POSTOPERATIVE PAIN ASSESSMENT NEWBORNS
Category: Pediatric Surgery
Abstract : POSTOPERATIVE PAIN ASSESSMENT IN NEONATES One factor that has contributed
to inadequate pain management in neonates has been the pervasive belief that
neonates do not feel pain. This misconception has been perpetuated, at least in
part, by the conspicuous absence of adequate tools to assess pain levels in this
patient population. To a large extent, pain assessment in older patients reli
POSTOPERATIVE PAIN ASSESSMENT IN NEONATES
One factor that has contributed
to inadequate pain management in neonates has been the pervasive belief that
neonates do not feel pain. This misconception has been perpetuated, at least in
part, by the conspicuous absence of adequate tools to assess pain levels in this
patient population.
To a large extent, pain assessment in older patients relies
upon the patient's ability to report pain level in some form to the caregiver.
When patients cannot express pain verbally, pain assessment depends more on
evaluations by the caregiver. Even when pain is evident, quantifying the pain
level is not easy.
An effective pain assessment tool must be able to
objectively quantify the pain level of the patient so that the healthcare
provider can accurately measure the effectiveness of interventions designed to
alleviate unnecessary suffering. Although no perfect tool exists yet for
assessing pain in neonates, infants, and preverbal children, several very useful
tools are available.
The Children's Hospital of Eastern Ontario Pain
Scale (CHEOPS) was one of the first observational pain scales. This tool
includes the categories of (1) cry, (2) facial expression, (3) verbal response,
(4) torso position, (5) leg activity, and (6) arm movement in relationship to
the surgical wound. In general, each category is scored 0, 1, 2, or 3, with
higher scores indicating higher pain levels, but the scale varies with each
category evaluated. Originally, CHEOPS was used to evaluate postoperative pain
in children aged 1-7 years. Evaluators determined that it was both valid and
reliable for assessing pain in this patient group. Admittedly, a pain assessment
tool that is appropriate for other preverbal children may not be appropriate for
neonates. However, the development of CHEOPS has provided a tool against which
the validity of other pediatric pain assessment tools can be
measured.
The Objective Pain Scale (OPS), developed by Broadman and
Hannallah, has demonstrated both validity and reliability in pain assessment.
OPS assesses (1) blood pressure, (2) crying, (3) movement, (4) agitation, (5)
posture, and (6) verbalization. Each parameter is scored 0, 1, or 2, with higher
scores indicating greater distress. This instrument is important because it
includes a cardiovascular parameter in the assessment of postoperative pain.
Many advocate use of cardiovascular parameters as the most objective means of
measuring the pain response in preverbal children. However, the utility of
cardiovascular parameters is limited because other causes of distress may also
cause dramatic changes in these parameters.
Cardiovascular parameters,
while not sufficient as the sole means of assessing pain in this patient
population, may be helpful. Unfortunately, OPS, like CHEOPS, has been used
largely for infants and children, not neonates.
The COMFORT scale has
been favorably received as a tool to assess postoperative pain in the neonatal
population. This tool was originally developed to assess distress in ventilated
patients in the pediatric ICU. However, the COMFORT scale demonstrated
reliability and validity for assessing pain in postoperative patients in one
large study that evaluated pain in 158 neonates along with older infants and
children.
This scale is composed of 6 behavioral items, (1) alertness,
(2) calmness, (3) muscle tone, (4) movement, (5) facial tension, and (6)
respiratory response, and 2 physiologic items, (1) heart rate and (2) mean
arterial blood pressure. Each item may be scored 1, 2, 3, 4, or 5, with a higher
score indicating a greater level of distress. The greater number of variables
assessed and the increased number of scores possible for each variable may
enable this tool to identify more subtle changes in patient discomfort. On the
other hand, greater complexity may be a disadvantage in terms of the clinical
utility of this scale. A fourth scale, CRIES, may also be useful to assess the
pain of neonates postoperatively. This scale analyzes 5 variables, (1) crying,
(2) requirement of increased oxygen administration, (3) increased vital signs,
(4) expression, and (5) sleeplessness. Each variable is scored 0, 1, or 2. This
instrument has demonstrated validity, reliability, user friendliness, and
acceptance as a postoperative pain assessment tool among neonatal intensive care
nurses.
Each of the pain assessment instruments discussed has strengths
and limitations. For optimal use of any pain assessment tool, the physicians and
neonatal nursing staff of a given hospital should select a tool, familiarize
staff with its use, and systematically integrate its use into the institution's
policies. This maintains the validity and reliability of the tool in measuring
pain in neonates and allows appropriate intervention to be undertaken, thereby
minimizing unnecessary suffering in the postoperative neonatal patient.
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