Lower pain was associated with propofol (p = 0.008), as well as lower anxiety (p = 0.002), and increased patient age (p = 0.014). The administration of propofol was significantly associated with lower needle recall (p < 0.001), pre- to post-operative difference in systolic BP (p = 0.029), and mean BP (p = 0.044). Low-dose propofol given immediately prior to administration of local anaesthesia was associated with reduced pain and needle recall, as well as lower BP.In this paper, we investigate the effect of sedation using low-dose propofol on patient reported outcome measures (PROMS) in patients undergoing cataract surgery. This is a randomised, single-blinded observational prospective study. Patients undergoing elective cataract surgery using peribulbar anaesthesia over consecutive cataract lists were selected for this trial. Patients were randomised to receive either no sedation or low-dose propofol  prior to the administration of local anaesthesia. Pain, satisfaction, anxiety, needle recall, pulse, and blood pressure (BP) were measured. A total of 97 patients were included, 50 of whom received propofol. There were 4 senior surgeons and anaesthetists. There were no ocular or systemic complications and all patients had uncomplicated surgery. Anxiety ( Cataract surgery is the most common intraocular operation and is most often performed under local anaesthesia (LA) . LA optiSedation may be helpful with LA to lessen the experience of discomfort, movement and anxiety, which may in turn positively influence haemodynamic parameters, patient satisfaction, and overall improve surgical safety ,3,4,5,6.Patients are understandably anxious about undergoing cataract surgery under local anaesthesia and PROMS such as pain, satisfaction, needle recall, and anxiety are important measures of the success of cataract surgery. We found that increased levels of pain were associated with younger patients and increased pre-operative anxiety. The level of pain was lower with the use of propofol regardless of the surgeon or anaesthetist. Pain was associated with increased anxiety and reduced overall satisfaction. Anxiety can adversely affect haemodynamic parameters and since cataract surgery is typically performed in an ageing population with associated co-morbidities, many groups have tried using sedation to relax the patient, control patient haemodynamics, and minimise movement to favour the surgeon ,3,4,5,6.Previous studies have shown propofol to be an excellent choice for short-term sedation as a single low-dose bolus in comparison to other agents, due to its rapid induction, achieving adequate light sedation with anxiolytic effect whilst allowing the patient to remain co-operative. There is quick recovery to a clear-thinking state, with a low incidence of nausea and vomiting due to its rapid metabolism and mechanism of action, with few adverse effects . FurtherPropofol is an ultra-fast-acting Gamma Aminobutyric Acid-A (GABA-A) receptor agonist which is administered as an intravenous bolus and is rapidly metabolised by the liver . The dosA reduction in patient reported outcome measures (PROMS) such as pain, anxiety, and increased patient satisfaction are important measures of the quality of cataract surgery. We, therefore, investigated the effects of a single small bolus of propofol, ensuring the patient was still awake and co-operative, prior to administration of LA on haemodynamic parameters, and the following PROMS: anxiety, pain, satisfaction, and needle recall.All consecutive adult patients undergoing elective cataract surgery over 5 theatre sessions on 5 separate days were included in this prospective study. Each theatre session had 2 theatre lists running concurrently. Patients had been randomly allocated to each of the theatre lists by waiting-list staff without involvement of the anaesthetists or surgeons. In one list, all patients received low-dose propofol prior to the anaesthetic block, whilst patients in the other list had no propofol. No pre-operative medication was prescribed. All patients had signed a written informed consent form and the study was conducted in accordance with the declaration of the procedure of Helsinki. Local Ethics Committee approval by the Institutional Board from the Royal Liverpool University Hospital was obtained with approval code 02062008 and trial registration number SP/RCT/08/anes/prop.A single intravenous bolus of 20 to 30 mg propofol, dose determined by the patient’s build, was given by the anaesthetists followed by an increment of 10 mg every minute until the patient developed slurred speech only. The patient was otherwise awake and co-operative. A single transcutaneous peribulbar block of 5 mL dose  was then administered to each patient. The same method of anaesthetic block was performed in all patients. Any ocular and systemic complications or adverse events or reactions from propofol and or the anaesthetic block were documented.Blood pressure and pulse oximetry were measured pre- and post-operatively immediately following completion of the surgery by nurses who did not know which cohort the patient belonged to (single-blind). After surgery in the recovery area, each patient was given a questionnaire including a visual analogue scale, consisting of a 10 cm line, with two end points representing 