|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 3 | Page : 138-143
Postoperative pain management in children: A survey of practices of pediatric surgeons in Nigeria
Abdulrasheed A Nasir1, Emmanuel A Ameh2, Lukman O Abdur-Rahman1, Israel K Kolawole3, Olanrewaju O Oyedepo3, James O Adeniran1
1 Department of Surgery, Division of Paediatric Surgery, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Department of Surgery, Division of Paediatric Surgery, National Hospital, Abuja, Nigeria
3 Department of Anaesthesia, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin, Nigeria
|Date of Web Publication||17-Aug-2017|
Abdulrasheed A Nasir
Department of Surgery, Division of Paediatric Surgery, University of Ilorin Teaching Hospital, PMB 1459, Ilorin
Source of Support: None, Conflict of Interest: None
Background: Postoperative pain has a negative effect on the process of recovery. There is paucity of literature on the postoperative pain management practice in children in developing countries. We sought to determine the current practice of postoperative pain management in children among pediatric surgeons in Nigeria. Methods: A cohort of 43 pediatric surgeons/trainees attending two annual meetings of Association of Paediatric Surgeons of Nigeria (2011 and 2013) were surveyed with a questionnaire enquiring about the practice of postoperative pain management in children and their perceptions. Results: Thirty-seven respondents had completed the survey (86% response rate). Of these respondents, 27 (73.0%) were consultants and 10 (27.0%) were trainees. Only 2 (5.4%) respondents used any guidelines, and 8 (21.6%) respondents had an established institutional protocol for the pediatric postoperative pain management. Almost half of the respondents (18, 48.6%) used clinical judgments for assessing postoperative pain, followed by crying, requires oxygen to maintain saturation > 95%, increased vital signs, expressions, and sleeplessness scale (13, 35.1%); alertness, calmness, respiratory response/crying, physical movement, muscle tone, and facial tension behavioral scale (11, 29.7%); and verbal rating (10, 27.0%). In neonates, 89% of the respondents used paracetamol and 32% used pentazocine for routine postoperative analgesia. None of the respondents used morphine for neonatal postoperative analgesia. In older children, commonly used analgesics include paracetamol (35, 94.6%), pentazocine (30, 81.1%), and nonsteroidal anti-inflammatory drugs (28, 75.7%). More than half of the respondents (20, 54.1%) were not satisfied with their current practice of postoperative pain management. Conclusion: Pain was infrequently assessed, and analgesic therapy though multimodal was largely not protocol based and therefore subject to inadequate pain relief. Postoperative pain should be more visible in our hospitals, and efforts should be made to improve its assessment and management.
Keywords: Acute pain services, children, pain assessment, postoperative analgesia, postoperative pain
|How to cite this article:|
Nasir AA, Ameh EA, Abdur-Rahman LO, Kolawole IK, Oyedepo OO, Adeniran JO. Postoperative pain management in children: A survey of practices of pediatric surgeons in Nigeria. J Clin Sci 2017;14:138-43
|How to cite this URL:|
Nasir AA, Ameh EA, Abdur-Rahman LO, Kolawole IK, Oyedepo OO, Adeniran JO. Postoperative pain management in children: A survey of practices of pediatric surgeons in Nigeria. J Clin Sci [serial online] 2017 [cited 2021 Apr 11];14:138-43. Available from: https://www.jcsjournal.org/text.asp?2017/14/3/138/213080
| Introduction|| |
Postoperative pain involves multiple physiological mechanisms precipitated by surgical trauma. It is associated with autonomic, endocrine, metabolic, physiological, and behavioral responses. Evidence suggests that inadequate relief of postoperative pain results in harmful physiological and psychological consequences that eventually leads to significant morbidity, which may delay recovery and return to daily living and mortality. Although there were guidelines for the management of acute pain in children, many children still experienced pain during hospitalization because of noncompliance with the available guidelines.,, Some authors recently argued that mismanaged or undertreated acute pain from procedures or surgery is an adverse care event.
