Pediatric Pain Scale Research Articles

Efficacy of intratracheal dexmedetomidine on recovery from general anaesthesia in paediatric patients undergoing lower abdominal surgeries: A randomised controlled trial.

This study investigated the effectiveness of intratracheal dexmedetomidine in reducing untoward laryngeal responses in paediatrics undergoing lower abdominal surgeries. This trial included 60 patients divided into two groups scheduled for lower abdominal surgeries. Group D were given intratracheal dexmedetomidine at a dosage of 0.5mg/kg, while Group C received intratracheal saline (0.9%). The cough severity score, the Paediatric Objective Pain Scale for pain assessment, awareness, extubation, emergence agitation score, Ramsay sedation score and adverse effects were recorded. There was a significant difference in the incidence of coughing severity between Groups D and C both at extubation and after five minutes of extubation (p < 0.001). The median scores of the Paediatric Objective Pain Scales and the median agitation scales of Group D were significantly lower over the first four hours (p < 0.050). The mean time to first request rescue analgesia was significantly longer in the D group than in the control group (p < 0.001). The mean total consumption of rescue analgesia in the first 24 hours postoperatively was significantly lower in the dexmedetomidine group (p < 0.050). Awareness and extubation times were comparable in both groups, and none of the subjects reported any adverse effects. In the current study, lower abdominal surgery patients who received intratracheal dexmedetomidine at a dose of 0.5mg/kg 30 minutes before the completion of the procedure experienced smooth extubation and balanced anaesthetic recovery.

Effect of Dexmedetomidine, Dexamethasone, and Ondansetron on Postoperative Nausea and Vomiting in Children Undergoing Dental Rehabilitation: A Randomized Controlled Trial

BACKGROUND: Postoperative nausea and vomiting (PONV) are common unpleasant adverse effects after surgery. The incidence of PONV in pediatric patients is often twice as high as in adults. OBJECTIVES: This study aimed to evaluate the effects of dexmedetomidine, dexamethasone, and ondansetron for preventing PONV in children undergoing dental rehabilitation surgery. STUDY DESIGN: A prospective, randomized controlled clinical trial. SETTING: Sharurah Armed Forces Hospital, Ministry of Defense Medical Services, Saudi Arabia. METHODS: One hundred patients (6-12 years old) scheduled for dental rehabilitation were included. Patients were randomly allocated into 4 groups (25 each) to receive either 0.15 mg/kg dexamethasone (DEX), 0.05 mg/kg ondansetron (OND), 0.3 microgram/kg dexmedetomidine (DEXMED), or normal saline (control[CONT]) in DEX, OND, DEXMED or CONT groups, respectively, via infusion after induction of anesthesia. The primary outcome was a PONV incident in the first 24 hours. Secondary outcomes were: granisetron doses during 24 hours postoperative, Paediatric Anaesthesia Emergence Delirium (PAED) scale, Pediatric Objective Pain Scale (POPS) for 4 hours postoperatively, and complications in the first 24 hours. RESULTS: The reduction of PONV and the overall number of patients who developed PONV was statistically significant in the DEXMED group compared to the CONT group (P = 0.041). However, the DEXMED group was higher compared to the DEX and OND groups but not statistically significant. Granisetron requirements and doses were statistically significantly lower in the DEXMED group than in the CONT group. PAED and POPS scores were much better in the DEXMED group than in the other groups with a statistically significant difference in most of the time measurements. LIMITATION: Optimal dexmedetomidine dose for better effect on PONV without affecting hemodynamic stability requires more studies. CONCLUSION: Dexmedetomidine is effective in reducing PONV in children undergoing dental rehabilitation with better sedative and analgesic scores as compared to the control group. KEY WORDS: Dexmedetomidine, dexamethasone, dental rehabilitation, ondansetron, postoperative nausea and vomiting

Analgesia Nociception Index Monitoring in the Evaluation of Postoperative Pain in Children: A Prospective Observational Pilot Study

PurposeIn this study, we aimed to evaluate the relationship between the analgesia nociception index (ANI) device and pain scales used in the postoperative pain assessment of pediatric patients who underwent laparoscopic appendectomy. DesignThe study was designed as a correlation observational pilot study. MethodsPostoperative pain was evaluated using pediatric pain scales (face, legs, arms, cry, consolability scale; numerical rating scale; Wong–Baker scale) and ANI device in school-aged children and adolescents. ResultsThe mean age of the children was 14.00 ± 1.63 years, and the mean BMI was 22.52. We found a statistically significant positive correlation between the pain scale scores and a statistically significant negative relationship between the pain scale score and the ANI. ConclusionsThe ANI device can be used safely and constantly for the objective assessment of postoperative pain in pediatric patients.