0 (‘no pain’) and 10 (‘pain as bad as it could possibly be’), to record their perceived level of anxiety and pain prior to and during surgery followed by a satisfaction score and recall of the needle being inserted around the eye. Needle recall was recorded categorically as either ‘yes’ or ‘no’ and patient satisfaction with the anaesthetic as 1 of 4 options ranging from ‘very dissatisfied’ through to ‘very satisfied’.p < 0.05 was considered significant. A generalised linear model was used for discrete and categorical outcomes and a general linear model (SPSS 22) for the continuous and normally distributed dependent variable. Propofol, anaesthetist and surgeon were factors; age, pulse, systolic, diastolic, and mean blood pressure were covariates, with pain, satisfaction and anxiety scores, and needle recall were dependent outcome variables. Bland Altman plots were used to investigate the differences in pre- to post-operative blood pressure with the pre-operative measurement.Statistical analysis which was performed using SPSS (version 22). A total of 97 patients (mean age 74.8 years) were included, 50 of whom received propofol. There were 4 anaesthetists and 4 surgeons. Adequate sedation was achieved in the propofol group, with the patients in a relaxed and co-operative state, responsive to verbal commands and tactile stimuli with all returning to a clear-thinking state by the end of the procedure. Time from the block being given to the end of the surgery ranged from 15 to a maximum of 20 min. There were no ocular nor systemic complications from propofol or local anaesthesia, and all patients had uncomplicated surgeries.A summary of the results are included in p = 0.002), a younger age (p = 0.014), and non-use of propofol (p = 0.010). Propofol use was associated with a lower needle recall (p < 0.001); 36% in the propofol group and 83% in the non-sedation cohort.Increased pain was significantly associated with increased pre-operative anxiety (p < 0.001) during the procedure, pre-operative anxiety (p < 0.001), and age (p < 0.001). The corresponding change in the level of anxiety, pre- to post operatively, was significantly associated with the level of pre-operative anxiety (p < 0.001) and level of pain (p = 0.005) experienced.Post-operative anxiety was significantly associated with pain experienced (p < 0.001), and the combination of surgeon and propofol use (p = 0.03), but not the anaesthetist (p = 0.24), patient’s age (p = 0.10), or pre-operative (p = 0.23) and post-operative anxiety scores (p = 0.40).Patient satisfaction was high overall. The patients’ level of satisfaction, however, was significantly associated with the level of pain experienced during the procedure (p = 0.024), reduced post-operative anxiety (p = 0.017) and pain (p = 0.016), as well as increased post-operative systolic (p = 0.02) but reduced post-operative diastolic BP (p = 0.02) and a reduced difference in pre-to post-operative pulse (p = 0.02). The changes in blood pressure are shown in p < 0.01), which were also significantly greater than in patients who did not receive propofol (p < 0.01) (Increasing age was significantly associated with a higher pre-op systolic BP ( < 0.01) . In comp < 0.01) .In this prospective, randomised, single-blinded study, we have shown that sedation using low-dose propofol can reduce the level of pain and effectively and safely reduce BP and pulse rate with all patients being co-operative and rapidly returning to a clear-thinking state. Interestingly, we used a lower dose compared to that used for sedation by previous investigators; yet the favourable effects continued beyond that expected for normal duration of action for propofol. Importantly, there were no adverse reactions despite the age group and concurrent co-morbidities.Previous studies have also shown a reduction in BP following the administration of propofol, at higher doses than our study, and with variable lowering of heart rate, with only a few reported adverse but easily manageable cardiovascular disturbances ,17,18,19The current literature reports a good safety profile of low-dose propofol for conscious sedation in non-fasted patients undergoing cataract surgery ,22,23. GSub-optimal anaesthesia such as eye movement or vitreous bulge, has been associated with an increase in ophthalmic surgical complication . AvoidanThere are limitations in this study. Although the 4 surgeons operated on patients with and without propofol, the use of propofol was limited to 2 of the 4 anaesthetists. The satisfaction scores were skewed to high, possibly as the patients were pleased to have had successful cataract surgery. The results pertain to peribulbar anaesthesia; however, it would be reasonable for the results to apply to sub-Tenon’s space local anaesthesia. Whether a similar benefit would apply to propofol use for topical anaesthesia is unclear.This study helps demonstrate that low-dose propofol can be a helpful alternative when additional anaesthesia is deemed necessary by the operating surgeon and anaesthetic support is available. Although there are cost and resource implications for using sedation in patients undergoing cataract surgery, improving the patient experience and potentially reducing risk, are important considerations particularly in selected cases.