The age-long misconception that young infants cannot feel pain also adds to the reason for inadequate treatment of pain in infants., Recent evidence suggests that neonates feel more pain than older children., Inadequate pain relief in hospitalized patients led the Joint Commission on Accreditation of Healthcare Organizations in the United States to introduce standards in 2001, demanding pain assessment and management. Pain assessment has now become standard practice among national organizations, including the American Pain Society, and hospitals including The Hospital for Sick Children, Toronto, Ontario, have endorsed this standard. Although substantial evidence exists regarding the methods of effective pain assessment and management, it is not clear how well this knowledge is translated into clinical practice among pediatric surgeons in Nigeria.
The purpose of this survey is to ascertain the practice of postoperative pain management among pediatric surgeons in Nigeria, and to identify gaps in knowledge that require improvement and education, to ensure best practices.
| Methods|| |
In September 2011, a questionnaire was administrated to pediatric surgeons attending the 10th annual meeting of the Association of Paediatric Surgeons of Nigeria, and the same questionnaire was also administered at the 12th annual meeting of the Association of Paediatric Surgeons of Nigeria in September 2013, to enroll participants who did not attend the previous meeting. A structured, self-administered questionnaire was distributed to 43 pediatric surgeons/trainees. During the survey, there were 62 pediatric surgeons in 24 pediatric surgical centers in Nigeria. Information requested included year of experience, commonly used analgesia in neonates and children, availability of established protocols, use of guidelines, and satisfaction with the current postoperative pain management.
The collected data were analyzed using descriptive statistics. They were represented as median values (interquartile range [IQR]) and proportions calculated on the basis of total answers. The responses of consultants and residents were compared using Chi-square and Fisher's exact test as appropriate. Analysis was performed using SPSS, version 21, (SPSS, Inc., Chicago, IL, USA). Differences were considered statistically significant at P < 0.05.
| Results|| |
Thirty-seven respondents returned a filled questionnaire (86% response rate). All the respondents were working in public hospitals (18 teaching hospitals and 4 federal medical centers; 2 respondents did not indicate their location of practice) covering the six geopolitical zones of Nigeria. Eighty-three percent (29/37) of the respondents had more than 10 years of professional experience in the management of pain. Of the total 37 respondents, 27 (73.0%) were consultants and 10 (27.0%) were trainees. The median age of the trainees was 35 years (IQR, 31–35.5 years) with median professional experience of 3 years (IQR, 2.5–5 years). The median age of the consultants was 44 years (IQR, 40–45.8 years), and the median duration of professional experience was 10 years (IQR, 7–17 years). Four participants did not report their age [Table 1]. Only 2 (5.4%) respondents used any guidelines, and 8 (21.6%) respondents had an established protocol in their institutions for pediatric postoperative pain management [Table 2]. More than half of the respondents (51.4%) reported that a doctor usually assessed pain while 10 (27%) agreed that pain was not assessed in their institutions [Table 2]. The most commonly used assessment tool was clinical judgment by 18 (48.6%) respondents, crying, requires oxygen to maintain saturation >95%, increased vital signs, expressions, and sleeplessness scale 13 (35.1%), (alertness, calmness, respiratory response/crying, physical movement, muscle tone, and facial tension) scale 11 (29.7%), verbal rating 10 (27.0%), visual analog scale 8 (21.6%) and others 4 (10.8%) [Figure 1]. While the differences were nonsignificant (P = 0.164), there was a notably larger proportion of trainees (70%) than that of consultants (44%) who endorsed using clinical judgment to assess pain.
Surgeons prescribed postoperative drugs in most of the institutions (28, 75.7%) [Table 3]. Multimodal approach to postoperative pain therapy in the form of systemic analgesia and local wound infiltration was the most commonly used analgesic technique (27, 73.0%) [Table 4]. In neonates, 89% of the respondents used paracetamol and 12 (32.4%) used pentazocine for routine postoperative analgesia. None of the respondents used morphine for neonatal postoperative analgesia.