Evaluating the French version of an online training course for a pediatric pain assessment scale

There is no French-language training to educate nurses on the use of the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, whose scores guide the treatment of pediatric pain. The aim of this study was to evaluate a French online training program for the FLACC scale offered to Francophone undergraduate nursing students. Online training was offered to nursing students enrolled in a pediatric nursing course. Participants completed online questionnaires pre- and post-training to assess their perception of their knowledge and confidence, the accuracy of their pain assessment scores, as well as the usefulness and user-friendliness of the training. The FLACC online training improved students’ perceived knowledge (p = 0.0004) and confidence (p = 0.0053) in the FLACC pediatric pain scale. Students’ accuracy of severe pain assessment scores significantly improved (p = 0.0159) and slightly improved for moderate pain (p = 0.6363). However, accuracy for mild pain assessment was slightly decreased post-training (p = 0.7686). An improvement of the quality of videos linked to mild pain, and the quantity of videos for all levels of pain, is required for this study to be replicated among a larger sample. The online training fills the gap in nurses’ lack of knowledge about the use of the FLACC pain scale and improves access to quality training in French.

Efficacy of fascia iliaca nerve block in daily routine for children with femoral fractures in a pediatric emergency department

ObjectivesWe aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED). MethodsThis retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB. ResultsOf 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%–70%). Overall, 21 children (15%) required a second analgesic after the FINB. ConclusionThe routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.

Comparison of Caudal Tramadol with different doses of Midazolam addon for Postoperative analgesia in Children Undergoing Inguinoscrotal Operations

Background: Safe and effective postoperative analgesic modalities have remained a subject of contemporary clinical research, particularly in children. The present study aimed at comparing the effectiveness of pain relief in children undergoing inguinoscrotal surgery with caudal tramadol alone and in combination with different doses of midazolam.&#x0D; Methods: Ninety children of either sex, aged one year to fifteen years, undergoing inguinoscrotalsurgical procedures under general anesthesia were recruited in a randomized double blinded fashion to receive one of the three study medications through caudal route. Group T (n= 30) received injectiontramadol 2mg/kg in a volume of 0.5ml/kg up to a maximum volume of 20ml, while group TM (n= 30)and TM/2 (n= 30) received additional midazolam 50mcg/kg and 25mcg/kg respectively. The study medications were administered immediately after induction of anesthesia. Postoperative analgesia was measured using a modified Hannallah 10 points Pediatric Objective Pain Scale described by Hannallah and colleagues. Pain score of ≤ 4 was considered effective analgesia. Duration of analgesia was defined as the time between caudal injection to the first need of analgesia.&#x0D; Results: The duration of analgesia in group TM (1145±281.41 min) and TM/2 (1012.67±260.68 min)was significantly longer than that in group T (690.83±215.7 min) (p&lt;0.005). The sedation score was the highest in group TM and the least in group T. Nausea vomiting was the commonest side effect in all the three groups without any significant differences in the incidences between the groups.&#x0D; Conclusion: Addition of midazolam to tramadol for caudal administration in children undergoinginguinoscrotal operations produces significantly longer duration of postoperative analgesia than produced by epidural administration of tramadol alone.

Oral sucrose for analgesia in children aged between 3 months and 3 years undergoing transurethral bladder catheterisation: A randomised, double-blinded, clinical trial.

