.Peak SC values may serve as indicators of unmitigated pain. Further studies are needed to fully investigate the effect of MOR A118G SNP on the post operative pain scores and SC values in the larger infant population in order to validate both the clinical significance of the skin conductance for routine pain assessment in infants and the observed genetic effect.