There are some clinical circumstances that require the parenteral administration of opioids, as an alternative to the oral route. A parenteral route of administration is often indicated in patients with severe pain intensity requiring rapid analgesia or in those who develop nausea and vomiting, dysphagia, or have limited intestinal surface for drug absorption. Subcutaneous and intravenous routes are effective in providing rapid analgesia, particularly the intravenous route. Many opioids have proved to be effective when administered in clinical conditions where oral opioids cannot be used or are poorly effective. Although most studies on this topic are not controlled, there is a body of experience suggesting that parenteral opioids may be useful in some specific circumstances.Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Although oral administration of opioids is generally preferable, a parenteral route may be advisable and mandatory in some clinical circumstances. Parenteral administration of opioids may accelerate the achievement of analgesia. The intravenous route fits the need of rapid achievement of analgesia in patients poorly responsive to other opioids and provides a fast analgesia in patients with breakthrough pain, that has a specific temporal pattern requiring a rapid analgesic effect. When the oral route is unavailable for the presence of nausea, vomiting, or dysphagia. the parenteral route is one of the principal options. Opioids have different pharmacokinetic and pharmacodynamic characteristics and should be chosen according to the individual needs. Thus, the knowledge and experience with these routes of administration are mandatory for anesthesiologists committed to cancer pain management. Pain is a significant problem in patients with advanced cancer. Despite increased attention to cancer pain, the number of patients with cancer has not significantly changed over the last decades. It has been reported that more than one third of patients receiving anticancer therapy suffer from moderate to severe pain and approximately 50% of those with an advanced cancer experience moderate to severe pain . The lacCancer pain is challenging and requires high level clinical competence in all available methods to relieve it. World Health Organization (WHO) guidelines for cancer pain management were based on the use of a sequence of analgesic drugs with increasing efficacy to be used according to the level of pain intensity . The aimThe wide variety and ranges of cancer pain cannot be included in the three step ladder, and any specific clinical circumstance requires profound knowledge of all available pharmacological techniques. Opioids still remain the cornerstone of cancer pain management and should be prescribed to patients with moderate-to-severe pain related to cancer . The phaSubcutaneous and intravenous routes have been reported for the management of cancer pain by early studies. These studies were the basis of subsequent studies published later in the third millennium, which will be examined in detail in the subsequent paragraphs. Opioids may be administered parenterally by either continuous infusion or regularly scheduled intermittent injections. The relative advantages and disadvantages of each modality are not very clear. Continuous infusion produces steady drug levels, thus avoiding the “peak effect” of adverse effects, such as nausea and sedation, immediately after an injection, and breakthrough pain prior to the next dose . Its use in the treatment of cancer pain is historically well established . AdminisPrevious studies reported that approximately 15% of cancer patients were administered opioids by intravenous route prior to death . The firPrevious recommendations on continuous infusion of opioids suggest some indications for continuous infusion  . The druSubcutaneous opioid administration is easy and can be effectively used in settings such as hospices, nursing homes, or home care. However, patients with poor peripheral circulation, coagulation disorders, or generalized edema, or those who develop erythema, soreness, or abscesses are unfit for this route of administration . StudiesThe intravenous route may be advantageous in patients who already have an indwelling intravenous line. Most patients in specialized units have a long-term intravenous line to provide hydration and to facilitate therapeutic procedures that require a rapid effect, such as opioid dose titration, administration of rescue doses, and treatment of emergencies, other than for injecting urticant chemotherapic agents . BecauseThe principal advantage of the intravenous route over the subcutaneous one is pharmacokinetic: the direct administration into the circulation provides a fast and predictable effect that is independent of absorption problems . HoweverA protocol for cancer pain emergencies has been proposed. After initial assessment, patients were managed according to a protocol whereby intravenous boluses of opioid are administered with rapid upward titration until an effective analgesic dose was found. The initial dose of intravenous opioid was arbitrarily selected within the range of of 10–20 mg of intravenous morphine and was administered over 15 min. The dose was doubled every half hour until the achievement of acceptable analgesia. All patients obtained satisfactory relief of excruciating pain in approximately 90 min . In FiguIn a randomized controlled study, intravenous morphine was compared against oral morphine for opioid dose titration . HoweverOther studies have examined other opioids. Hydromorphone given by intravenous route, as a continuous infusion or by patient-controlled analgesia (PCA) was effective in dose titration studies . When usIn another comparison study with intravenous morphine, significant analgesia was faster with oxycodone; however, the pain relief stabilization success rates within 24 h were similar .Methadone is a peculiar agent with a broad spectrum activity. In addition to being a potent μ-opioid agonist and possessing some affinity for the κ- and δ-opioid receptors, it exerts extra-opioid activities, including the decrease in monoamine reuptake and inhibition of presynaptic NMDA receptors . ClinicaOther studies provided promising data regarding the use of intravenous methadone in difficult pain conditions . More reTransdermal fentanyl is unfit for inducing a rapid analgesia, given its pharmacokinetic profile. The approximate steady state is reached 12–24 h after application of the patch. Plasma concentrations remain relatively constant thereafter for 48–60 h. Indeed, intravenous fentanyl has distribution and redistribution times of 1.7 and 13 min, respectively, a terminal elimination half-life of about 220 min, and a duration of analgesic effect of about 60 min. For this reason, the intravenous route was proposed the facilitate the transition from and to transdermal fentanyl ,28,29. T2 did not significantly change and O2 saturation was maintained at ≥92% [Concerns regarding respiratory depression are one of the most important physician barriers against the use of parenteral opioid dose titration. However, parenteral opioid dose titration for relief of severe cancer pain has been found to be not associated with respiratory depression. In a study of patients with severe cancer undergoing parenteral dose titration, end-tidal CO at ≥92% . This su at ≥92% .There are a variety of indications for using parenteral opioids. Patients with severe pain and poorly responsive to previous opioid therapy are typically candidates for a personalized, rapid opioid dose titration obtainable with parenteral administration. In most cases, this corresponds to an opioid switching, characterized by a more intensive approach. Morphine is the more commonly used drug. In the presence of an intravenous line, the intravenous route is more advisable than the subcutaneous one. The rapidity of opioid dose titration is dependent on the patient’s level of previous opioid tolerance, the staff experience and ability to assess analgesia, the ability to monitor the development of adverse effects, and the capacity to use all available intravenous opioids. When using intravenous methadone, substantial clinical experience is necessary for the use of appropriate dosing according to any changes in the patient’s clinical response. Of concern is that, while intravenous dose titration has been performed in specialized medical care centers with a high level of experience, expertise in settings such as hospice or home care is lacking. In the hospice or home setting, the subcutaneous route is suggested, if not contraindicated, although an accumulation of experience and expertise would be desirable even in these settings. Education and information on the use of parenteral opioids should be implemented, with studies specifically designed with a clinical perspective.


Background: The sanitary measures imposed by COVID-19 intensified challenges in the pain management of cancer patients. Methods: A descriptive study was conducted in a chronic pain unit of an oncological hospital aiming to explore the experiences of cancer patients with chronic pain and their caregivers during the pandemic period, as well as identify strategies to improve care in chronic pain management. An electronic questionnaire was developed containing sociodemographic variables, the Depression, Anxiety and Stress Scale-21, and open-ended questions exploring the experiences and circumstances of pain management. Results: A total of 30 patients and 13 caregivers filled in the questionnaire. Patients revealed a higher level of depression, anxiety, and stress than caregivers, without statistically significant differences. Both groups mentioned having experienced difficulties in self-care, particularly in relation to sleep, nutrition, and recreation. In total, 83.7% patients needed pain relief medication related to uncontrolled pain. Both mentioned that they would have benefited from a digital application to ease the communication with the healthcare professionals of the chronic pain unit, as well as non-pharmacological interventions, such as therapeutic massage. Conclusions: Recognizing that chronic pain leads to significant limitations, it is essential to implement and anticipate objective and effective responses in pain management. Pain is a common symptom in cancer patients, with 70% of patients being expected to report it . Based oTo reduce the complications associated with chronic pain and improve the quality of care, healthcare professionals need to be aware of and implement strategies to an effective chronic pain management for both patients and their caregivers in a continuous manner throughout the clinical pathway ,11.Therefore, effective chronic pain management is crucial in many domains both at the patient- and the organizational-level and should be integrated in a comprehensive assessment and symptom control performed by the healthcare professionals ,12,13,14The biopsychosocial model of pain is the golden standard