A descriptive feasibility study to evaluate scheduled oral analgesic dosing at home for the management of postoperative pain in preschool children following tonsillectomy.

OBJECTIVES: The purpose of this study, in a sample of preschool children (ages 3-5 years; N = 47), was to evaluate the feasibility of scheduled analgesic dosing following outpatient tonsillectomy in order to optimize pain management. METHODS: Parents were instructed to give their child acetaminophen with hydrocodone (167 mg/5 mL) every 4 hours around the clock for the first 3 days following surgery. Parents recorded ratings of their child's pain with/without swallowing using the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale, pain relief ratings, and severity of analgesic side effects in a home diary. Audiotaped interviews were conducted with parents to document descriptions of their experiences in managing their child's pain at home. RESULTS: Mean FLACC scores with/without swallowing were less than two at each measurement time and pain relief scores increased over time. Total analgesic dose decreased, and the number of missed doses increased over the first 3 days after surgery. Moderate-to-severe daytime sedation, nausea, vomiting, and constipation were reported by parents. DISCUSSION: Study results suggest that acetaminophen with hydrocodone is effective in relieving preschool children's pain following tonsillectomy and that parental adherence to a scheduled analgesic regimen decreases over time. Time-contingent dosing was associated with moderate to severe side effects and should be addressed in discharge teaching with parents. Findings provide insight into parents' perspective of pain management at home following tonsillectomy and methods for relieving their child's pain.

Children's expectations of pain, perceptions of analgesic efficacy, and experiences with nonpharmacologic pain management strategies at home following tonsillectomy.

PURPOSE: To document children's (ages 6-15 years) descriptions of their pain management at home following tonsillectomy. DESIGN AND METHODS: Audio-taped interviews of 80 children were transcribed and coded. Data for each response category were tabulated. RESULTS: Children reported they had more pain after surgery than expected, the pain medicine helped to take their pain away, taking the pain medicine was associated with a negative response by some children, and cold liquids/food by mouth provided pain relief. PRACTICE IMPLICATIONS: Findings provide insight into children's perspective of pain management at home following tonsillectomy and methods for relieving their pain.

Antinociceptive and motor effects of delta/mu and kappa/mu combinations of intrathecal opioid agonists.

Interactions between selective opioid agonists acting at spinal mu-, delta-, and kappa-opioid receptors were evaluated by co-administering a low-antinociceptive dose of the selective delta-agonist, DPDPE, or the selective kappa-agonist, U50,488H, with sequentially increasing doses of the selective mu-agonist, DAMGO, intrathecally. Antinociceptive synergy (i.e., a more than additive antinociceptive effect) was observed with both combinations of opioid agonists tested. The demonstration of antinociceptive synergy suggests that the subtypes of spinal opioid receptors can act, at least in part, through a common neural circuit. Since our measure of antinociception, the Randall-Selitto paw-withdrawal test, is dependent on a normally functioning motor system, we also evaluated the effects of these same combinations of opioid peptides on motor coordination using a rotarod treadmill. A low-antinociceptive dose of DPDPE or U50,488H co-administered intrathecally, with sequentially increasing doses of DAMGO, did not worsen the decrement in rotarod performance observed with the same doses of DAMGO administered as a single agent. In fact, the low-antinociceptive dose of DPDPE significantly attenuated the decrease in rotarod performance produced when the same dose of DAMGO was administered as a single agent. The results of this study suggest that intrathecal combinations of selective mu- with both delta- or kappa-selective opioid agonists can produce antinociceptive synergy without producing an increase in motor side effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Analgesic efficacy and safety of single-dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy.

The efficacy of ketorolac, a non-steroidal anti-inflammatory drug, in the management of moderate to severe pain in adults, has led us to conduct a trial of this analgesic in children following tonsillectomy. Children were randomized to receive intramuscular (i.m.) ketorolac (1 mg/kg, EXP group, n = 45) or saline (CTL group, n = 42) at the completion of surgery. Intravenous (i.v.) fentanyl (0.5 micrograms/kg/dose) was administered in repeated doses postoperatively. Pain intensity was measured using both the Oucher and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) to allow for comparison between self-report and behavioral measures of pain intensity. Severity of postoperative bleeding was measured using a 4-point rating scale. The EXP group had a significant reduction in total fentanyl dose (mean: 35.9 micrograms) compared to the CTL group (mean: 48.3 micrograms, t = -2.21, P < 0.03). There was a statistically significant decrease in pre-fentanyl CHEOPS scores in the Post-Anesthesia Care Unit (PACU) in the ketorolac group (F (2, 30) = 5.34, P < 0.01), but not in the saline group (F (2.24) = 2.46, P > 0.05). In the first hour postoperatively, the CHEOPS demonstrated significant decreases in pain intensity scores in response to opioids, in both groups. In the PACU, children were unable to provide a self-report of pain intensity potentially due to a variety of factors (e.g., emergence delirium, agitation, excitement, sedation, and/or pain). However, during the remainder of the postoperative stay, the photographic scale of the Oucher was a more valid measure of pain intensity than the CHEOPS.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized clinical trial of the effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in children following tonsillectomy.

