A Prospective Audit of

Postoperative Pain Control

in Pediatric Patients
JACQUELINE D. TRUDEAU, MD, PHD; ELIZABETH LAMB, RGN/RSCN, BMEDSCI (HONS);
MARGOT GOWANS, MNUTDIET; GILLIAN LAUDER, MD

ain management in pediatric

populations is a rapidly
evolving area of study; however, studies examining pain control
outcomes in the immediate postoperative period are limited. Many
studies have compared anesthetic
technique or mode of analgesia in
specific patient or surgical populations,1 but there are no published
studies that describe the quality of
pain relief in pediatric patients in the
postoperative recovery area. There is
variability associated with pain
assessment among different practitioners and institutions, and these differences are compounded by comparisons of children of different ages and
developmental stages. Together with
important ethical considerations that
underlie the study of pediatric populations, this means that there are comparably few randomized controlled
trials that direct pain management in
children.2 Consequently, consensus
statements and expert opinion comprise a large proportion of practice
guidelines.1,3-5 Therefore, it is up to
each institution to establish an effective pain management strategy and
monitor its effectiveness.
To determine whether quality pain
control was achieved in patients admitted to the postanesthesia care unit
(PACU) at British Columbia Childrens
Hospital in Vancouver, Canada, we
conducted a quality improvement project during a seven-day period in July
2007. Additional aims of the quality
improvement project were to
determine whether pain was treated
in a timely and effective manner,
determine whether patients were
discharged from the PACU with
significant pain,
AORN, Inc, 2009

identify surgical procedures at high

risk for producing significant postoperative pain,
determine the frequency with which
regional analgesia was used and its
effect on postoperative pain, and
establish the frequency with which
patients were referred to the Acute
Pain Service (APS) at our institution.

BACKGROUND
Pain is defined as an unpleasant
sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such
damage.6(p210) Pain is a subjective,
unique experience that is influenced
by many factors that exist before a patient presents for care. Past experience,
family background, emotional status,

ABSTRACT
Pain is a subjective experience that is affected by
physical, emotional, and psychological factors, and
reliable assessment of pain can be a challenge in the
pediatric population.
A quality improvement project was conducted at one
Canadian health care facility to examine the effectiveness
of the postoperative pain management strategy for children admitted to the postanesthesia care unit (PACU).
Effective control of postoperative pain involves several
preventive strategies that include preoperative analgesia, appropriate use of intraoperative analgesic techniques, and identification of children at risk for
significant postoperative pain. Successful implementation of these techniques requires a multidisciplinary
team approach involving the patient, the PACU nurses,
the anesthesia care provider, and other surgical
team members.
Key words: pediatric surgery, pain control, quality
control, pain measurement. AORN J 90 (October 2009)
531-542. AORN, Inc, 2009.

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The usefulness of a pain scale for

directing optimal pain management
will be affected by many factors that
include ease of use, familiarity with
the scale, the experience of the RN or
physician using the scale, and the
population being assessed.

expectations, and physiological variables all

affect a patients perception of and experience
with pain. For children in particular, there
is a large emotional component to the pain
experience that is affected by factors such as
the presence or absence of caregivers and
fears related to unfamiliar surroundings
and procedures.7
PAIN ASSESSMENT. Optimal pain management
starts with pain assessment.2,7 The inability
to communicate verbally does not imply that
a person does not experience pain; rather,
it underscores the importance of accurate
and sensitive methods of pain assessment.
Neonates; children who are preverbal, developmentally delayed, critically ill, or unconscious;
and those with language barriers are examples
of patient populations that make assessment of
pain more challenging. Difficulty with pain
assessment places these populations at higher
risk for inadequately controlled pain.2,3,8
Regular assessment leads to improved pain
management and results in overall patient,
parent, and hospital staff member satisfaction
with pain assessment and management.9 A
verbal self-report of pain is considered the
gold standard for assessment and can be used
with some children.7,10 In pediatric populations, the selection of an appropriate assessment tool must take into consideration the
patients age, developmental stage, and the

