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Table of Content Volume 6 Issue 3 - June 2018
Assessment of post-operative pain relief after bupivacaine infiltration in paediatric patients
Original Research Article
Suryakant Mundhe1, Sachin Bhavthankar2*
{1Assistant Professor, Department of Anaesthesiology} {2Professor and HOD, Department of Biochemistry} MIMSR Medical College, Latur, Maharashtra, INDIA. Email: suryakantmundhe2018@gmail.com, drbhavthankar@rediffmail.com Abstract Background: Pain assessment is the most important and critical component of pain management. Assessing pain in children is an ever challenging as well as a difficult task. Aim: To assess the post-operative pain relief after bupivacaine infiltration in paediatric patients. Material and Methods: A total of 70 patients were grouped as: Group I: (n=35): Patients in which wound was infiltrated with bupivacaine hydrochloride at the end of surgery. Group II: (n=35): Patients in which wound was not infiltrated. Assessment of pain in children of age group 1-5 years was done by simple linear analogue pain diagram of facial expression, by vital parameters and with the help of pain score assessed by parents and was represented in their own words. Assessment of pain in children of age group 6-12 years was done by vital parameters and with the help of visual analogue scale. Results: In both groups from 20 minutes onwards differences were statistically significant upto 4 hrs (p<0.05). The duration of analgesia by all three methods was same. All the methods used to assess the pain were comparable (p>0.05). Conclusion: All the three methods of assessment used were found to be useful. Thus, a combination of self-report and at least one other measure may be a better approach than using a single tool. Key Words: Bupivacaine infiltration, children, simple linear analogue pain diagram of facial expression, visual analogue scale, vital parameters, global assessment.
INTRODUCTION Pain assessment is the most important and critical component of pain management. Assessing pain in children is an ever challenging as well as a difficult task, mainly because so far no reliable method of assessing and measuring child’s pain is available. The three main principles of assessing pain in children are self-reporting, measuring the perceived experience of pain by the parent or carer, and measuring physiological arousal consequent to pain.1 Bupivacaine is a long-acting reliable local anesthetic agent that is used as a caudal analgesic. Local infiltration of bupivacaine requires less skill and sophisticated equipments. Also continuous monitoring is not required. Hence, this is better technique for postoperative pain relief in paediatric patients. Bupivacaine infiltration for postoperative pain relief has been used effectively by many workers.2,3 The present study was undertaken to assess the post-operative pain relief after bupivacaine infiltration in paediatric patients.
MATERIAL AND METHODS This prospective study was conducted over a period of two years in the Department of Anesthesiology of Government Medical College, Aurangabad. Informed consent of parent of each child was obtained. Inclusion Criteria
Exclusion Criteria
A total of 70 patients were grouped as: Group I: (n=35): Patients in which wound was infiltrated with bupivacaine hydrochloride at the end of surgery. Group II: (n=35): Patients in which wound was not infiltrated. All the included patients were not premedicated and operated under general anaesthesia. Induction was done with thiopentone sodium (2-5 mg/kg) or ketamine (2 g/kg). Intubation was done under the effect of suxamethonium chloride (2 mg/kg). Maintenance was done with oxygen + halothane + pancuronium bromide. Vital parameters were monitored continuously. No analgesics were given intraoperatively. At the end of the surgery, subcutaneous infiltration of incisional wound with bupivacaine hydrochloride (2 mg/kg) was done in 35 children (Group I). The dilution of bupivacaine was done according to length of incision. In remaining 35 patients (Group II), wound was not infiltrated with bupivacaine. The patients were decurarised with neostigmine (0.04 mg/kg) and atropine (0.01 mg/kg). Local antibiotics were not applied after closure of wound. Every patient was observed in recovery room for one hour as the peak level after infiltration of bupivacaine reach at 10.4 minutes (Epstein et al. 1988). Duration of analgesia was noted as time from infiltration of drug till child starts complaining of severe pain or cries due to pain. Assessment of pain in children of age group 1-5 years was done by simple linear analogue pain diagram of facial expression, by vital parameters and with the help of pain score assessed by parents and was represented in their own words. Assessment of pain in children of age group 6-12 years was done by objective and subjective methods. In objective method, vital parameters such as pulse rate and respiratory rate were used. Subjective assessment was done with the help of visual analogue scale. Assessment of pain was carried out at 0 minutes, 20 minutes, 30 minutes, 40 minutes, 60 minutes, 2 hrs, 4 hrs, 5 hrs and 6 hrs after infiltration of drug till the pain became very severe. RESULTS Average of the patients in group I was 3.85±3.46 years and in group II was 4.21±2.28 years. There were 25 males and 10 females in group I and II. Weight of the patients ranged between 6-25 kgs. Both the groups were comparable as far as age and sex were considered. In group I, 16 patients had congenital talipusequinovarus, 9 had postpolioand post traumatic contracture of knee and hip joints, 5 patients had inguinal hernia and 5 had bladder stone. In group II, 12 patients had congenital talipusequinovarus, 6 had postpolio and post traumatic contracture of knee and hip joints, 11 patients had inguinal hernia and 6 had bladder stone.