Many children admitted to hospital undergo invasive, painful and stressful procedures, including children who are not toilet trained undergoing transurethral bladder catheterisation (TUBC). Oral sucrose is commonly given to children to reduce procedural pain. In this study, we evaluated the effectiveness of oral sucrose in reducing procedural pain in children aged between 3 months and 3 years undergoing TUBC. This study was a randomised, double-blind, placebo-controlled study conducted at Nepean Hospital, Sydney, Australia from June 2005 to June 2010. A total of 40 participants requiring TUBC for diagnostic evaluation were included. The participants were randomly assigned to receive 4 mL of 75% oral sucrose (n = 20) or a placebo (sterilised water) (n = 20). The primary outcomes were changes in two paediatric pain scale scores (the FLACC pain scale and the OUCHER pain scale), assessed by the parent/guardian(s), the doctor performing the TUBC and the nurse assisting. The secondary outcomes were physiological (changes in heart rate) and behavioural pain (crying) indicators. Of the outcome measures, 65% favoured the oral sucrose group, 31% favoured the placebo group, and 4% found no difference between the oral sucrose and placebo groups. While the trends favouring the sucrose group in this study were encouraging, as the results were not statistically significant, there was insufficient evidence to demonstrate the effectiveness of oral sucrose in reducing procedural pain in children aged between 3 months and 3 years undergoing TUBC.

The Jumping Up (J-Up) Test: Making the Diagnosis of Acute Appendicitis Easier in Children.

We evaluate a new clinical test, jumping up (J-up) test, to diagnose easier appendicitis in children. A total of 407 patients, aged 5 to16 years, with right lower quadrant abdominal pain were asked to jump rising both hands and trying to reach a toy hanging down from the ceiling of the examination room. Bieri pediatric Face Pain Scale was used for recording the pain response. J-up test has sensitivity of 87% and specificity of 70%. A positive J-up test combined with leukocytosis (white blood cells count >12 000/mm3), neutrophilia >75%, neutrophil/lymphocyte >2, and C-reactive protein >5 mg/dL, achieved a posttest probability of appendicitis of 85%. A negative J-up test combined with the aforementioned blood markers within normal range had a posttest probability for non-appendicitis of 92%. J-up test is a reliable clinical test, which could be used even by an inexperienced doctor. Combined with classical blood markers, it could successfully predict which child is in urgent need or not of surgery.

Pain Management in the Pediatric Palliative Care Population.

The purpose of this integrative review was to identify, review, synthesize, and analyze the current literature related to pain management in the pediatric palliative care population from infancy through adolescence. The literature was searched for the terms palliative, pediatric, and pain in PubMed, PsycINFO, Cumulative Index to Nursing and Allied HeALTH LITERATUre (CINAHL) Complete, and Google Scholar. The search was limited to papers in English that had been published from January 1, 2005, to December 31, 2016. These searches resulted in 918 articles, of which 29 met inclusion criteria. These 29 articles were reviewed and reported. Four broad themes emerged: patient and family experience, pain assessment, pharmacological pain management, and nonpharmaceutical interventions. Gaps in current research have been identified, such as investigating pediatric pain scales for the palliative care population and new complementary and alternative medical therapy and other interventions. More research is needed to bring innovative pain management interventions to the attention of pediatric caregivers. A better understanding of current research on pain in the pediatric palliative care population can improve patient care and lead to better research in this specialty field.

Pain during office removal of K-wires from the elbow in children.

Closed reduction and K-wire fixation is standard treatment for displaced supracondylar fractures in children. The purpose of this study is to evaluate pain using 2 pediatric pain scales when removing K-wires from the distal humerus in children in the office setting. A total of 98 percutaneous smooth K-wires were removed from 47 patients who had sustained displaced supracondylar fractures of the elbow. Pain was measured using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The maximum score is 13 and the minimum score is 4 points. In addition, after K-wire removal, each child indicated on a numbered pain-face diagram (Wong-Baker FACES: a scale consisting of faces with varying emotional expressions and corresponding numbers on a scale from 0 to 5) the amount of pain that they felt. The average age of the patients treated was 7.1 years (range, 2 to 14 y). There were 28 males and 19 females. Thirty patients (64%) had a CHEOPS score of ≤6. The average CHEOPS was 6 (range, 4 to 10). Seventeen patients (37%) had a FACES score of ≤1. The average FACES score was 2 (range, 1 to 5). Higher CHEOPS and FACES scores correlated with younger patient age and higher number of K-wires removed. K-wire removal in the clinic is common practice. The pain associated with K-wire removal and the safety of this practice has received minimal previous study in the literature. In the present manuscript, 64% of patients had little or no pain measured by the CHEOPS scale--score of ≤6 and 36% had little or no pain self-reported by the FACES scale--score of ≤1. No patient reported severe pain by the CHEOPS scores (CHEOPS 11 to 13) and only 1 patient reported having severe pain with a FACES of 5. No complications occurred. The results of this study suggest that the removal of K-wires in the office setting is safe and acceptable. Retrospective analysis.