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context of the pain experience. A childs ability to describe the quality and intensity of
pain, to differentiate level of severity, and to
distinguish between emotional and physical
factors contributing to his or her pain experience changes vastly with age and developmental stage.7,11
PAIN SCALES. Many pain scales have been developed for pediatric populations; these scales
use physical and/or behavioral signs as surrogate markers for pain.7,10,12,13 The sensitivity and
validity of a pain assessment scale depends on
the study population and the context within
which it is used (eg, type of noxious stimulus,
the presence of other comorbidities and illnesses that will influence measurement). For
the preverbal and developmentally delayed
populations, no single assessment scale has
been shown to be superior and none has been
universally adopted.7,10,12
The usefulness of a pain scale for directing
optimal pain management will be affected by
many factors that include ease of use, familiarity with the scale, the experience of the RN
or physician using the scale, and the population being assessed.12 For this reason, the routine use of one or two pain scales may be the
most important component of successful
implementation of a given scale in a pain
management strategy.
STANDARD OF CARE. In the postoperative period,
good pain control is expected by patients and
their family members and is required by the
Joint Commission.14 Recent standards for pain
management adopted by the Joint Commission
require that health care personnel
assess all patients for the presence of pain;
provide effective pain management;
educate patients and their family members
about pain and ongoing pain management,
particularly before discharge; and
incorporate pain management practices into
their institutions performance measurement and improvement programs.14
Good pain management is associated with
improved outcomes from surgery, quicker
clinical recovery, shorter hospital stays, fewer
readmissions, improved quality of life, and improved patient and parent satisfaction.9,14-17 The
American Society of Anesthesiologists (ASA)

Pain Control in Pediatric Patients

practice guidelines for the management of

perioperative pain endorse developmentally
appropriate pain assessment and therapy,3(p1577)
including behavioral techniques to address the
emotional aspects of pain. These guidelines do
not define what is representative of adequate
pain relief in terms of the commonly used pain
assessment tools, however. The recent practice
guidelines of the Association of Paediatric
Anaesthetists of Great Britain and Ireland
merely state that patients should not be discharged from the Postoperative Care Unit until
satisfactory pain control is established and ongoing analgesia is available.1(p86)

METHODS
The quality improvement project at
British Columbia Childrens Hospital was
approved by and conducted in accordance
with the guidelines of the University of
British Columbia Board of Ethics. A prospective audit of all patients admitted to the
PACU at British Columbia Childrens
Hospital during a seven-day period in July
2007 was undertaken. All children admitted
to the PACU were included in the study.
Children were admitted from both the surgical suites and the radiology department.
There were no exclusion criteria.
Data were collected from the anesthetic
record and the PACU nursing record. As this
investigation was an audit of the quality of
pain control, we collected only data that were
a part of the established practice in the routine monitoring and assessment of patients
admitted to the PACU.
Data were collected using a simple flow
sheet that included the following information:
date of birth;
weight;
ASA Physical Status Classification18;
pain score (as described in more detail in
the text);
medications given before the procedure (ie,
premedication);
procedure performed;
duration of anesthesia;
medications given during the procedure;
medications given during the PACU
admission;

OCTOBER 2009, VOL 90, NO 4

the latency to dispensing medication in the

PACU (ie, time between pain assessment
and medication administration);
the effectiveness of medication given in the
PACU as assessed by repeat pain score
measurements;
requirement for reassessment by an
anesthesiologist;
pain score on discharge from the PACU;
use of local or regional analgesia intraoperatively;
involvement of the APS postoperatively;
and
length of stay in the PACU.
A pain score at the time of admission to the
PACU or within five minutes of eye opening
was generated using the FLACC (ie, face, legs,
activity, cry, consolability) Scale19 or the Linear
Analogue Pain Scale (LAPS).20 The FLACC
Scale scores each variable on a 3-point scale
from zero to 2 for a total score of zero to 10
(Table 1). The FLACC Scale is appropriate for
use in preverbal patients who are younger
than three years and in older nonverbal patients.19 It is valid for patients one to 18 years
of age for assessing procedural and postoperative pain. The LAPS is a verbal selfreport of pain and is valid for postoperative
pain in children eight years of age and older;
the child rates his or her pain on a scale of 1 to
10.10 The decision to use either the FLACC
Scale or LAPS was made by the RN caring for
the patient.
After admission to the PACU, patients were
reassessed and subsequent pain scores were
assigned
if the childs condition changed,
for monitoring ongoing pain,
before and after the administration of
analgesia, and
before discharge.
For the purpose of this investigation, a pain
score of 4 out of 10 was taken as a measure
of adequate pain control as defined by Leykin
and Pellis.21

