Pediatric Pain Assessment at Recovery Room in Srinagarind Hospital

Background: Acute pain is a common postoperative problem, especially among pediatric patients (between 1 and 6 years of age). Since children cannot report their pain to health care providers, pain needs to be promptly assessed as untreated pain may lead to sustained changes in the central neural system. Behaviour is also a useful measure and indicator of pain in children. In the Post Anesthetic Care Unit (PACU) at Srinagarind Hospital, the Face, Legs, Activities, Cry, Consolability (FLACC) scale is used for pain assessment.Objectives: To determine the proportion of pediatric patients who have undergone the FLACC pain assessment scale in the PACU and the correlation between FLACC scale and treatment.Design: Retrospective descriptive studySetting: PACU, Department of Anesthesiology, Srinagarind Hospital, Khon Kaen UniversityMaterials \& method: 180 pediatric (under 6 years of age) patients’ records in the PACU were reviewed since June 2005. Outcome measurements including sex, age, ASA status, type of operation and procedure, type of pain assessment, number of FLACC scale (0-10) used for pain assessment, causes of non-assessment and number of assessment were recorded. The results were analyzed using descriptive statistics and presented as means and percentages.Results: Among the 180 pediatric patients, 65% were male and 34% were in middle childhood. 67% of pediatric patients in the PACU were assessed by FLACC pain scale. Almost all nurses (98%) used FLACC scale to assess pain in their pediatric patients. It was found that patients’ sleep (46%) at the time of admission to the PACU was the common cause of non-assessment. In term of pain treatment, 61% of the patients were assessed for their pain before treatment, however 21% of the patients having pain (FLACC\>2) did not receive any pain treatment. The most common cause (89%) of non-assessment was due to patients’ crying. The mean of FLACC scale before and after treatment were 3.64 + 6.25 and 3.27 + 8.26, respectively.Conclusion: The pediatric pain assessment was used in the PACU more frequently than previously surveyed; however the use rate was not 100% (as expected) and some of patients having pain (FLACC\>2) did not receive any treatment. As a result, education and personnel support might be useful in order to improve the quality of pain assessment and treatment in the PACU.Key words :  Pediatric pain assessment, FLACC scale, PACU    

Patient satisfaction with postoperative pain management at recovery room in Srinagarind Hospital

Background: The assessment of patient satisfaction is one of the most significant indicators for the improvement of anesthetic service, especially postoperative pain relieving service. We fully realized its importance. In order to improve its performance and health service, this survey on patient satisfaction has been conducted. Objective: To study patient satisfaction with postoperative pain management and also other additional outcomes relating to patient’s pain in recovery room.Design: Both prospective and descriptive studies Setting: Surgical ward at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University.Materials \& methods: A total of 200 patients have been self-administered questionnaire and interviewed in the survey within 24 hrs after surgery in surgical ward at Srinagarind Hospital. The level of patient satisfaction (5 scales) was assessed. Other pain related outcomes such as pain scores (NRS; 0-10) and pain relief were also assessed.Results: The level of patient satisfaction with pain management was rated as fair and satisfied about 36% and 35% respectively. Forty–six percent of the patients reported pain after surgery. Among these patients, moderate and severe pain were reported as 36.96% and 29.35% respectively. Regarding the level of pain relief after treatment, we found that 52.94% had moderate pain relief and 23.53% had mild pain relief. Conclusion: The satisfaction level in terms of pain management was rated as fair and satisfied in 71% of the patients; however it was quite difficult to survey on patient satisfaction at recovery room. As some residual effects from anesthesia and patients impaired memory in recovery room, we found it very difficult to get the exact results. After this study, we found a number of possible ways to improve our pain service. Key words: Satisfaction, postoperative pain management, recovery room

Quality of Recovery Score and Pain Control between Continuous Epidural Bupivacaine – Morphine and Intravenous Patient Controlled Analgesia after Upper Abdominal Surgery