|Table 3: Participants response on prescription and assessment of postoperative pain|
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In older children, commonly used analgesics included paracetamol (35, 94.6%), pentazocine (30, 81.1%), nonsteroidal anti-inflammatory drugs (NSAIDs) (28, 75.7%), ketamine injection (22, 59.5%), and tramadol (21, 56.8%). Other analgesics used by the respondents are shown in [Table 4]. The most common form of nonpharmacological approach used for postoperative pain management was sucking/breastfeeding (27, 73.0%); other methods are shown in [Table 4]. More than half of the respondents 20 (54.1%) were not satisfied with their current practice of postoperative pain management. There was no significant difference between consultants and trainees on the methods of pain assessment (P = 0.164), use of written guidelines (P = 0.068), and satisfaction with current postoperative pain management (P = 0.435) [Table 4].
| Discussion|| |
This study found that pain is inadequately assessed in children in our hospitals. Pain is hardly assessed, and even where assessment is done, it is not done with validated instruments. Consequently, pain is underrecognized and undertreated in children. This inadequate treatment of postoperative pain may lead to physical complications, prolonged recovery time, and long-term behavioral changes. Despite advances in both pharmacological and nonpharmacological methods of preventing and treating pain, many children still suffer unacceptable levels of pain and distress during their hospitalization. Several guidelines have been published on evidence-based practice in pain management in children.,,, The worldwide adoption of these guidelines to improve management postoperative pain of hospitalized children is largely inadequate.
In this survey, only 5.4% of the respondents have written guidelines in the care of postoperative pain in children. About 22% of the respondents used some form of protocol for postoperative pain care in their institution. These findings fall short of international best practice on postoperative pain care.
The improved practice has been reported in more advanced countries. In a survey of 650 anesthesiologists attending the annual Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care Medicine National Congress in 2006, 87.6% of anesthesiologists use operative protocols for postoperative pain.
Establishment of an acute pain service (APS) has been advocated as crucial to optimal postoperative pain relief. This APS is expected to have five recognized qualities: Dedicated personnel, 24 h organization of patients' care, written protocols, regular assessment of pain, and documentation of pain scores in the patients' charts. In two national surveys conducted in the UK  and Ireland, 83% and 71%, respectively, of the respondents had formalized APS in their institutions. In another survey of 383 departments in which pediatric surgery was performed in Germany, 37.3% operated an APS. This service is often nonexistent in our hospitals.,, The guidelines represent standards of efficacy and safety, and therefore, their use should be developed and implemented in Nigerian hospitals.
Pain assessment and documentation are the cornerstones of pain management. Therefore, attention to pain assessment and documentation will make pain problems more visible. Treatment of pain remains suboptimal until pain assessment and documentation are routine. Although about three-quarters of our respondents reported that they had knowledge of pain assessment, almost half of the respondents used their clinical judgments to assess postoperative pain, and 27% agreed that pain was not usually assessed in their institution. Clinical judgment is a very subjective means of assessing pain and usually will lead to the syndrome of “treating physician” not the patient who is experiencing the pain. Pain assessment and documentation is a global problem drawing attention., In a prospective, cross-sectional survey of 290 inpatients at The Hospital for Sick Children (Toronto, Ontario), a Canadian tertiary and quaternary, well-resourced pediatric hospital, 73% had no pain score documented during the preceding 24 h, in spite of moderate or severe pain experienced by 64% of the patients sometime in the previous 24 h. The authors concluded that pain was infrequently assessed, yet occurred commonly across all age groups and services, and was often moderate or severe. Rawal and Allvin in a survey of 105 European hospitals from 17 countries noted that routine pain assessment and documentation on a vital sign chart was rarely practiced. These findings call for concerted efforts to make pain more visible in children and to improve its assessment and management.
The global trend in pediatric pain management is the establishment of pediatric pain service administered by departments of anesthesiology. In a 17-nation survey conducted in Europe, 38% of hospitals' anesthesiologists “on call” are usually available for pain consultations. However, in a German survey, postoperative pain management in children was mainly performed by surgeons or pediatricians in 58.8% of the hospitals. Seventy-six percent of the respondents in the current survey reported that doctors prescribed postoperative analgesia in their institutions and only 21% of the respondents reported that either surgeon or anesthetist prescribed postoperative analgesia. In a prospective descriptive study of 106 postoperative children in Togo, Sama et al. reported that anesthetists supervised postoperative care in 21.7% of cases. Limited human and material resources may explain the low involvement of anesthesiologists in postoperative pain in our centers., However, in Sweden, the nurse-based anesthesiologist supervised that APS was found to be a more cost-effective approach. In our setting with limited resources, a sustainable, cost-effective approach needs to be instituted. In the interim, regular update courses can be organized for pediatric surgeons, residents, and nurses to optimize postoperative pain care in children. Others have also suggested a multidisciplinary pain committee that can also oversee APSs as a gap-bridging approach.