STATISTICAL ANALYSIS
Data analysis was performed and descriptive statistics were generated using SPSS.22
Statistical associations between continuous
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TABLE 1

FLACC Nonverbal Pain Scale*

Category

Score: 0

Score: 1

Score: 2

Face (F)

No particular
expression, or smile

Occasional grimace or
frown, withdrawn,
disinterested

Frequent to constant
quivering chin, clenched
jaw

Legs (L)

Normal position,
or relaxed

Uneasy, restless, tense

Kicking or legs drawn up

Activity (A)

Lying quietly, normal Squirming, shifting

position, moves easily back and forth, tense

Arched, rigid, or jerking

Cry (C)

No crying (awake or
asleep)

Moans or whimpers,
occasional complaint

Crying steadily, screams

or sobs, frequent complaints

Consolability (C)

Content, relaxed

Reassured by occasional
Difficult to console or
touching, hugging, or
comfort
being talked to, distractible

Each of the 5 categories is assigned a score from 0 to 2, resulting in a total score of 0 to 10.
*Adapted from Merkel SI, Voepel-Lewis, T, Shayevis JR, Malviya S. The FLACC: a behavioral scale for scoring
postoperative pain in young children. Pediatr Nurs. 1997;23(3):293-297. Copyright Janetti Co, University of
Michigan Medical Center. Reprinted with permission.

and categorical variables were identified using

the independent t test and paired t test. Results
were deemed to be significant if P < .05.

RESULTS
Of the 173 patients admitted to the PACU
during the seven-day investigation period, 171
(99%) were included in our quality improvement project. The two patients who were not
included were omitted because of an inability
to access their data. The age and ASA classifications18 of the study population are shown in
Figures 1 and 2. Of the 171 patients, 27 (15.8%)
were admitted to the PACU from the radiology
department after imaging procedures with
procedural sedation. Because these were noninvasive and nonpainful procedures, these
patients generally were not assessed for pain
in the PACU and were therefore excluded from
the analysis of pain scores.

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PAIN CONTROL. On admission to the PACU or

within five minutes of eye opening, 101 patients (70.1%) had a pain score of zero out of 10
and 120 (83.3%) had pain scores of 4 out of
10 (Figure 3). For patients with pain scores of
> 4 (n = 24), the average time to administration
of analgesic medication was 6.7 minutes (median, five minutes; range, zero to 25 minutes)
and the average time to achieve a pain score of
4 was 38 minutes (n = 21; range, five to
75 minutes). In the PACU, analgesic medication was administered by a PACU nurse to a
total of 56 children (39%), 33 of whom had
pain scores of 4. In the population of children with pain scores of 4 who received
postoperative analgesia, the majority received
acetaminophen (64%), and most received acetaminophen plus codeine (61%). At the time of
discharge from the PACU, four patients had
pain scores of > 4 (2.8%).

Pain Control in Pediatric Patients

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25

Frequency

20

15

10

0
1

10

11 12

13 14 15

16 17 18 19

20

Year of life

Figure 1 Age of subjects (N = 171).

ASA class
Emergency

40

Percentage of patients

Analgesic medication
was given to 93 patients
(64.6%) before their surgical
procedures. Of these,
84 (90.3%) received preoperative acetaminophen,
48 (51.6%) received preoperative codeine, and nine
(9.7%) received preoperative
gabapentin. Intraoperative
administration of local
anesthetic to the surgical site
was performed in 83.1% of
appropriate cases (n = 74).
Appropriate cases were considered any surgery or procedure where it was possible
and appropriate to administer local (ie, infiltrated or
topical) anesthetic. The use
of preoperative medication
and intraoperative use of
local anesthetic based on
type of surgery is presented
in Table 2.