The purpose of this study was to determine whether around-the-clock (i.e. ATC) dosing of acetaminophen with codeine, with or without nurse coaching, compared to standard care with as needed (i.e. PRN) dosing: reduced children's reports of pain intensity with and without swallowing; increased pain relief, and increased analgesic consumption. Eighty children, 6-15 years, undergoing tonsillectomy were randomized to one of three treatment groups to receive acetaminophen with codeine (120 mg/12 mg/5 ml) for 3 days after surgery: PRN group (N = 28)-every 4 h PRN, with standard postoperative instructions, without nurse coaching; ATC group (N = 26)-every 4 h ATC, with standard postoperative instructions, without nurse coaching; and ATC+coaching group (N = 26)-every 4 h ATC, with standard postoperative instructions and nurse coaching. In all three groups, significant decreases were found over time in pain intensity scores at rest (P < 0.001) and with swallowing (P < 0.001). However, mean pain scores at rest and with swallowing were >3/10 until the fourth evening after tonsillectomy. Children in both ATC dosing groups received significantly greater amounts of acetaminophen and codeine than children in the PRN group (P < 0.003). No significant differences were found in the amount of analgesic administered between the ATC dosing groups with and without nurse coaching. No significant differences were found in the amount of nausea and vomiting among the three groups. Scheduled dosing of acetaminophen with codeine did not provide adequate pain relief for children following tonsillectomy. Nurse coaching does not increase parent's adherence with an ATC dosing schedule.

Posttonsillectomy pain in children.

Tonsillectomy, used to treat a variety of pediatric disorders, including obstructive sleep apnea, peritonsillar cellulitis or abscesses, and very frequent throat infection, is known to produce nausea, vomiting, and prolonged, moderate-to-severe pain. The authors review the causes of posttonsillectomy pain, current findings on the efficacy of various pharmacologic and nonpharmacologic interventions in pain management, recommendations for patient and family teaching regarding pain management, and best practices for improving medication adherence.

The pediatric PRO-SELF©: pain control program: an effective educational program for parents caring for children at home following tonsillectomy.

PURPOSE: The purpose of this paper was to provide a description of the components of the PEDIATRIC PRO-SELF©: Pain Control Program. DESIGN AND METHODS: The Program, adapted from studies of this intervention in adults with cancer pain, was tested in two randomized clinical trials of acute pain management in pediatrics. RESULTS: Key strategies most effective for parents in the pediatric ambulatory surgery setting included use of an educational booklet and timer to facilitate adherence to the prescribed analgesic regimen, as well as interactive nursing support. PRACTICE IMPLICATIONS: The PEDIATRIC PRO-SELF©: Pain Control Program can be used with parents caring for children at home following tonsillectomy.

A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy.

OBJECTIVES: To determine the effectiveness of around-the-clock (ATC) analgesic administration, with or without nurse coaching, compared with standard care with as needed (PRN) dosing in children undergoing outpatient tonsillectomy. METHODS: Children 6 to 15 years of age were randomized to receive acetaminophen and hydrocodone (167 mg/2.5 mg/5 mL) for 3 days after surgery: Group A (N=39)-every 4 hours PRN, with standard postoperative instructions; Group B (N=34)-every 4 hours ATC, with standard postoperative instructions, without nurse coaching; and Group C (N=40)-every 4 hours ATC, with standard postoperative instructions, with coaching. Parents completed a medication log, and recorded the presence and severity of opioid-related adverse effects and children's reports of pain intensity using a 0 to 10 numeric rating scale. RESULTS: No differences were found in analgesic administration or pain intensity scores between the 2 ATC groups. Therefore, they were combined for comparison with the PRN group. Children in the ATC group received more analgesic than those in the PRN group (P<0.0001). Children in the PRN group had higher pain intensity scores compared to children in the ATC group, both at rest (P=0.017) and with swallowing (P=0.017). Pain intensity scores for both groups were higher in the morning compared with the evening (P<0.0001). With the exception of constipation, scheduled analgesic dosing did not increase the frequency or severity of opioid-related adverse effects. DISCUSSION: Scheduled dosing of acetaminophen and hydrocodone is more effective than PRN dosing in reducing pain intensity in children after tonsillectomy. Nurse coaching does not impact parent's adherence to ATC dosing.

Time-contingent dosing of an opioid analgesic after tonsillectomy does not increase moderate-to-severe side effects in children.