According to the current recommendations, a multimodal approach is believed to be the gold standard for postoperative pain treatment in children. The effectiveness of multimodal analgesia in pediatric surgery has been proven in Nigeria and Mali., The current survey showed that 83.1% of the respondents practiced multimodal approach to postoperative pain care with the 73.0% of those employing systemic analgesics and local anesthetic wound infiltration. Neonates are a particularly vulnerable group of patients to inadequate postoperative analgesia partly because of traditional beliefs that neonates are incapable of experiencing pain , and partly due to the fear of serious adverse effects of some of the potent analgesia such as respiratory depression. It is important to note that nociceptive pathways are intact by the second trimester. Thus, even the most preterm infants have the capacity to experience pain.
Despite mounting evidence of maturation of the pain system in neonate and documented clinical consequences of pain in neonates,, neonatal pain remains inadequately treated in most hospitals. In this study, the respondents often used paracetamol (33, 89.2%), pentazocine (12, 32.4%), and tramadol (7, 19.0%) for postoperative pain relief in neonates. This is consistent with a report from Benin in Nigeria where Osifo et al. in a study of postoperative analgesics in 368 neonates reported paracetamol, pentazocine, pethidine, fentanyl, tramadol, and breast milk/glucose drinks as commonly used analgesics.
The ideal postoperative analgesia should have a wide therapeutic range, minimal cardiovascular and respiratory depressant effects, and its effects should be reversible in the event of an emergency. Optimal postoperative pain management is best achieved with opioid analgesics. However, many reasons such as fear of serious adverse effects, in particular respiratory depression, have led to reluctance to administer parenteral opioids to children., This may explain why the most common systemic analgesia used for neonates by the respondents in this study is paracetamol. In developed countries, most (84%) neonates receive opioid analgesia; only 35% receive nonopioid analgesics following major surgery.,
Although pentazocine has been implicated in the development of postoperative respiratory depression in neonates,, this adverse effect of pentazocine may be reduced by avoiding rapid bolus injection and administration should be by frequent small aliquots or by infusion over several minutes.
In infants and older children, analgesia use is not better. The commonly used analgesia in this survey included paracetamol, pentazocine, and NSAIDs. The use of opioids was also abysmally low or nonexistent. This is similar to findings of a survey of postoperative pain in 106 children at an average age of 9 years at Sylvanus Olympio University Teaching Hospital, Togo, where varied postoperative combinations of paracetamol and NSAID was used in up to 40% of patients.
The survey has indicated lack of satisfaction with postoperative pain management among majority of pediatric surgeons in this study. This is consistent with similar survey among 105 anesthesiologists from 17 European countries where over 50% of anesthesiologists were also dissatisfied with postoperative pain management on surgical wards. The dissatisfaction may reflect willingness of the practitioners to improve their practice when they have opportunity to update their knowledge through continued professional development on pain care for children. This can also be a powerful motivator for practice change among Nigerian pediatric surgeons. We do hope our findings will lead to a number of strategies aimed at improving pain management in our hospitals. Regular audit and feedback like this can be an effective form of knowledge translation to improve professional practice.
The limitation of this study is the expression of the result as percentages of respondents even when two or more respondents work in the same hospital.
| Conclusion|| |
Pain was infrequently assessed and even where assessment is done, it is not done with validated instruments. Analgesic therapy though multimodal was largely not protocol based and therefore subject to inadequate pain relief. Most practitioners were not satisfied with their postoperative pain management. A regular update on postoperative pain care is needed to improve pain assessment and management in children.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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