30

20

10

0
I

II

III

IV

ASA classification

Figure 2 American Society of Anesthesiologists (ASA) Physical Status

Classification of participants. Class I = healthy patient; class II = patient
with mild systemic disease; class III = patient with severe systemic disease;
class IV = patient with severe systemic disease that is a constant threat to life;
class V = a moribund patient who is not expected to survive without surgery.

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Trudeau Lamb Gowans Lauder

Percentage of patients

epidural, two caudal blocks,

five regional nerve blocks). Of
80
these eight instances, 75% of
patients had pain scores of
70
zero on admission to the
PACU. The two remaining
60
children had pain scores of 5
50
(epidural) and 8 (regional
nerve block).
40
APS. Three children were
referred to the APS of a possi30
ble 19 who were deemed potentially appropriate for refer20
ral based on review of the
caseload. Eight of these pa10
tients were transferred to the
postsurgical ward with a mor0
0 1 2 3 4 5 6 7 8 9 10
phine infusion that was ordered and supervised by the
Pain score
surgical service rather than
the APS.
Figure 3 Pain scores on admission to the postanesthesia care unit or within
DURATION OF PACU STAY. The
5 minutes of eye opening for surgical patients (n = 144).
mean duration of PACU stay
for surgical patients was
There was a significant association be49 minutes (range, 12 to 144 minutes). Approtween postoperative pain and surgical propriate length of stay in the PACU was detercedure. Of the 24 children with initial pain
mined based on patient age and surgical
scores of > 4, the majority (n = 15, 62.5%)
procedure. Twenty-two patients (15.3%) had a
had undergone orthopedic or otorhinolarynprolonged PACU admission. This was because
gology (ORL) procedures (Figure 4). Of the
of pain (46%); sedation (23%); agitation (14%);
children admitted after an ORL procedure
respiratory distress (9%); hospital administra(n = 24), eight (33.3%) had pain scores of > 4,
tion issues (ie, bed or staff availability) (12%);
and half of those children (n = 4) underwent
and cause not identified (14%).
tonsillectomy with or without adenoidectomy
(ie, a total of eight tonsillectomies were perDISCUSSION
formed during the investigation period). Of
This quality improvement project demonthe children admitted after an orthopedic
strated that in our institution postoperative
procedure (n = 16), seven (44%) had pain
pain is well managed in pediatric patients, as
scores of > 4.
evidenced by low pain scores on PACU admisThere were two instances in which the pasion and discharge. At the time of admission to
tient was seen by an anesthesiologist in the
the PACU, 70.1% of patients (n = 101) had pain
PACU. One case was because of respiratory
scores of zero and 83.3% (n = 120) were below
distress and the second because of agitation.
the defined acceptable criterion of 4.
REGIONAL ANALGESIA. On review of the surgical
Several evidence-based pain management
procedures completed during the investigation strategies were used that minimized postperiod, we noted that a regional anesthetic
surgical pain and were presumed to be
technique (eg, epidural, caudal anesthesia,
responsible for the low pain scores on patients
penile block) was considered an option in 39
admission to the PACU. Preventive analgesia
of 144 procedures. Regional techniques were
encompasses analgesic medication that is
used in eight of these procedures (ie, one
given before, during, or after surgery that

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Pain Control in Pediatric Patients

OCTOBER 2009, VOL 90, NO 4

TABLE 2

Preoperative Medication and Local Anesthetic*

Use Based on Surgical Service

Surgical service

Percentage of patients
receiving preoperative
analgesia

Percentage of patients
receiving intraoperative
local anesthetic

Otorhinolaryngology

91.7

90.0

General surgery

48.0

95.7

Gastroenterology

5.9

Not applicable

Interventional cardiology

0.0

100.0

Neurosurgery

50.0

100.0

Ophthalmology

69.6

33.3

Orthopedics

87.5

69.2

Plastic surgery

94.7

100.0

Urology

61.5

85.7

Total (services combined)

64.6

83.1

* infiltrated or topical

Figure 4 Pain scores on admission to the postanesthesia care unit or within 5 minutes of eye opening based on surgical
service (n = 142). The mean for each group is indicated by the horizontal dashes. Patients undergoing urological (n = 13),
interventional cardiology (n = 3), neurosurgical (n = 2), or other procedures (n = 2) were excluded from analysis involving pain based on surgical service because of insufficient power. Pain scores of patients undergoing orthopedic or otorhinolaryngology surgical procedures were significantly greater than pain scores of patients undergoing ophthalmologic, plastic,
or gastrointestinal procedures (P = .001 to .018).