in the understanding of chronic pain among the scientific community . This frWhen uncontrolled, chronic pain often negatively impacts the person’s lifestyle and daily activities, such as sleep, diet, physical activity, consumption habits, demanding a substantial effort from the patients and caregivers to regain control .In a context of chronic pain experience, the patients are challenged to develop a set of new behaviors to promote symptomatic control and enhance QoL. Such an approach benefits from the support of informal caregivers, who may support the daily activities and restore autonomy and QoL .Self-care is as an important area of nursing practice, since it has a significant impact on the way in which the person manages chronic disease and the inherent therapeutic regimen ,23.The consecutive decrease in QoL, the chronic pain and its impact in the self-care ability additionally bring uncertainty, as the structure of daily life is disrupted and the person must readjust their routines and activities. Living with chronic pain requires an effective adaptation to a health-disease transition. Specifically, a poorly coordinated transition can potentiate the risk of re-hospitalization or even death ,25.COVID-19 has affected the self-management of patients with chronic disease all over the world , raisingThe sanitary measures to control the COVID-19 dissemination led to a sustained reduction in the number of cancer patients diagnosed, referred, and treated , and altThe recent evidence emphasizes the importance of considering a dyadic perspective (patient–caregiver) to the understanding of the pain experience and of its impact on the QoL of both patients and caregivers .The present study aimed to explore the experiences of cancer patients with chronic pain and their caregivers during the COVID-19 pandemic period, as well as identify strategies to improve care in chronic pain management.A descriptive study was developed with cancer patients with chronic pain and their caregivers. It was used the STROBE Statement—checklist of items that should be included in reports of observational studies .The study was carried out during the COVID-19 pandemic period, in a pain unit of a hospital in the center region of Portugal, during 2021 until March 2022. The pain unit is manned by a multidisciplinary team composed of two nurses, five physicians with pain management expertise recognized from physicians’ professional order, a social worker, and a psychologist. During the study’s period, the healthcare team followed 362 new cancer patients with chronic pain, in a total of 1758 appointments, which was about 20% less compared to the same period before the COVID-19 disease.The pain unit offers pharmacological and non-pharmacological approaches to pain management in a complementary relationship. Concerning the non-pharmacological approaches, the oncology nurses working at the unit provide a systematic program composed of therapeutic massage and relaxation techniques, aiming for efficient pain management. The program takes place once a week over the course of eight weeks; however, it was interrupted during the research period due to the sanitary measures imposed.Convenience sampling was used to recruit participants to this study. The participation was based on a voluntary decision, after the individual made the informed decision to participate. In this study, we included all patients who had a planned appointment at the pain unit during the study period and their informal caregivers, and who consented to participate after invitation from the healthcare team. The invitation was made by one of the nurses from the pain unit team in the waiting room, during the time when patients and caregivers were expecting their planned appointment.The inclusion criteria for the patients’ sample were having a cancer diagnosis, regardless of the disease or the treatment stage; having a chronic pain diagnosis; and having an appointment with the healthcare team at the pain unit during the study period. All informal caregivers accompanying the patients to the pain unit appointment were invited to participate in the study. Patients and informal caregivers should preferably have digital skills to complete data collection. The digital skills were tested by nurses through a test survey applied to the participants, before providing the final link to the questionnaire. All invited people were required to consent to participation.All patients and informal caregivers who were not able to complete the questionnaire were excluded from the study. The responses of participants who decided to withdraw from the study were also excluded.An online questionnaire was made available on a tablet by the pain unit nurse or sent by email according to the participants preference. The questionnaire was estimated to take around 10 min to be completed.The online questionnaire was composed of sociodemographic variables such as sex, age, marital status, education level, and residential area. The second part included the Depression, Anxiety and Stress Scale-21 (DASS-21)  and the DASS-21 enables the assessment of the levels of depression, anxiety, and stress. Each dimension is composed of seven questions, answered on a 5-point Likert scale, ranging from totally disagree (1) to totally agree (5), with higher levels indicating a greater level of the assessed construct. The scale has been translated and culturally adapted to Portuguese and revealed evidence of validity and good reliability in a sample of 200 