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Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy.

ABSTRACT: Race and ethnicity are associated with disparities in pain management in children. While low English language proficiency is correlated with minority race/ethnicity in the United States, it is less frequently explored in the study of health disparities. We therefore investigated whether English language proficiency influenced pain management in the post-anesthesia care unit (PACU) in a cohort of children who underwent laparoscopic appendectomy at our pediatric hospital in San Francisco. Our primary exposure was English language proficiency, and our primary outcome was administration of any opioid medication in the PACU. Secondary outcomes included the amount of opioid administered in the PACU and whether any pain score was recorded during the patient's recovery period. Statistical analysis included adjusting for demographic covariates including race in estimating the effect of language proficiency on these outcomes. In our cohort of 257 pediatric patients, 57 (22.2%) had low English proficiency (LEP). While LEP and English proficient (EP) patients received the same amount of opioid medication intraoperatively, in multivariable analysis, LEP patients had more than double the odds of receiving any opioid in the PACU (OR 2.45, 95% CI 1.22-4.92). LEP patients received more oral morphine equivalents (OME) than EP patients (1.64 OME/kg, CI 0.67-3.84), and they also had almost double the odds of having no pain score recorded during their PACU recovery period (OR 1.93, CI 0.79-4.73), although the precision of these estimates was limited by small sample size. Subgroup analysis showed that children over the age of 5 years, who were presumably more verbal and would therefore undergo verbal pain assessments, had over triple the odds of having no recorded pain score (OR 3.23, CI 1.48-7.06). In summary, English language proficiency may affect the management of children's pain in the perioperative setting. The etiology of this language-related disparity is likely multifactorial and should be investigated further.

SUBMITTER: Dixit AA

PROVIDER: S-EPMC7600632 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy.

Dixit Anjali A AA Elser Holly H Chen Catherine L CL Ferschl Marla M Manuel Solmaz P SP

Children (Basel, Switzerland) 20201004 10

Race and ethnicity are associated with disparities in pain management in children. While low English language proficiency is correlated with minority race/ethnicity in the United States, it is less frequently explored in the study of health disparities. We therefore investigated whether English language proficiency influenced pain management in the post-anesthesia care unit (PACU) in a cohort of children who underwent laparoscopic appendectomy at our pediatric hospital in San Francisco. Our prim ...[more]

PMID: 33020409

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Project description:Laparoscopic appendectomy (LA) is one of the most commonly performed surgical procedures in children and is associated with extreme postoperative discomfort due to peritoneal inflammation and infection. The main objective of this study was to investigate the effects of postoperative pain (POP) in children after laparoscopic appendectomy. Articles describing or evaluating the control of POP in children with LA were considered eligible. All available literature such as randomized controls, prospective controls, retrospective as well as clinical studies were considered. A comprehensive search was performed in PubMed, Medline, Embase, Cochrane Library, Clinical trials.gov, and Google scholar. The initial search took place on 23 April 2021, and was updated on 24 August 2021. There were no language or date restrictions. Each of the included articles was evaluated separately by two independent reviewers. Additional papers were found by searching the reference lists of eligible studies. Eighteen papers were considered. All papers, and many of them used different methods to treat POP in children undergoing LA, such as lidocaine infusion, different analgesic approaches, ultrasound-guided transverse abdominis blockade (UGTAP), ultrasound-guided quadratus lumborum blockade (UGQLB), and comparison of open appendectomy (OA) with local anesthetics in relation to POP management in children. Laparoscopic appendectomy is the surgical procedure preferred by clinicians compared with open appendectomy in children. A multimodal analgesic approach is optimal and efficient surgical techniques such as UGBRSB, UGQLB, and UGTAP block might significantly impact POP in children except that there are contraindications. Dexmedetomidine proved to be an effective adjuvant that can enhance the effect of local anesthetics. The lack of a sufficient number of studies may be a factor affecting our confidence in the results of this study. Therefore, further evidence-based randomized control trials with a large sample size are needed to provide clarity.