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diminishes the degree of postoperative pain

and/or decreases the amount of analgesia
required to treat postoperative pain.23 At
our institution, preoperative medication is
given 30 minutes before the child arrives
in the OR. In this investigation, 64.6% of
patients (n = 93) received premedication.
Although there was no statistical significance
between the use of premedication and the
degree of postoperative pain, premedication
tended to be used with a greater frequency
for procedures that were anticipated to have
a greater degree of postoperative pain, such
as ORL or orthopedic procedures. The appropriate use of intraoperative analgesia, which
includes the use of infiltrated or topical local
anesthetic, also contributes significantly to
the reduction of postoperative pain. The

It can be difficult to distinguish

pain behavior from other behaviors,
especially in preverbal and
nonverbal children.

application of local anesthetic to the surgical

site has been shown to decrease postoperative
pain for certain procedures such as tonsillectomy24 and herniotomy.25 During our investigation, local anesthetic was used in 83.1% of appropriate procedures (ie, 74 out of 89). An
improvement could be made in the use of local
anesthetic in orthopedic procedures (ie, only
used in 69.2% of appropriate cases during our
investigation), where there is a higher proportion of postoperative pain scores of > 4, and in
the use of topical local anesthetic in ophthalmologic procedures (ie, only used in 33.3% of
appropriate cases during our investigation).
We believe a large part of our overall success in perioperative pain management is

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because of the management of pain while

patients are in the PACU. The PACU nurses
routinely administer preventive analgesia to
patients with pain scores of < 4. The PACU
nurses use their experience to anticipate pain
based on a childs behavior, the surgical procedure, and the timing of the analgesia administered before and during surgery. The nature of
the role of the PACU nurse is complex. It can
be difficult to distinguish pain behavior from
other behaviors, especially in preverbal and
nonverbal children. These behaviors may be a
result of anxiety, dizziness, lack of parental
presence, unfamiliar surroundings, emergence
delirium, or thirst and hunger. Attempts are
made by nurses to understand the nature of
the childs distress by use of appropriate language, family involvement, comfort measures,
and analgesia or anxiolytics. The experienced
PACU nurse will use a combination of these
comfort factors in an attempt to understand
and relieve the childs distress, which may or
may not be pain related, while applying his or
her knowledge and experiences of anesthetic
agents and type of surgery.
In those children admitted to the PACU
with pain scores of > 4, analgesic medication
was administered promptly (mean, 6.7 minutes) and 88% of the time (n = 21) was effective in reducing pain scores to 4. In four instances, children were discharged from the
PACU with pain scores of > 4. One case involved a 13-year-old boy who described his
pain as a 6 but expressed that he would only
require analgesic medication at a pain intensity of 7. This example highlights the benefit of
a patient-directed goal-based approach to pain
management, where analgesia is administered
depending on the patients expressed threshold pain level. An arbitrarily designated pain
score (eg, 4 out of 10) that defines wellmanaged pain may overestimate or underestimate the actual success of pain management
in any given investigation. In pediatric and
other nonverbal populations, one has to accept
an arbitrary definition of well-managed pain,
but this remains a limitation in the interpretation of the data.
Our data draw attention to those surgical
procedures with a higher incidence of post-

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operative pain, namely ORL and orthopedic

