Assessing ‘desire for more pain treatment’ reveals much room for improvement after tonsillectomy and appendectomy in children

In this issue of the British Journal Anaesthesia, Stamer and colleagues1Stamer U. Bernhart K. Lehman T. et al.Desire for more analgesic treatment: pain patient-reported outcome after paediatric tonsillectomy appendectomy.Br J Anaesth. 2021; 126: 1182-1191Abstract Full Text PDF Scopus (6) Google Scholar highlight that not all centres routinely administer intraoperative multimodal analgesia open or laparoscopic appendectomy in children. They conclude they should. reached conclusion by asking if children (or their parent child was too young) desired during first 24 h surgery. Research how best to assess has given rise various intensity measurement tools a range developmental, cognitive, communication needs.2Berde C.B. Walco G.A. Krane E.J. al.Paediatric clinical trial designs, measures, extrapolation: report an FDA scientific workshop.Pediatrics. 2012; 129: 354-364Crossref PubMed (69) Scholar,3Walco Kopecky E.A. Weisman S.J. al.Clinical designs models medications acute neonates, infants, toddlers, children, adolescents: ACTTION recommendations.Pain. 2018; 159: 193-205Crossref (13) These are based on physiological parameters, observed behaviours, biomarkers (e.g. HR variability, cortical responses noxious stimuli) or, when possible, self-report, continue be psychometrically evaluated evolve. However, validated useful research purposes fail answer important question, is sufficient? settings, should complement multidimensional assessment function4Von Baeyer C.L. Self report: primary source infancy.in: McGrath P.J. Stevens B.J. Walker S.M. Zempsky W.T. Oxford textbook pain. University Press, Oxford, UK2013Crossref requires contextual interpretation clinician. Asking patient doubles as patient-focused, pain-related measure directly leads us we seeking rate simple question across multiple institutions allowed authors compare patient-focused 12 hospitals four countries with different practices. It showed better administered intraoperatively tonsillectomy. The robustness confirmed higher composite scores greater interference who analgesia. could anticipated other factors such tolerance, risk concern adverse effects, perception, beliefs, cultural meaning influence child's carer's desire Unpicking details optimal regimen follow. Of note, referred three non-opioid (paracetamol, NSAID, metamizole) highlighted metamizole available countries, some rectal analgesia, route variable absorption,5Anderson non-steroidal anti-inflammatory drugs acetaminophen.in: paracetamol may provide clinically relevant latter point interesting regular foundation regimens many centres.6Palmer G.M. Alcock M.M. Chapter 10, (volume 2).in: Schug S.A. Palmer Scott D.A. Halliwell R. Mott J. Acute management: evidence. 5th Edn. Australian New Zealand College Anaesthetists Faculty Pain Medicine, Melbourne2020: 922-1247Google Furthermore, use regional/local anaesthetic techniques part approach rarely reported, despite potential benefit reduce dosing systemic drugs,7Wiegele M. Marhofer P. Lonnqvist Caudal epidural blocks patients: review practical considerations.Br 2019; 122: 509-517Abstract (48) numerous studied setting both appendectomy.6Palmer Although frequently recommended,8Howard Carter B. Curry Good practice postoperative procedural management, 2nd edition.Pediatr Anesth. 22: 1-79Google attempts examine its effectiveness often inconclusive.6Palmer Conducting large RCTs expensive, time consuming, difficult power sufficiently coordinate. PAIN OUT infant registry, linking perioperative pharmacological data patient/carer-reported outcomes, enabled continuous multisite collection from can rapidly analysed periodically, even changes practice. By limiting number operative procedures two commonly performed surgeries postoperatively, elegantly demonstrated benefits Whilst registry cannot control confounding variables substitute RCTs, it increase visibility scrutiny variability daily practice, help guide which questions will most value invest resources required conduct RCT. Measuring added richness collected administration analgesics reduced worst group movement-evoked those undergoing appendectomy, being less likely have relief day. also found similar, debunking myth minimally invasive surgery painful immediate period. This surprising results previous adults postoperatively colonic similar.9Allvin Rawal N. Johanzon E. Backstrom Open versus surgery: does surgical technique outcome? Results international registry.Pain Res Treat. 2016; 2016: 4087325PubMed treatment assessed For having tonsillectomy, key would typically coincide day discharge, provides insight into quality early there need extend beyond post-discharge period where responsibility assessing administering transferred patient/carer, activity increases recovery progresses. particularly patients whom peaks second third day.10Stewart D.W. Ragg P.G. Sheppard S. Chalkiadis severity duration requirements orchidopexy inguinal hernia repair.Pediatr 136-143Crossref (145) Global satisfaction measures new concept, but recommendation include these trials than decade ago,11McGrath Finley al.Core domains pediatric chronic/recurrent trials: PedIMMPACT recommendations.J Pain. 2008; 9: 771-783Abstract (579) uptake been slow. Including dichotomous applauded. draws attention must strive do for, remain hidden literature estimates mean/median primarily reported. small: nearly one carers reported similar incidence adult patients.12Guntinas-Lichius O. Geissler Komann Schlattmann Meissner W. Inter-hospital tonsillectomy: prospective registry-based multicentre cohort study.PLoS One. 11e0154155Crossref (14) Questions arise regarding include: predict, either preoperatively intraoperatively, be, modifiable finding surgery, received doses opioids, powerful have, suggests improving care optimising intervention alone. biopsychosocial nature Factors incident pain, emotional social aspects experience occur alongside sensory component easily amenable analgesics. sleep disturbance increased probability treatment. link prompt consider promote setting, actively undermined. timing (morning, afternoon, evening), impact routine observations taken, environmental noise lighting examples sleep. considerations deeper understanding needs development tailored effective non-pharmacological interventions improve overall care. Examining served improvement exercise lead did Sharing knowledge inform outside participating hospitals. Ongoing analysis future field management. Drafted, revised, finalised manuscript: authors. declare no conflicts interest. ‘Desire treatment’: appendectomyBritish AnaesthesiaVol. 126Issue 6PreviewInsufficiently treated frequent. We aimed identify associated poor outcomes. Full-Text Archive