Patterns and severity of vincristine-induced peripheral neuropathy in children with acute lymphoblastic leukemia.

Vincristine, a critical component of combination chemotherapy treatment for pediatric acute lymphoblastic leukemia (ALL), can lead to vincristine-induced peripheral neuropathy (VIPN). Longitudinal VIPN assessments were obtained over 12 months from newly diagnosed children with ALL (N = 128) aged 1-18 years who received vincristine at one of four academic children's hospitals. VIPN assessments were obtained using the Total Neuropathy Score-Pediatric Vincristine (TNS©-PV), National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE©), Balis© grading scale, and Pediatric Neuropathic Pain Scale©-Five (PNPS©-5). Of children who provided a full TNS©-PV score, 85/109 (78%) developed VIPN (TNS©-PV ≥4). Mean TNS©-PV, grading scale, and pain scores were low. CTCAE©-derived grades 3 and 4 sensory and motor VIPN occurred in 1.6%/0%, and 1.9%/0% of subjects, respectively. VIPN did not resolve in months 8-12 despite decreasing dose density. VIPN was worse in older children. Partition cluster analysis revealed 2-3 patient clusters; one cluster (n = 14) experienced severe VIPN. In this population, VIPN occurs more commonly than previous research suggests, persists throughout the first year of treatment, and can be severe.

Pain management following myringotomy and tube placement: Intranasal dexmedetomidine versus intranasal fentanyl

PurposeDespite the brevity of the procedure, bilateral myringotomy and tympanostomy tube placement (BMT) can result in significant postoperative pain and discomfort. As the procedure is frequently performed without intravenous access, non-parenteral routes of administration are frequently used for analgesia. The current study prospectively compares the efficacy of intranasal (IN) dexmedetomidine with IN fentanyl for children undergoing BMT. MethodsThis prospective, double-blinded, randomized clinical trial included pediatric patients undergoing BMT. The patients were randomized to receive either IN dexmedetomidine (1μg/kg) or fentanyl (2μg/kg) after the induction of general anesthesia with sevoflurane. All patients received rectal acetaminophen (40mg/kg) and the first 50 patients also received premedication with oral midazolam. Postoperative pain and recovery were assessed using pediatric pain and recovery scales, and any adverse effects were monitored for. ResultsThe study cohort included 100 patients who ranged in age from 1 to 7.7 years and in weight from 8.6 to 37.4 kg. They were divided into 4 groups with 25 patients in each group: (1) midazolam premedication+IN dexmedetomidine; (2) midazolam premedication+IN fentanyl; (3) no premedication+IN dexmedetomidine; and (4) no premedication+IN fentanyl. Pain scores were comparable when comparing groups 2, 3 and 4, but were higher in group 1 (midazolam premedication with IN dexmedetomidine). There was no difference in total time in the post-anesthesia care unit (PACU) or time from arrival in the PACU until hospital discharge between the 4 groups. The heart rate (HR) was significantly lower in group 3 when compared to the other groups at several different times after arrival to the PACU. No clinically significant difference was noted in blood pressure. ConclusionFollowing BMT, when no premedication is administered, there was no clinical advantage when comparing IN dexmedetomidine (1μg/kg) to IN fentanyl (2μg/kg). The addition of oral midazolam as a premedication worsened the outcome measures particularly for children receiving IN dexmedetomidine.