procedures. Of the 24 ORL procedures, eight
children were admitted to the PACU with pain
scores of > 4, and half of those children had
undergone tonsillectomy and adenoidectomy.
This procedure is well known to cause significant postoperative pain.26 There was no single
surgical procedure that could account for the
higher incidence of postoperative pain among
children undergoing orthopedic procedures.
The application of regional techniques of
anesthesia (eg, epidural, caudal, regional nerve
blocks) has been shown to improve postoperative pain outcomes.27 In our investigation,
regional techniques were only used in 20.5%
(n = 8) of appropriate procedures (N = 39).
The regular use of an anesthesiologist-,
nurse-, or pediatrician-directed APS has been
shown to improve pain outcomes, improve patient and parent satisfaction with pain assessment and management, reduce pain-associated
complications, and reduce length of stay.28,29
Despite this, at our institution, the anesthesiologist- and nurse practitioner-run pain service
was underused. We retrospectively reviewed
all of the cases and based on the recommendations and standards for our APS looked at all
of the patients who would be expected to
come to the APS (ie, based on complexity of
the procedure, expected postoperative pain,
difficulty controlling the pain). Only 15.8%
(n = 3) of procedures that were appropriate for
APS referral (N = 19) subsequently were managed by the APS. A significant number of patients who were appropriate for APS referral
were admitted to the postsurgical ward with
morphine infusions that were supervised by
the surgical service. This suggests that underuse of the APS is not from an inability to identify patients who require management of
postoperative pain; however, this finding highlights a gap in the pain management strategy
at our facility. Improvement of communication
between APS staff members and the surgical
team might improve use of the APS and has
the potential to improve pain outcomes for
these patients.
Routine standardized pain assessment is
critical in implementing an effective pain
management plan. Many studies have shown

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that applying a standardized approach to

pain assessment (ie, timing, selection of pain
scale, consistent examiner) improves pain
outcomes.7,30,31 A standardized approach to
pain management not only ensures that pain
is assessed routinely, but it also results in
practitioners becoming more experienced
with pain assessment and treatment outcomes in a given population. This becomes
particularly important in pediatric patients,
who are at high risk for undertreatment
of pain.

LIMITATIONS
There are several limitations to this investigation. Given that the data were collected over
seven days in July 2007, the sample size was
limited, and there were sampling limitations in
the type of surgical procedures, of surgeons
within a given specialty, and of anesthesiologists. The practice of this limited number of
surgeons and anesthesiologists may have affected the results. Despite our efforts to not interfere with the normal practice of the nurses
and anesthesiologists in the PACU, they eventually knew that the investigation was taking
place as the week progressed. In addition to
this practice bias, there was the influence of
not having an unbiased observer assessing for
pain scores. This is a limitation inherent to
audit studies in that they are meant to assess
for current practice, and the PACU nurse
assessing for pain is an integral part of that
practice. Lastly, the use of a pain score of 4 as
a measure of adequate pain control is arbitrary
and may overestimate or underestimate the
degree of clinically significant pain outcomes,
particularly in preverbal and nonverbal
populations.

CLINICAL IMPLICATIONS
Effective implementation of a pain management program is multifaceted and requires commitment from the entire health
care team, including physicians, nurses, and
administrators. The heterogeneity of pain assessment and treatment makes this goal difficult because no one protocol will suffice for
all patients. Studies have shown that a health
care professionals assessment of a childs

Pain Control in Pediatric Patients

pain is affected by many individual, social,

and contextual factors32,33 and is consistently
an underestimate when compared with the
childs self-report.32,34,35 Nurses with a focus in
perioperative care have shown that specialized training and familiarization with pain
assessment and management largely reverses
this underestimate of pain and results in a
more accurate reflection of the childs experience.36 Fundamental components of a successful pain management program include
multidisciplinary collaboration;
staff member education about pain pathophysiology, assessment, and management;
staff member participation in the development of a setting-specific protocol;
simple-to-use, standardized, routine pain
assessment for all patients;
formal documentation of pain assessment in
medical records;
mutual goal setting for pain control among
the health care provider, child, and family
members; and
monitoring of adherence and effect of pain
assessment on pain management.7
Quality improvement interventions using these
principles have been shown to result in improved
pain assessment and management and enhanced
patient and staff member satisfaction with
pain assessment and management.9
The results of the quality improvement
project at British Columbia Childrens
Hospital will be used to stimulate reexamination of perioperative pain management for
patients undergoing procedures at high risk
of causing postoperative pain, with a focus
on orthopedic and ORL procedures. We will
generate new practice guidelines through
consultation with the surgical team, the anesthesia care providers, and the PACU nursing
team. Strategies to reduce postoperative pain
will include improved use of intraoperative
local anesthetic and regional anesthetic techniques, optimization of premedication and
preventive analgesia in the intraoperative
and postoperative periods, and optimized
use of the APS for patients who require ongoing pain management postoperatively. A
reaudit is planned after these guidelines have
been implemented.