Background: Good perioperative analgesia especially in upper abdominal surgery may reduce the occurrence of serious postoperative complications. The efficacy and effects of continuous epidural analgesia (CEA) compared with intravenous patient-controlled analgesia (IV PCA) have not been reported in patients undergoing upper abdominal surgery.Objectives:  To compare CEA with IV PCA opioid for postoperative pain control following upper abdominal surgery in cholangiocarcinoma (CHCA) patients in terms of analgesic efficacy, side effects, quality of recovery and duration of hospital stayDesign: Prospective and randomized – controlled trialSetting: Surgical ward at Srinagarind Hospital, Khon Kaen UniversityMaterials \& method: Thirty CHCA patients were randomized allocated to two groups. The patients were received the same general anesthesia plus postoperative continuous epidural morphine (0.05 mg/ml) with 0.0625% bupivacaine in CEA group or postoperative PCA using morphine sulfate (1mg/ml) in PCA group during a period of 24 hrs. Numeric Rating Scale at rest (NRS-R) and on movement (NRS-M) , Likert’s scales, ambulation scores, dosage of morphine consumption and side effects were assessed at 6 and 24 hours postoperatively. The quality of recovery scores (QoR Scores) was performed after 24 hours.Results: The demographic and surgical data were similar in both groups. The pain scores at 6 and 24 hours between two groups were not statistically significant. The ambulation scores at 24 hours was significantly greater in group CEA compared with group PCA (p=0.046). Intravenous morphine requirement at 24 hrs was significantly less in group CEA (p=0.02). The Likert’s scales, QoR Scores, side effects and duration of hospital stay were comparable for the two groups.Conclusion: Continuous epidural analgesia( CEA ) was associated with greater ambulation scores and reduced postoperative intravenous morphine requirement compared with morphine base PCA (IV PCA) in CHCA patients undergoing upper abdominal surgery.Key words: Epidural, analgesia, postoperative pain, upper abdominal surgery 

Survey of Leaked Pressure in Anesthetized Pediatric Patients with Uncuffed Endotracheal Tube

Background: Generally, an uncuffed endotracheal tube is used for general anesthesia in pediatric patients; thus, an inappropriate tube size intubation can lead to complications. In clinical practice, tube size selection can be done using a formula then adjusting for each patient. An appropriate tube size should allow a leak at airwaypressures (leak pressure) between 20-40 cmH2O, but leak pressure is not routinely monitored.Objective: To study the incidence of inappropriate tube size used in pediatric patients receiving general anesthesia by using leak pressure test.Design: Prospective, descriptive study. Setting: Operating room, Srinagarind Hospital Subject: Pediatric patients between 0 and 8 years of age undergoing general anesthesia with uncuffed endotracheal tube.Methods: After anesthesia was induced and the patient was intubated, leaked pressure was measured. Leak pressure between 20 and 40 cmH2O was considered appropriate. We recorded each patient’s characteristics, number of attempts to intubate, leak pressure, duration of intubation, and respiratory complication. The results were analyzed using descriptive statistics and were presented as means, percentages and 95% confidence intervals (95% CI).Results: We enrolled 98 patients averaging 2.3 + 2.2 years of age (67 males and 31 females). Patients with inappropriate leak pressure numbered 39 (39.80%), of which 24.49% (95% CI: 17,33) were in the group where leak pressure was \> 40 cmH2O and 15.31% (95% CI: 10,23) in the group where leaked pressure was \< 20 cmH2O. The most frequent complication was hoarseness 27.55% (95% CI: 20,37). No patients had any serious respiratory complications.Conclusion: Pediatric patients between 0 and 8 years of age, undergoing general anesthesia with an uncuffed endotracheal tube had a 39.80% incidence of inappropriate endotracheal size used. Hoarseness was the most common complication (27.55%). Tube size selection should be done carefully and include leak pressure test.Keywords: Uncuffed endotracheal tube; Leak pressure; General anesthesia; Pediatric patients

Pain Knowledge and Attitudes Towards Acute Pain Service (APS) of Healthcare Providers in Srinagarind Hospital