Effect of Thermal Welding Tonsillectomy on Emergence Agitation

: This study sought to examine the effect of thermal welding tonsillectomy that reduces pain and length of anesthesia on emergence agitation. A total of 60 patients (age range, 3–6 years) with chronic recurrent tonsillitis with an indication for tonsillectomy were included. Patients were randomly assigned to 2 groups. The control group (the CD group) was composed of patients undergoing cold dissection (CD) tonsillectomy. The study group (TW group) included patients undergoing thermal welding (TW) tonsillectomy. All patients were given sevoflurane as an anesthetic agent. For all patients, anesthesia time, operation time, extubation time, Pediatric Anesthesia Emergence Delirium scale, pain scale, nausea/vomiting score, and delivery time were recorded. The duration of anesthesia, operation, and delivery was significantly lower in the TW group as compared with the CD group (P = 0.000 < 0001). The pain and agitation scores were significantly lower in the TW group as compared with the CD group (P = 0.000 < 0001). We assume that, besides reducing pain and allowing surgery without bleeding, the TW tonsillectomy method diminishes emergence agitation induced by anesthetic agents, such as sevoflurane.

Clinical evaluation of a PHMBimpregnated biocellulose dressing on paediatric lacerations

To evaluate the clinical benefits, primarily tolerability and reduction in pain levels, associated with the use of a PHMB-impregnated biosynthetic cellulose dressing (Suprasorb X + PHMB) on paediatric heel lacerations. These lacerations were caused when children, who were being transported on their parents' bicycles, got their heels trapped in the wheel spokes. Where these injuries just comprised skin contusion and laceration, treatment had previously comprised cleansing followed by application of conventional dressings and moist wound healing dressings. However, the high incidence of infection necessitated regular dressing changes, which caused parents and children stress and anxiety. This clinical evaluation assessed the benefits of a new treatment protocol, where the PHMB-impregnated biocellulose dressing was applied and left in situ until epithelialisation occurred. A cork splint was used for 3 days to prevent pes equinus and to let the ankle joint rest. Change in wound size (cm²), incidence of local infection, wound bed characteristics and pain levels (measured on a 0-10 paediatric pain scale) were assessed at 3-day intervals during the 14-day treatment period. Satisfaction with the dressing was also evaluated. Twenty children (mean age 5.6 years (± 1.33) were recruited into the study and included in the analysis. The mean baseline wound area was 8.60cm² (± 6.57). The mean time to complete wound closure was 12.95 days (± 7.69) with a mean total of 4.70 visits (± 1.56). The mean VAS pain score was 9.55 (± 0.69), compared with 0.15 (± 0.37) on day 14 (p<0.003). At the second visit (after 3 days) 17 of the 20 children were reported to be free of pain. No cases of local infection were noted. The dressing was found to be child and parent friendly. The evaluation also showed that it was well tolerated and achieved good healing outcome. It has now been incorporated into the clinic's treatment protocol for these wounds. None. The authors have no relevant financial interest in this article. All authors were involved in the critical revision of the manuscript for important intellectual content.

Reliability and validity of the Modified Preverbal, Early Verbal Pediatric Pain Scale in emergency department pediatric patients

Research has demonstrated that children are at particular risk for oligoanalgesia due to assessment difficulties when they are unable to self-report. We sought to evaluate the psychometric properties of the Modified Preverbal, Early Verbal Pediatric Pain Scale (M-PEPPS) when used in an emergency department pediatric population. We conducted a secondary analysis of data from a prospective, observational study of pain in emergency patients to evaluate the M-PEPPS tool. Data from 118 pediatric patients was subjected to item analysis, reliability analysis, and common factor analysis. Item difficulties suggest that the items capture the range of pain states from mild to severe. Corrected item-total correlations indicate that the instrument discriminates between various levels of pain. Common factor analysis yielded a single, unrotated common factor solution providing evidence that the M-PEPPS measures the single construct of pain. Cronbach's alpha for the scale (0.954) suggests excellent reliability. Findings indicate that the M-PEPPS instrument is reliable when used by emergency nurses to measure pediatric pain. The single-factor common factor solution provides support for the scale as measuring the single construct of pain. Additional research is necessary to establish the degree of change in score required for a clinically meaningful reduction in pain to be present.

