Good Practice in Postoperative and Procedural Pain Management ...

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Section 3.0Pain AssessmentContents3.1 General principles of pain assessment3.2 Pain measurement toolsChildren’s pain should be assessed. Effective painassessment is essential both in terms of its contribution tothe prevention and relief of a child’s pain (1–4) and alsoin its role as a diagnostic aid. The centrality of painassessment to high-quality pain management is enshrinedin many current pain management recommendations,position statements, reports, and guidelines (5–9).Assessment refers to a broad endeavor aiming toidentify the factors that shape the pain experienceincluding physiological, cognitive, affective, behavioraland contextual, and their dynamic interactions.Measurement refers to the application of a metricon one aspect of pain, usually intensity. This guidelinefocuses primarily on pain measurement assuming thatthe appropriate pain assessment as per clinical practicetakes place.Table 1 Evaluation criteria for IMMPACT reviews (12)I. A wellestablishedassessmentCriteria for categoriesThe measure must have been presented in atleast 2 peer-reviewed articles by differentinvestigators or investigatory teams.Sufficient detail about the measure to allowcritical evaluation and replication.Detailed information indicating good validityand reliability in at least 1 peer-reviewedarticle.II. Approaching The measure must have been presentedwell-established in at least 2 peer-reviewed articles, whichassessment might be by the same investigator orinvestigatory team.Sufficient detail about the measure to allowcritical evaluation and replication.Validity and reliability information eitherpresented in vague terms (e.g., no statisticspresented) or only moderate valuespresented.III. PromisingassessmentThe measure must have been presented in atleast 1 peer-reviewed article.Sufficient detail about the measure to allowcritical evaluation and replication.Validity and reliability information eitherpresented in vague terms or only moderatevalues presented.Existing guidelines: An evidence-based guideline ‘TheRecognition and Assessment of Pain in Children wasfirst produced by the Royal College of Nursing (RCN),UK, in 1999 and was revised in 2009 (10). The RCNguideline was endorsed in 2001 by the Royal College ofPaediatrics and Child Health that produced ‘Guidelinesfor Good Practice’ (11), which were the recommendationsbased on the original RCN guideline. We suggestthat both these documents be consulted for further andmore detailed information; the evidence and recommendationspresented here are intended to support and supplementthis existing guidance.Technical note for this section of the guideline: inaddition to the SIGN criteria, and in line with currentpractice, instruments were also evaluated based on a setof evaluation criteria for the assessment of quality ofevidence for IMMPACT reviews (12) (see Table 1, andAppendix 1, Technical Report for further information).3.1 General principles of pain assessmentGood pain assessment contributes to the preventionand/or early recognition of pain as well as the effectivemanagement of pain (1,4). There are three fundamentalapproaches to pain assessment in children:Self-report: measuring expressed experience of pain.Observational/Behavioral: measuring behavioral distressassociated with pain or measuring the perceivedexperience of pain by parent or carer report.Physiological: primarily measuring physiologicalarousal consequent to painAs self-report is the only truly direct measure ofpain, it is often considered the ‘gold standard’ of measurement.However, for developmental reasons, selfreportmay be difficult or impossible in some childrenand therefore a proxy measure must be used. For painto be measured as accurately as possible, the principlesunderpinning assessment at different developmentalages and in different settings must be appreciated.Good practice pointsChildren’s pain should be assessed, documented, andappropriate action taken. This requires both training ofhealthcare professionals in pain assessment and measurementwith standardized instruments.10 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79
In order to assess pain, effective communication shouldoccur between the child whenever feasible, their family orcarers, and the professionals in the multidisciplinary team.Standardized instruments should be used in their finalvalidated form. Even minor modifications alter the psychometricproperties of the tool and render comparisonsbetween studies invalid and clinical assessment biased.RecommendationsNo individual measure can be broadly recommended forpain assessment across all children or all contexts:Grade B (12–14).Children’s self-report of their pain, is the preferredapproach, where feasible: Grade B (13).An observational measure should be used in conjunctionwith self-report with 3–5 year olds as there is limited evidencefor the reliability and validity of self-report measuresof pain intensity in this age group: Grade B (15).Sole use of physiological measures in clinical practice isunproven and therefore not recommended: Grade D (16,17).EvidenceThe results of pain assessment must be documented,acted