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, 9 (2), 174-8

Postoperative Pain Assessment Using Four Behavioral Scales in Pakistani Children Undergoing Elective Surgery


Postoperative Pain Assessment Using Four Behavioral Scales in Pakistani Children Undergoing Elective Surgery

Faisal Shamim et al. Saudi J Anaesth.


Background: Several measurement tools have been used for assessment of postoperative pain in pediatric patients. Self-report methods have limitations in younger children and parent, nurse or physician assessment can be used as a surrogate measure. These tools should be tested in different cultures as pain can be influenced by sociocultural factors. The objective was to assess the inter-rater agreement on four different behavioral pain assessment scales in our local population.

Materials and methods: This prospective, descriptive, observational study was conducted in Pakistan. American Society of Anesthesiologists I and II children, 3-7 years of age, undergoing elective surgery were enrolled. Four pain assessment scales were used, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Toddler Preschool Postoperative Pain Scale (TPPPS), objective pain scale (OPS), and Face, Legs, Activity, Cry, Consolability (FLACC). After 15 and 60 min of arrival in the postanesthesia care unit (PACU), each child evaluated his/her postoperative pain by self-reporting and was also independently assessed by the PACU nurse, PACU anesthetist and the parent. The sensitivity and specificity of the responses of the four pain assessment scales were compared to the response of the child.

Results: At 15 min, sensitivity and specificity were >60% for doctors and nurses on FLACC, OPS, and CHEOPS scales and for FLACC and CHEOPS scale for the parents. Parents showed poor agreement on OPS and TPPS. At 60 min, sensitivity was poor on the OPS scale by all three observers. Nurses showed a lower specificity on FLACC tool. Parents had poor specificity on CHEOPS and rate of false negatives was high with TPPS.

Conclusions: We recommend the use of FLACC scale for assessment by parents, nurses, and doctors in Pakistani children aged between 3 and 7.

Keywords: Behavioral scales; children; pain assessment; pediatric pain; postoperative pain.

Conflict of interest statement

Conflict of Interest: None declared.

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    1. von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3-18 years. Pain. 2007;127:140–50. - PubMed
    1. Maunuksela EL, Olkkola KT, Korpela R. Measurement of pain in children with self-reporting and behavioral assessment. Clin Pharmacol Ther. 1987;42:137–41. - PubMed
    1. Finley GA, Kristjánsdóttir O, Forgeron PA. Cultural influences on the assessment of children's pain. Pain Res Manag. 2009;14:33–7. - PMC - PubMed
    1. Chorney JM, McMurtry CM. Behavioural measures of pain. In: McGrath PJ, Stevens BJ, Walker SM, Zempsky WT, editors. Oxford Textbook of Pediatric Pain. 1st ed. New York: Oxford University Press; 2014. pp. 379–90.
    1. Suraseranivongse S, Montapaneewat T, Manon J, Chainchop P, Petcharatana S, Kraiprasit K. Cross-validation of a self-report scale for postoperative pain in school-aged children. J Med Assoc Thai. 2005;88:412–8. - PubMed