Escala LLANTO: instrumento español de medición del dolor agudo en la edad preescolar

This study was designed to validate a new paediatric acute pain scale, LLANTO, comparing its scores with those obtained from the CHEOPS scale in 54 Spanish children aged 1 month-6 years. LLANTO is an acronym of five behavioural or physiological variables previously shown to be associated with pain in children (crying, attitude, respiratory pattern, muscle tone and facial expression). The LLANTO pain scale was tested for validity and inter-rater reliability. The children's behaviour was observed after surgery, before and after analgesics administration in the post-anaesthesia care unit (PACU). Three observers (an experienced physician, a resident in training and a nurse) then simultaneously rated pain behaviour in a blinded way with both scales. LLANTO scale had an acceptable inter-rater correlation (0.809, 0.686 and 0.908, P<0.0001). Construct validity was determined by the ability to differentiate the group with a high pain level before analgesia and after analgesia ( P<0.002). The positive correlation between both scales ( r=0.804, P<0.0001) supported concurrent validity. Use of the κ statistic indicated that LLANTO scale yielded a perfect agreement with the CHEOPS scale, with an appropriate sensitivity and specificity (96% and 87% respectively). On the basis of data from this study, we recommend LLANTO as a valid, reliable and practical tool for Spanish speakers.

60: Reliability and Validity of the Modified Preverbal, Early Verbal Pediatric Pain Scale In Emergency Department Pediatric Patients

Pain is an important impetus for patients to seek emergency care, with as many as 78% of emergency patients reporting the presence of pain. Despite this, clinicians continue to struggle to provide adequate pain management to emergency patients. Children are at particular risk for oligoanalgesia, due in part to difficulties assessing pain when children are unable to self-report the presence and characteristics of their pain. The purpose of this study was to evaluate the psychometric properties of the Modified Preverbal, Early Verbal Pediatric Pain Scale (M-PEPPS) when used in an emergency department pediatric population.

Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

Summary Background: Assessing procedural pain and distress in young children is difficult. A number of behavior-based pain and distress scales exist which can be used in preverbal and early-verbal children, and these are validated in particular settings and to variable degrees. Methods: We identified validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. We analysed in detail six behavioral pain and distress scales: Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD). Results: Despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited. Conclusions: There is a need to validate behavioral pain and distress scales for procedural use in preverbal or early-verbal children.

Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

Assessing procedural pain and distress in young children is difficult. A number of behavior-based pain and distress scales exist which can be used in preverbal and early-verbal children, and these are validated in particular settings and to variable degrees. We identified validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. We analysed in detail six behavioral pain and distress scales: Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD). Despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited. There is a need to validate behavioral pain and distress scales for procedural use in preverbal or early-verbal children.

A Comparison of Single-Dose Caudal Clonidine, Morphine, or Hydromorphone Combined with Ropivacaine in Pediatric Patients Undergoing Ureteral Reimplantation

Caudal blockade is a common technique for pediatric postoperative analgesia. While safe and effective, caudal opioids are associated with troublesome side effects. Caudal clonidine may offer significant analgesic benefits. We prospectively compared the analgesic, side effect, and rehabilitation profiles of caudal clonidine, hydromorphone, or morphine in a group of 60 pediatric patients undergoing ureteral reimplantation. Patients aged 6 mo to 6 yr were evenly and randomly enrolled in a double-blind manner. Patients received a single caudal dose of 2 mcg/kg of clonidine, 10 mcg/kg of hydromorphone, or 50 mcg/kg of morphine, combined with 1.0 mL/kg of 0.2% ropivacaine with epinephrine. After sevoflurane in oxygen/air anesthesia, all subjects received proxy nurse-controlled analgesia with morphine. Postoperative pain intensity, use of IV morphine, and side effects were assessed during the first 24 h. Oral intake and discharge home were recorded. Caudal clonidine resulted in less postoperative nausea and vomiting (P = 0.01) and pruritus (P = 0.007) than did caudal hydromorphone or caudal morphine. Caudal morphine produced more sustained initial analgesia than did caudal clonidine (P = 0.02). No difference was observed in pain scores, total morphine use, time to first oral intake or discharge home. No postoperative respiratory depression, excessive sedation, hypotension, or bradycardia was identified. Although caudal morphine may result in more sustained initial analgesia, caudal clonidine combined with nurse-controlled analgesia appears to provide comparable analgesia with fewer side effects. Based on these results, the use of caudal clonidine may be superior to caudal opioids after pediatric ureteral reimplantation.