upon, reassessed, and re-evaluated to determinethe effectiveness of interventions (1,18–21). Improveddocumentation can result in improved pain management(22–25). Studies demonstrate that there is low utilizationof pain tools and policies (26) and that pain isunder-assessed (3,27) and poorly documented (28,29),resulting in children being under-medicated and/ortheir pain being poorly managed (3,27,30–32). Regularpain evaluation can contribute to the safety and efficacyof the management of acute pain (33).Self-report: Pain is a highly complex and multidimensionalexperience, and pain intensity scores are a necessaryoversimplification. Children’s self-report of pain isregarded as the gold standard, and in most circumstances,it is the preferred approach. Children’s selfreportof pain may differ to that of their parents or thenurse caring for them (34). However, it must also berecognized that self-report in both children and adultsis complex (13,35), dependent upon age and/or level ofcognition (36), affected by a range of social and otherinfluences (37–39), and is subject to biases (15,37,40).Nevertheless, although children’s subjective reports ofpain are probably the best way of documenting the presenceand intensity of pain, it requires quite advancedcognitive skills (including classification, seriation, andmatching) for children to be able to provide reliable andvalid self-reports of pain intensity. Faces scales may notrequire the ability to seriate or estimate quantitiesbecause the task can be handled by matching how onefeels to one of the faces, which is presumed to be easierthan quantitative estimation (41). However, self-reportis subject to individual response biases, reflecting theperson’s appraisal of the consequences of the pain report(36). Although children of preschool age are often askedto confirm or deny that they are feeling internal statessuch as hunger or thirst, they are rarely, if at all, askedto make quantitative estimates of these states. Thus,using a self-report pain scale is an unusual experiencefor most young children (15). Alternative strategies foranswering confusing questions are frequently adoptedby young children. Response bias is a propensity torespond systematically to test items in ways unrelated tothe item content. Response biases that have been documentedin the pediatric literature include:l Anchor effects which refer to the influence of surroundingconditions or prior experience on the estimationof a quantity. For example, pain ratings on facesscales are influenced by whether the lower anchor faceis smiling or not.l Sequence bias such as the child selecting (for example)the leftmost face to answer the first question, andthen picks the adjacent face to the right in response toeach successive question, in a sequence of responsesthat would be scored in an ascending or descendingseries (e.g., 0–2–4–6–8).l Giving the same answer to all questions (15,42–44).In experimental situations where children were askedto rate hypothetical pain situations, it has been demonstratedthat young children from four to seven cannotdistinguish as many faces as proposed by the majorityof available faces scales (45). These results stronglyrecommend a reduction in the number of response levelsof faces scales for pain assessment in children.It should be noted that not all inaccurate responsesindicate the occurrence of response biases as inaccurateresponses can occur for other reasons such as failureto understand the question, deliberate random orincorrect responding, lack of motivation and attentionto the task, or undetected learning or cognitive difficulties(15). Clinicians should be aware that young children’spain scores can be misleading, particularly whena pain scale is used only once to measure pain on asingle occasion, making it difficult for the clinician todetect any underlying response bias. Therefore, selfreportpain scores from children below 5 years of ageshould generally be treated with caution and should becorroborated by observational measures.ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 11
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Page 26 and 27: Good practice pointLubricant contai
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Page 36 and 37: necessary to ensure that the patien
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tinuous epidural infusion in childr
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245 Morton NS, O’Brien K. Analges
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321 Taenzer AH, Clark C, Taenzer AH
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Section 6.0AnalgesiaContents6.1 Ana
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enhance systemic absorption. Lidoca
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undergoes hepatic biotransformation
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tein binding are reduced and the ha
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a low-dose infusion but the child m
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Table 6.6.1 Paracetamol dosing guid
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steps that health care professional
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