Introduction: The adequate treatment of acute pain after surgery is a humanitarian obligation for heath care professionals. Analgesia plays an important role in speeding the patient’s recovery, in reducing and limiting morbidity, as well as probably improving clinical outcomes. Significant knowledge deficit regarding currently accepted principles of pain management practice as well as beliefs that could interfere with optimal care, mandate a need for educational interventions.Objective: To assess the pain knowledge and attitudes toward postoperative pain management by acute pain service (APS) of healthcare providers in Srinagarind HospitalDesign: Descriptive \& prospective research Setting: The surgical, obstetrics \& gynecological, orthopaedics and otorhinolaryngology wards in Srinagarind Hospital, Faculty of Medicine, Khon Kaen University Population: All physicians and nurses work at those wards in Srinagarind Hospital Material and methods: The total 286 questionnaires from physicians and nurses were collected during August to October 2005. The informed consents were obtainedfrom all subjects. The demographic data, previous pain education, clinical experience, pain knowledge scores, level of satisfaction to APS and other variables were analysed. The data were analyzed using, and presented as, descriptive statistics. The Chi-square test was used to test for significant difference variables. A p-value of less than 0.05 was considered statistically significant.Results: The response rate of questionnaire in physicians and nurses were 99.2% and 77.5%, respectively. The physicians’ knowledge scores were moderate to high and higher in nurse groups. The level of physicians’ knowledge significantly associated with previous pain education (p= 0.001). Attitudes toward postoperative pain management by APS of healthcare providers in term of physicians and nurses on satisfaction level were satisfied and highly satisfied, respectively. This survey suggests that our healthcare providers need the continuing organization and education in pain management and consultation system.Conclusion: Most physicians and nurses were satisfactory in attitudes towards postoperative pain management by APS. Practical recommendations are presented for increasing physicians and nurses’ knowledge about pain management. The continuing education and good consultation system might be useful in order to improve the quality of postoperative pain management in our hospital.Keywords: knowledge, Attitude, Acute pain service

Inhaled Anesthetic Delivery System Problems during General Anesthesia at Srinagarind Hospital, Khon Kaen University

Background and Objective: During general anesthesia, inhaled anesthetic delivery system problems may contribute to anesthetic morbidity and mortality. The magnitude and pattern of these problems had not been established at Srinagarind Hospital. The objectives of this study are to identify the incidence and severity of common problems of inhaled anesthetic delivery system and find strategies for prevention.Methods: Prospective, descriptive study at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University. All patients received general anesthesia in the year 2005. Details of anesthetic management in all patients were recorded on the anesthetic charts on a routine basis. When inhaled anesthetic delivery system problems had occurred, the anesthesia provider responsible for the cases wrote a short description of the event on the anesthetic charts and reported to the authors to record more details in the incidence form for further analysis about the incidence and severity.Results: There were 8,904 consecutive general anesthetic patients in 2005. Sixteen inhaled anesthetic delivery system problems were recorded (0.18 %). One-third of problems involved the anesthetic ventilators. Human error was a contributing factor in a half of the cases. No patient suffered any lasting morbidity. Conclusions: The incidence of inhaled anesthetic delivery system problems was very low and not severe during the study period. This was probably due to the improvement in routines for preoperative equipment checks, regular equipment calibration and good monitoring system in our hospital. However, there is still a potential for serious problems and strategies to prevent human error should be implemented. In addition, an improved check between cases should be encouraged to reduce the occurrence of the problems. Keywords: anesthesia, complications, inhaled anesthetic delivery system

The Effectiveness of Spinal Morphine plus Intravenous Patient-Controlled Analgesia on Postoperative Pain Controlled at Srinagarind Hospital

Background and Objectives: Effective pain control can minimize post operative complications especially for pulmonary complications. Previous reports showed pain management using combined spinal morphine (spinal MO) plus patient-controlled analgesia (IV PCA) was more effective than either intravenous or PCA alone. This technique had been conducted in our institute since 2004 but its effect on postoperative pain control was not reported. Aim is study the effect of spinal morphine plus IV PCA on postoperative pain control. Methods: The author conducted this descriptive study at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, by retrospectively reviewing all medical record of surgical patients who received spinal morphine plus PCA for postoperative analgesia between January 2005 and December 2006. Data extracted were age, gender, types of operation, dosage of spinal morphine, pain scores (both at rest and during movement) on the first post operative day, adverse effects, and patient’s satisfaction. Effect of the pain control were classified as; effective (pain score 0-4) and ineffective (pain score 5-10)Results: Two hundred and sixty two records were analyzed. There were 63% female with a mean age of 49.6+10.5 years. Most of patients (69%) underwent abdominal surgery (excluded cesarean section and kidney surgery). Median dosage of spinal morphine was 0.3 mg depending on types of surgery. There were 62% of cases received effective analgesia at rest whereas 35.4% received while movement. No respiratory depression was reported but 1.5% of patients experienced severe nausea and vomiting. However, 92% of patients were satisfied with the treatment received.Conclusion: Spinal morphine plus PCA is effective for pain control in the first postoperative day only for at rest, but not during movement. Keywords: postoperative pain, spinal morphine, patient-controlled analgesia