Project description:Intravenous lidocaine, a potent local anesthetic with analgesic and anti-inflammatory properties, has been shown to be an effective adjunct that reduces intra- and postoperative opioid consumption and facilitates pain management in adults. While it shows promise for use in the pediatric population, limited evidence is available.ObjectivesTo determine if general anesthesia with intraoperative intravenous lidocaine infusion versus general anesthesia without intravenous lidocaine infusion in children undergoing laparoscopic appendectomy decreased opioid requirements intra- and postoperatively.DesignA single-center parallel single-masked randomized controlled study. A computer-generated blocked randomization list was used to allocate participants. The study was conducted between March 2019 and January 2020.SettingPediatric teaching hospital in Poland.ParticipantsSeventy-four patients aged between 18 months and 18 years undergoing laparoscopic appendectomy. Seventy-one patients fulfilled the study requirements.InterventionIntravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. The infusion was discontinued before the patients' transfer to the postanesthesia care unit (PACU).Primary outcome measureThe primary outcome measure was total nalbuphine requirement in milligrams during the first 24 h after surgery.Secondary outcome measuresThe secondary outcome measures were intraoperative fentanyl consumption, intraoperative sevoflurane consumption, time to the first rescue analgesic request, incidence of postoperative nausea and vomiting during the first 24 h after surgery, frequency of side effects of lidocaine.ResultsChildren (n = 74) aged 5-17 randomly allocated to receive intraoperative lidocaine infusion (n = 37) or no intervention (n = 37). Seventy-one were included in the analysis (35 in the study group and 36 in the control group). There was no difference in the cumulative dose of nalbuphine in the first 24 h after removal of the endotracheal tube between groups [median of 0.1061 (IQR: 0.0962-0.2222) mg/kg in the lidocaine group, compared to the control group median of 0.1325 (IQR: 0.0899-0.22020) mg/kg, p = 0.63]. Intraoperative fentanyl consumption was lower in the lidocaine group [median of 5.091 (IQR: 4.848-5.714) μg/kg] than in the control group [median of 5.969 (IQR: 5.000-6.748), p = 0.03]. Taking into account the additional doses administered based on clinical indications, the reduction in the requirement for fentanyl in the lidocaine group was even greater [median of 0.0 (IQR: 0.0-0.952) vs 0.99 (IQR: 0.0-1.809) μg/kg, p = 0.01]. No difference was observed in the sevoflurane consumption between the two groups [median of 32.5 ml (IQR 25.0-43.0) in the lidocaine group vs median of 35.0 ml (IQR: 23.5-46.0) in the control group, p = 0.56]. The time to first analgesic request in the lidocaine group was prolonged [median of 55 (IQR: 40-110) min in the lidocaine group vs median of 40.5 (IQR: 28-65) min in the control group, p = 0.05]. There was no difference in the frequency of PONV between the two groups (48.57% in the lidocaine group vs 61.11% in the control group, p = 0.29). No lidocaine related incidence of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment was reported, during anesthesia or postoperative period.ConclusionsIntraoperative systemic lidocaine administration reduced the intraoperative requirement for opioids in children undergoing laparoscopic appendectomy. This effect was time limited, and hence did not affect opioid consumption in the first 24 h following discontinuation of lidocaine infusion.Trial registrationNCT03886896 .

Project description:Sleep disorder dramatically affects people's physical and mental health. Here, we investigated the effect of preoperative sleep disorders on anesthesia recovery and postoperative pain in patients undergoing laparoscopic gynecological surgery under general anesthesia. 120 patients who underwent elective laparoscopic gynecological surgery under general anesthesia in Taizhou Central Hospital from November 2021 to March 2022 were included. According to the score of the Pittsburgh sleep quality index (PSQI), the participating patients were divided into four groups: control group (control group), mild sleep disorder group A (group A), moderate sleep disorder group B (group B), and severe sleep disorder group C (group C), with 30 patients in each group. The changes of mean arterial pressure (MAP) and heart rate (HR) at different time points, operation time, anesthesia time, extubation time, the time when Aldrete score reached 10 points, visual analog score (VAS) serum interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor-α (TNF-α) were compared among different groups. Our study demonstrated that there were no significant differences in MAP and HR among the four groups at the same time points (all P > 0.05). Significant differences in the time of extubation and Aldrete score reaching 10 points had been found among the four groups (all P < 0.001), indicating more sleep disorder induced longer extubation and recovery time. There were significant differences in VAS scores among the four groups at both different and the same time points (all P < 0.001), suggesting more sleep disorders induced more pain in the sufferers. Serum IL-6 levels were significantly higher in the three sleep disorder groups than the control group at 6 h and 24 h after the operation (all P < 0.05), while group C has the highest IL-6 levels as compared to the other group (P = 0.09 and P < 0.001, respectively). At 6 h after operation, serum levels of TNF-α in group C were significantly higher than in the control group (P = 0.044), but no significant differences were found in the other two groups (all P > 0.05). Positive correlation with preoperative PSQI score has been found with the times of extubation, the time of Aldrete score reaching 10 points, the VAS at 1 h, 6 h, and 24 h after operation, the level of serum IL-6 at 1 day before operation and 6 h and 24 h after operation, and the TNF-α at 6 h and 24 h after operation (all P < 0.001). The present study showed that the degree of preoperative sleep disorders could affect the quality of postoperative awakening and pain of patients undergoing laparoscopic gynecological surgery under general anesthesia, which might be associated with the aggravation of inflammatory reactions in the body.