subjects by Ribeiro-Pais et al. . In the ® software version 2022.6, was used aiming for a content analysis.Descriptive and inferential statistics were used. Frequencies, percentages, medians, means, and standard deviations were determined for sample description. Since the data were not normally distributed, non-parametric tests were performed. Mann–Whitney U was used to compare differences between two independent groups, i.e., patients and caregivers. Quantitative data were analyzed using SPSS-26 at a significance level of 0.05. To analyze the data obtained from open-end question the maxQDAThe study was reviewed and approved by the Oncology Hospital’s Ethical Committee (TI no 20/2020). Verbal and written information about the study was provided to all the participants. Responses were anonymous and the self-determination principle was guaranteed. The participants gave their agreement to participate in the study before starting the online questionnaire.n = 31). The mean age of the patients was 55.47 ± 09.67 years (range 36–75), and for the informal caregivers the mean age was 51.54 ± 09.24 years (range 41–65). All the informal caregivers were married and had higher-school education (53.9%). As for the cancer patients, most of the participants had a basic education (76.7%).A total of 43 participants were involved in the study, including 30 patients and 13 informal caregivers. Most participants were women  said that they sought further support from the pain unit.For the first open-ended question, the answers revealed four categories of facilitating strategies for pain management and control during the confinement period, including frequent telephone calls, videoconferences, physical approaches, and psychosocial approaches.From the perspectives of both the patients and the caregivers, the use of telecommunication during the pandemic time to monitor and follow-up was an important strategy, corroborated by an increase in the number of regular phone calls (100%) and video-conference services (≈40%). Other non-pharmacologic approaches were also valued, such as physical .I didn’t have enough food at home, and I didn’t had way to go out to buy it, because I was afraid to catch COVID and transmit it to my husband…” and absence of leisure activities (P21: “I missed my card game…”.Concerning the lived experiences, the results evidence two categories, including changes in the self-care activities and personal suffering. All the participants mentioned interferences on their self-care activities, particularly portrayed in inadequate nutrition (C4: “I was scared and terrified with the situation, I was so afraid that I would never see my family again, and day after day I was losing all hope in future and in the possibility to survive…”.Personal suffering was portrayed on descriptions of despair (P3 “The results suggest that both patients and caregivers had similar outcomes for depression, anxiety, and stress. Patients revealed a higher level of depression, anxiety, and stress than caregivers. Despite these outcomes, no statistically significant differences were found between the two groups.Cancer patients with chronic pain and their informal caregivers experienced difficult times during the confinement period. The changes in daily life impacted on self-care and increased personal suffering. This reality has been described in other studies ,33,34, tThe informal caregivers are essential partners in caring for the person with cancer. Ensuring their well-being is as important as caring for the patient with cancer, who might see the care and support at home jeopardized otherwise ,36, withThe pandemic confinement period brought countless difficulties and constraints to patients and caregivers. The postponed or canceled follow-up pain appointments and treatments led to dissatisfaction and difficulties in the health/illness management experienced by patients and their caregivers . In the It is noteworthy that the results showed a negative impact on the sleep and nutrition patterns, as well as recreation, reinforcing the need to conduct a holistic assessment of the person in his/her context for optimal pain management.In this study, the patients and informal caregivers identify telehealth in the form of frequent phone calls and videoconference, as an important tool that they would have liked to have more often during the confinement period. The remote interactions were adopted worldwide during the pandemic and shifted the paradigm for chronic pain care ,39. TeleThe participants in this study identified the ease of contact with the pain unit team for emergent issues, as well as for regular follow-up as an important asset and essential to pain self-management at home, generally welcoming the use of an App and telehealth, including video and sound, to facilitate communication in situations where face-to-face contact was not advised or was compromised. Importantly, most of the participants in both groups identified the rural area as their area of residence. The acceptability and effectiveness of eHealth tools to complement communication and supportive processes throughout the cancer care journey are increasingly recognized , particuRecent evidence, aligned with calamity situations, recommends a comprehensive and systematized resilience assessment from the early stage of the health/illness journey in order to provide personalized support and interventions tailored to answer to the specific needs of individuals. Such assessment demands organizational changes, and the