As part of a randomized clinical trial that compared three different analgesic dosing regimens ( Sutters et al., 2004 ), the purpose of this study, in children who underwent tonsillectomy, was to determine whether around-the-clock (ATC) dosing of acetaminophen with codeine, compared with as-needed (PRN) dosing, increased the frequency of moderate-to-severe opioid-related side effects (i.e., daytime sedation, lightheadedness, nightmares, nausea, vomiting, and constipation) in the first 3 days after surgery. Because no differences were found in pain intensity scores and in the amount of analgesic administered between the two ATC groups (i.e., with and without coaching), for these analyses, the two groups were combined ( n = 52) and compared with the PRN group ( n = 28). Each side effect was recoded into a dichotomous response (i.e., 0 = did not have symptoms or had slight symptoms; 1 = symptoms that were moderate, severe, or very severe) to provide an adequate sample size in each cell for the statistical analyses. No differences were found in the frequency of moderate-to-severe side effects between the ATC and PRN groups at any of the postoperative assessments. The number of children who reported moderate-to-severe daytime sedation decreased over time in both the PRN ( p = .02) and ATC groups ( p = .01). Children in the ATC groups reported a statistically significant decrease over time in vomiting ( p = .001) and feeling lightheaded or dizzy ( p = .003), and a significant increase in constipation ( p = .018). Except for daytime sedation, changes, over time, in the frequency of moderate-to-severe side effects were not observed in the PRN group.

Efficacy of continuous epidural analgesia versus single dose caudal analgesia in children after intravesical ureteroneocystostomy.

PURPOSE: We compared the effects of single dose caudal injection and continuous epidural infusion of bupivacaine on postoperative pain intensity and supplemental opioid analgesic requirements in children undergoing intravesical ureteroneocystostomy. MATERIALS AND METHODS: Children 6 to 18 years old scheduled for ureteroneocystostomy were recruited for the study. Patients were randomized to group 1--caudal injection of 0.25% bupivacaine before approximately surgical incision and group 2--placement of an epidural catheter with injection of 0.25% bupivacaine, followed by a continuous epidural infusion upon completion of surgery. All patients received intravenous morphine patient controlled analgesic (PCA) as a rescue analgesic, and ketorolac and oxybutynin postoperatively. The epidural catheter was discontinued 48 hours after surgery, with removal of the urinary drainage catheter 4 hours later. Outcome measures included pain intensity rating, supplemental morphine requirements, presence and pain intensity of bladder spasms, analgesia related side effects, time to tolerating a regular diet, and patient and parent satisfaction. RESULTS: There was no statistically significant difference in average daily pain scores between the 2 groups. In the postanesthesia care unit. Significantly more patients in the caudal group required morphine than in the epidural group (56% versus 11%). The total PCA demand was significantly greater in the caudal group on days 1 and 2 postoperatively. Patients in the caudal group took significantly longer to tolerate a regular diet than those in the epidural group. CONCLUSIONS: Continuous epidural analgesia and single dose caudal injection of bupivacaine in conjunction with intravenous morphine PCA and ketorolac provide adequate pain control following intravesical ureteroneocystostomy. Continuous epidural analgesia reduces the need for supplemental intravenous morphine and allows children to tolerate a regular diet earlier.

A comparison of oral diazepam versus midazolam, administered with intravenous meperidine, as premedication to sedation for pediatric endoscopy.

OBJECTIVES: This study was performed to compare the effects of oral midazolam and oral diazepam, administered with intravenous (IV) meperidine, on pre-procedural, procedural, and post-procedural sedation and recovery in children undergoing diagnostic upper endoscopy. The costs of pre-procedure sedation were compared for the two benzodiazepines. METHODS: A randomized, double-blind study was conducted in 154 children (mean age 96.73 +/- 59.34 months, 53% male) undergoing endoscopy. Oral midazolam (0.5 mg/kg, maximum dose of 20 mg) or oral diazepam (0.3 mg/kg, maximum dose of 10 mg) was given before IV insertion, and with IV meperidine (2 mg/kg, maximum dose of 100 mg) given to all patients just before upper endoscopy. Further "rescue" midazolam doses (to a maximum cumulative dose of 5 mg) were given as needed to achieve a pre-procedure sedation score of > or =2. All patients received intravenous propofol for procedural sedation. Patients were evaluated for the efficacy and safety of pre-procedural sedation, sedation during upper endoscopy, and recovery following completion of the procedure. RESULTS: There were no significant differences between study groups for level of pre-procedural sedation, need for midazolam rescue in endoscopy, effectiveness of procedural sedation, occurrence of adverse events, and recovery parameters. CONCLUSIONS: Oral midazolam and diazepam, in conjunction with IV administration of meperidine, provide comparable, effective, and safe premedication for children undergoing upper endoscopy. The cost of midazolam was substantially higher than diazepam.