OCTOBER 2009, VOL 90, NO 4

Application of these principles can be used

for any population of patients at risk for pain.
Guidelines for pain assessment and management
can be accessed through the Internet,1,4,5 and
audit tools for assessing the adequacy of pain
management can similarly be accessed.4 It is up
to each individual clinical unit or institution to
generate a pain management strategy that
optimally serves its specific patient population,
and since the year 2000, this has been a

mandatory component of patient care.14

Editors note: Funding for this quality improvement project was granted through the British
Columbia Childrens Hospital Foundation
Fellowship Funding Program.

REFERENCES
1. Good Practice in Postoperative and Procedural Pain.
Association of Paediatric Anaesthetists. http://www.
apagbi.org.uk/docs/APA_Guidelines_on_Pain_
Management.pdf. Accessed June 16, 2009.
2. Howard RF. Current status of pain management
in children. JAMA. 2003;290(18):2464-2469.
3. American Society of Anesthesiologists Task Force
on Acute Pain Management. Practice guidelines for
acute pain management in the perioperative setting:
an updated report by the American Society of
Anesthesiologists Task Force on Acute Pain
Management. Anesthesiology. 2004;100(6):1573-1581.
4. Pain in children. Royal College of Nursing Institute. http://www.rcn.org.uk/development/practice/
clinicalguidelines/pain. Accessed May 15, 2009.
5. Acute Pain Management: Scientific Evidence.
National Health and Medical Research Council of
Australia. http://www.nhmrc.gov.au/publications/
synopses/cp104syn.htm. Accessed May 15, 2009.
6. International Association for the Study of Pain
Task Force on Taxonomy. IASP pain terminology. In:
Merskey H, Bogduk N, eds. Classification of Chronic
Pain. 2nd ed. Seattle, WA: IASP Press; 1994:209-214.
7. Franck LS, Greenberg CS, Stevens B. Pain assessment in infants and children. Pediatr Clin North Am.
2000;47(3):487-512.
8. Stallard P, Williams L, Lenton S, Velleman R.
Pain in cognitively impaired, non-communicating
children. Arch Dis Child. 2001;85(6):460-462.
9. Treadwell MJ, Franck LS, Vichinsky E. Using quality improvement strategies to enhance pediatric pain
assessment. Int J Qual Health Care. 2002;14(1): 39-47.
10. Stinson JN, Kavanagh T, Yamada J, Gill N,
Stevens B. Systematic review of the psychometric
properties, interpretability and feasibility of selfreport pain intensity measures for use in clinical
trials in children and adolescents. Pain. 2006;
125(1-2):143-157.
aornjournal.org