Project description:A few modes of perioperative local analgesia have been studied in order to reduce postoperative pain after laparoscopy, including preemptive local anesthetics in the trocar sites and intraperitoneal anesthetics administration at the end of the surgery. However, the evidence regarding their efficacy are conflicting. In addition, the combination of both aforementioned methods has been rarely studied. Our aim was to evaluate whether subcutaneous trocar site and/or intraperitoneal analgesia reduce pain after gynecologic operative laparoscopy. This was a single-centered, randomized, controlled, double-blinded trial. The patients were randomly assigned to one of four equally sized groups: group 1-subcutaneous and intraperitoneal analgesia; group 2-subcutaneous analgesia and intraperitoneal placebo; group 3-subcutaneous placebo and intraperitoneal analgesia; Group 4-subcutaneous and intraperitoneal placebo. The patients, the surgeons, and the pain evaluators were all blinded to the patient's allocation. Included were patients who underwent elective operative laparoscopy. Exclusion criteria were: active infection, pregnancy, known sensitivity to Bupivacaine-Hydrochloride, chronic pelvic pain, surgeries with additional vaginal procedures, conversion to laparotomy, and malignancy. A total of 9 ml of Bupivacaine-Hydrochloride (Marcaine) 0.5%, or Sodium-Chloride 0.9%, as a placebo, were injected subcutaneously to the trocar sites (3 ml to each trocar site), prior to skin incision. In addition, 10 ml of Bupivacaine-Hydrochloride 0.5%, diluted with 40 ml of Sodium-Chloride 0.9% (a total of 50 ml solution), or 50 ml of Sodium-Chloride 0.9%, as a placebo, were injected intraperitoneally at the end of the surgery. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. The study was approved by the local Institutional Review Board and has been registered at clinicaltrials.gov. We conformed to the CONSORT recommendations. Between December 2016 and July 2019, a total of 119 patients were included in the study. Demographic and interventional characteristics were similar among the groups. The level of postoperative pain, either at rest or with change of position, was not significantly different between the groups, at all-time points. Application of subcutaneous and/or intraperitoneal analgesia is not effective in reducing pain after gynecologic operative laparoscopy.Clinical trial identification number: NCT02976571. Date of trial registration 11/29/2016. URL of the registration site: https://clinicaltrials.gov .

Project description:ObjectiveTo evaluate racial and ethnic differences in women's postpartum pain scores, inpatient opioid administration, and discharge opioid prescriptions.MethodsWe conducted a retrospective cohort study of all deliveries at a single high-volume tertiary care center from December 1, 2015, through November 30, 2016. Women were included if they self-identified as non-Hispanic white, non-Hispanic black, or Hispanic; were at least 18 years of age; and did not have documented allergies to nonsteroidal antiinflammatory drugs or morphine. Medical records were queried for three outcomes: 1) patient-reported postpartum pain score (on a scale of 0-10) at discharge (dichotomized less than 5 or 5 or higher), 2) inpatient opioid dosing during postpartum hospitalization (reported as morphine milligram equivalents [MMEs] per postpartum day), and 3) receipt of an opioid prescription at discharge. The associations between each of these outcomes and maternal race-ethnicity were assessed using multivariable logistic regression models with random effects to account for clustering by discharge physician. A sensitivity analysis was conducted in which women of different race and ethnicity were matched using propensity scores.ResultsA total of 9,900 postpartum women were eligible for analysis. Compared with non-Hispanic white women, Hispanic and non-Hispanic black women had significantly greater odds of reporting a pain score of 5 or higher (adjusted odds ratio [aOR] 1.61, 95% 1.26-2.06 and aOR 2.18, 95% 1.63-2.91, respectively) but received significantly fewer inpatient MMEs/d (adjusted β -5.03, 95% CI -6.91 to -3.15, and adjusted β -3.54, 95% CI -5.88 to -1.20, respectively). Additionally, Hispanic and non-Hispanic black women were significantly less likely to receive an opioid prescription at discharge (aOR 0.80, 95% CI 0.67 to -0.96 and aOR 0.78, 95% CI 0.62-0.98) compared with non-Hispanic white women. Results of the propensity score analysis largely corroborated those of the primary analysis, with the exception that the difference in inpatient MMEs/d between non-Hispanic white and non-Hispanic black women did not reach statistical significance.ConclusionHispanic and non-Hispanic black women experience disparities in pain management in the postpartum setting that cannot be explained by less perceived pain.

Dataset Information

Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy.

Publications

Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy.

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