application of new technologies in pain medicine, especially when dealing with vulnerable groups ,45.Concerning the non-pharmacologic therapies, massage and supportive therapy were strategies identified as important by patients undergoing pain treatment. In this regard, the non-pharmacologic approaches should also be discussed before deciding about its suspension or delay.Overall, the results of the current study shed light on the need to attend to the dyad patient-caregiver throughout the care pathway. This evidence is not new and is particularly developed in the domain of palliative care . The resAs a study limitation, the sample size should be taken into consideration when seeking transferability of results across contexts. Having digital skills as an inclusion criterium might be considered to have biased the results. Future studies should consider alternative options to data collection that do not demand digital skills or provide assistance in digitally supported data collection.These contributions are expected to help healthcare professionals to rethink healthcare pathways in future similar situations.Person-centered care is a fundamental requirement in cancer patients with chronic pain and should attend to the needs of both patients and their caregivers in maintaining wellbeing. The oncology healthcare team’s role further encompasses the need for an effective follow-up to the dyad patients-caregivers, which is of particular significance in chronic pain management.Recognizing that chronic pain leads to significant impairment and changes in daily activities, the anticipation, planning, and implementation of effective responses to pain management is essential. Here, the intermittent face-to-face contact inherent to the outpatient oncology pathway should be redesigned, so to attend to the continuous of the pain experience, its assessment and implementation of non-pharmacological interventions, if aiming to the prevention of major damage.


IntroductionThe most frequently used local anesthesia administration techniques for extraction of lower teeth in dentistry are local infiltration and inferior alveolar nerve block. Therapeutic extraction of premolars is the most common procedure done for patients undergoing orthodontic treatment. Inferior alveolar nerve block has been used most commonly for extraction of mandibular posterior teeth; however, it is a technique-sensitive procedure and has complications such as facial nerve palsy, trismus, and long duration of anesthesia. Local infiltration is a simple and effective technique for anesthetizing teeth prior to extraction.AimThis study aims to compare the efficacy of local anesthesia administered through inferior alveolar nerve block and local infiltration techniques for extraction of lower premolar teeth for orthodontic purposes.Materials and methodsA prospective comparative study was conducted for a period of six months in which a total of 100 patients who were referred for extraction of lower premolar teeth for orthodontic purposes were included. Among 100 patients, 60 patients were males, and 40 patients were females with a mean age of 16.5 ± 1.25 years. The patients were equally divided into two groups, in which Group 1 received local infiltration and Group 2 received an inferior alveolar nerve block. The outcome parameters assessed were pain during injection and pain during extraction using the visual analog scale (VAS) score and Wong-Baker Faces Pain Rating Scale score. Statistical analysis was done using an independent sample t-test with SPSS version 23.0 software  at p < 0.05 considered statistically significant.ResultsThe difference in mean pain scores between the two groups during injection as assessed using the Faces Pain Rating Scale (p = 0.001) and VAS (p = 0.001) was statistically significant, with the infiltration group exhibiting less pain than the inferior alveolar nerve block group. The difference in mean pain scores between the two groups during extraction as assessed using the Faces Pain Rating Scale (p = 0.308) and VAS (p = 0.350) was statistically not significant, with the infiltration group not significantly differing from the inferior alveolar nerve block group. Thus, the pain during local infiltration was significantly lesser when compared to the inferior alveolar nerve block during injection, whereas pain perception during extraction was similar in patients with both injection techniques.ConclusionIt can be concluded that local infiltration is less painful for the patient during injection and as efficacious as nerve block for extraction, hence local infiltration can be routinely used for lower premolar orthodontic extractions. Local anesthesia is defined as “A temporary loss of sensation in a circumscribed area of the body. It is produced by an inhibition of the conduction process of the action potential in peripheral nerves without depressing the level of consciousness” . DespiteThe most common difficulty faced by dentists is achieving profound anesthesia in patients undergoing extraction of teeth with pulpitis. An ideal dental extraction must be painless and comfortable for the patient. The painless procedure makes the patient develop a much more positive mentality for the proposed treatments. The topical anesthetics application prior to injection is the routine practice in dentistry, especially in pediatric patients. Therapeutic extraction of premolars is the most common procedure done for patients undergoing orthodontic treatment who are mostly young patients