Table 1: Patients with pain (pain score 3) at different intervals in postoperative period
Difference in pain score of two groups upto 5 hours was significant (Table 1).
Table 2: Analgesia at different time with pain relief score (VAS/LAPD of facial expression)
In both groups, pulse rate and respiratory rate was comparable in preoperative period and was also comparable up to 20 minutes. After 20 minutes, the difference in group I and II was statistically significant. Also increase in pulse rate in group I and II was statistically significant. The increase in the pulse rate in both the groups corresponds with the severity of the pain. (Table 3 and 4).
Table 3: Pulse rate changes at different time in postoperative period
Table 4: Respiratory rate changes at different time in postoperative period
In both groups from 20 minutes onwards differences were statistically significant up to 4 hrs (p<0.05) (Table 2).The analgesia up to 40 minutes in group II might be due to residual effect of anaesthetic agent. The drug had analgesic effect up to 4-5 hours. (Table 3).
Table 5: Average duration of analgesia with VAS/LAPD and global assessment
DISCUSSION Pain is a subjective experience, and it is possible that a child might not be able to report pain precisely in unfamiliar surroundings, therefore, pain assessment in children is extremely challenging. Most professional bodies recommend that parents should be involved with their child's pain assessment; but the evidence that parents can accurately report pain on behalf of their children is mixed. In this study, an attempt was made to assess the post-operative pain relief after bupivacaine infiltration in paediatric patients. In the present study, we have used the LAPD of facial expression pain relief score (5 point) for the assessment of pain in children of age group 1-5 years. Tree-Trakenand Pirayavaraporns L had also used simple LAPD of facial expression for assessment of pain in children of 1-5 year age group.4 We have used VAS pain relief score for the assessment of pain in children of age group 6-12 years. Bailey B et al had also used VAS pain relief score for the assessment of pain in children above 6 years of age.5In the present study, we have also used the pain score i.e., global assessment for all children included in the study, up to 5 years pain score was assessed by mother and above 5 years by child itself. Munuksela EL et al had also used a verbal 4 points pain score for the assessment of pain in their study.6 We have used vital parameters (PR and RR) for the assessment of pain in children. Munuksela EL et al had also used vital parameters for assessment of pain.6 We have observed the duration of analgesia by VAS pain relief score/LAPD to no relief i.e., patient complained of severe pain and by pain free score from the no pain ‘0’ score to severe pain score ‘3’. In case (group I) group, duration of analgesia by VAS/LAPD was 243.42±41.01 minutes and by pain score was 238.28±47.31 minutes. In the control group (group II), the duration of analgesia by VAS/LAPD was 40±14.95 minutes and by pain score was 39.14±15.47 minutes. In both the groups differences were statistically significant up to 4 hours (p<0.05) hence, bupivacaine has analgesic effect upto 4-5 hrs. The analgesia in control group was up to 40 minutes might be due to residual effect of anaesthetic agent used during anaesthesia. Stoelting had also observed the duration of action of bupivacaine up to 4 hrs. The duration of analgesia by all three methods was same. All the methods used to assess the pain were comparable (p>0.05). Hence, all the three methods used were found to be useful. Voepel-Lewis and colleagues have previously reported a reasonable correlation between pain scores given by cognitively impaired children and their parents when using a structured pain assessment tool, although some parents tended to overestimate their child's pain.7 Parents may benefit from being taught pain assessment tools if they are to be effective in assessing and managing their child's pain.8 This is especially useful in paediatric ambulatory surgery, where parents undertake a significant component of postoperative care at home. Parents should be provided with information that is easily understood. Whatever tools are used to assess pain, factors such as age, anxiety, language, ethnic background, the child's level of cognition, and level of parental education need to be taken into account by health care professionals before making an informed choice.9Thus, a combination of self-report and at least one other measure may be a better approach than using a single tool.
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