541

OCTOBER 2009, VOL 90, NO 4

11. Stanford EA, Chambers CT, Craig KD. The role

of developmental factors in predicting young
childrens use of a self-report scale for pain. Pain.
2006;120(1-2):16-23.
12. von Baeyer CL, Spagrud LJ. Systematic review
of observational (behavioral) measures of pain for
children and adolescents aged 3 to 18 years. Pain.
2007;127(1-2):140-150.
13. Wong DL, Baker CM. Pain in children: comparison
of assessment scales. Pediatr Nurs. 1988; 14(1):9-17.
14. Phillips DM. JCAHO pain management
standards are unveiled. Joint Commission on
Accreditation of Healthcare Organizations. JAMA.
2000;284(4):428-429.
15. Ballantyne JC, Carr DB, deFerranti S, et al.
The comparative effects of postoperative analgesic
therapies on pulmonary outcome: cumulative metaanalyses of randomized, controlled trials. Anesth
Analg. 1998;86(3):598-612.
16. Rodgers A, Walker N, Schug S, et al. Reduction
of postoperative mortality and morbidity with
epidural or spinal anaesthesia: results from overview
of randomised trials. BMJ. 2000;321(7275): 1493.
17. Kehlet H, Holte K. Effect of postoperative
analgesia on surgical outcome. Br J Anaesth.
2001;87(1):62-72.
18. ASA Physical Status Classification System. American Society of Anesthesiologists. http://www
.asahq.org/clinical/physicalstatus.htm. Accessed
May 15, 2009.
19. Merkel SI, Voepel-Lewis T, Shayevis JR, Malviya
S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs.
1997;23(3):293-297.
20. Champion GD, Goodenough B, von Baeyer CL,
Thomas W. Measurement of pain by self-report. In:
Finley GA, McGrath PJ, eds. Measurement of Pain in
Infants and Children. Seattle, WA: IASP Press; 1998:
123-155.
21. Leykin Y, Pellis T. A model of postanesthesia
care unit-based acute pain service. Anesth Analg.
2006;103(1):263-264.
22. SPSS [software]. Version 16.0. Chicago, IL: SPSS,
Inc; 2007.
23. Pogatzki-Zahn EM, Zahn PK. From preemptive
to preventive analgesia. Curr Opin Anaesthesiol.
2006;19(5):551-555.
24. Grainger J, Saravanappa N. Local anaesthetic for
post-tonsillectomy pain: a systematic review and
meta-analysis. Clin Otolaryngol. 2008;33(5): 411-419.
25. Miniche S, Mikkelsen S, Wetterslev J, Dahl JB. A
qualitative systematic review of incisional local
anaesthesia for postoperative pain relief after abdominal operations. Br J Anaesth. 1998;81(3): 377-383.
26. Warnock FF, Lander J. Pain progression,
intensity and outcomes following tonsillectomy.
Pain. 1998;75(1):37-45.
27. Rathmell JP, Wu CL, Sinatra RS, et al. Acute
post-surgical pain management: a critical appraisal
of current practice, December 2-4, 2005. Reg Anesth

542

AORN JOURNAL

Trudeau Lamb Gowans Lauder

Pain Med. 2006;31(4 Suppl 1):1-42.

28. Wheatley RG, Madej TH, Jackson IJ, Hunter D.
The first years experience of an acute pain service.
Br J Anaesth. 1991;67(3):353-359.
29. Mackrodt K. The role of an acute pain service.
An overview. Br J Perioper Nurs. 2001;11(11):492-497.
30. Gould TH, Crosby DL, Harmer M, et al. Policy
for controlling pain after surgery: effect of sequential changes in management. BMJ. 1992;305(6863):
1187-1193.
31. Moore A, Edwards J, Barden J, McQuay H.
Bandoliers Little Book of Pain. Oxford, United
Kingdom: Oxford University Press; 2003:14-18.
32. Marqui L, Raufaste E, Lauque D, Marin C,
Ecoiffier M, Sorum P. Pain rating by patients
and physicians: evidence of systematic pain miscalibration. Pain. 2003;102(3):289-296.
33. Craig KD, Lilley CM, Gilbert CA. Social barriers
to optimal pain management in infants and children.
Clin J Pain. 1996;12(3):232-242.
34. Rmsing J, Mller-Sonnergaard J, Hertel S,
Rasmussen M. Postoperative pain in children:
comparison between ratings of children and nurses.
J Pain Symptom Manage. 1996;11(1):42-46.
35. LaMontagne LL, Johnson BD, Hepworth JT.
Childrens ratings of postoperative pain compared
to ratings by nurses and physicians. Issues Compr
Pediatr Nurs. 1991;14(4):241-247.
36. Lebovits AH, Florence I, Bathina R, Hunko V,
Fox MT, Bramble CY. Pain knowledge and attitudes
of healthcare providers: practice characteristic
differences. Clin J Pain. 1997;13(3):237-243.

Jacqueline D. Trudeau, MD, PhD, is a

resident at the Department of Anesthesia,
Faculty of Medicine, University of British
Columbia, Vancouver, Canada.
Elizabeth Lamb, RGN/RSCN, BMedSci
(Hons), is a clinical nurse coordinator, PostAnesthetic Care Unit, British Columbia
Childrens Hospital, Vancouver, Canada.
Margot Gowans, MNutDiet, is a
researcher at the Department of Family
Practice, Faculty of Medicine, University
of British Columbia, Vancouver, Canada.
Gillian Lauder, MD, is a pediatric anesthesiologist and director of the Integrated
Pain Service, British Columbia Childrens
Hospital, University of British Columbia,
Vancouver, Canada.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.