below the age of 25 years. Being young adults, the pain threshold is comparatively lesser in these patients. Thus, using the proper injection technique is essential to make the patient cooperate during extraction. The most often used injectable techniques for producing local anesthesia in these patients are infiltration and inferior alveolar nerve block (IANB) . IANB haDue to various variables, including the difficulty in identifying landmarks, this procedure is challenging for beginners and has the greatest failure rates. Furthermore, it could lead to issues such as limited mouth opening, hematoma formation, and facial nerve palsy . MandibuThis study aims to compare the efficacy of local anesthesia administered through IANB and local infiltration techniques for the extraction of lower premolar teeth for orthodontic purposes. The objectives of the study were to assess and compare pain perception during injection and extraction among patients with local infiltration and IANB injection techniques.Study design and settingThis prospective comparative study was performed in the Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Chennai for a period of six months after obtaining approval from the Institutional Human Ethics Committee, Saveetha Dental College . Written informed consent was obtained from all the study participants.Inclusion criteriaAll the patients irrespective of gender, with ages ranging from 12 to 25 years, referred for therapeutic extraction of lower premolars for orthodontic purposes were included in the study.Exclusion criteriaPatients with existing systemic illness and referred for extraction of teeth other than premolar teeth were excluded from the study.Sampling and recruitmentThe sample size calculation was done with the help of G*Power software version 3.0 at 90% power. The sample size obtained was 96 and was rounded off to 100. A total of 100 patients between 12 and 25 years, referred for extraction of lower premolars for orthodontics purposes were divided into two groups of 50 each. Group 1 received the local infiltration injection technique (2 ml) and group 2 received the IANB injection technique (2 ml). The local anesthetic used was 2% lignocaine with 1:80,000 adrenaline (Xylocaine). Randomization was done with the help of an online random allocation software . Details like the number of groups, participants, and anesthesia techniques used were fed into the software. Each participant received a random number. The treatment allocation number was placed in an opaque envelope. Allocation protocol was not available to the primary surgeon. Blinding was done by asking a secondary surgeon to give a nerve block or infiltration and extraction of the tooth was done by the primary surgeon to avoid bias. Effect size calculation was done using Cohen’s d formula for the two independent groups 1 and 2.ProcedureLocal infiltration group 1) was given by injecting 2 ml of 2% lignocaine with 1:80,000 adrenaline  at the mucobuccal fold  scores. Facial pain scale uses facial expression to evaluate the amount of pain. It has scores ranging from 0 to 10 with 0 as the least pain and 10 as the worst pain.Statistical analysisStatistical Package for Social Sciences  was used to analyze the data. The normality of the results was assessed using the Shapiro-Wilk test of normality. The results were checked and found to follow a normal distribution. To comparatively analyze two different groups, an independent samples t-test was used. If the p-value was ≤ 0.05, the differences were considered statistically significant.Among 100 patients, 60 patients were males and 40 patients were females, with a mean age of 16.5 ± 1.25 years. In Table In Table Table Table Based on our study results assessed with the help of the facial pain scale and VAS scores, at the time of injection, there was a significant difference between the two groups, with infiltration injection being less painful than IANB. However, during extraction, there was no significant difference between the two groups in pain perception. Cohen's d effect size calculation gave a value of 1.17, which signifies a large effect size in accordance with the results representing that infiltration is 1.17 times better than those with IANB.Local anesthesia plays a critical role in dental treatment, especially for extractions where pain is inevitable. But to achieve proper anesthesia, the usage of appropriate techniques is essential. Though pain while injection can be managed with topical anesthetics, techniques like infiltration and nerve blocks require expertise. Despite being technique-sensitive and the possibility for complications, IANB still is considered the gold standard for the extraction of mandibular posterior teeth -13. The The reason for preferring IANB can also be attributed to the dense structure of the mandibular bone and the inability of local anesthesia to diffuse this structure via simple supra-periosteal infiltration . HoweverOur study results revealed that the facial pain scale score was significantly less during injection for the infiltration group than the IANB group, and there was no significant difference while doing extraction in both groups. A study by Bahrololoomi et al. revealed similar results in pain scores using the facial pain scale during infiltration and IANB . On evalAccording to Madeira et al., 87.3% to 96.2% of the specimens had accessory foramina in the human mandible . Pogrel Limitations of the studyThe limitation of the study is less sample size, and the injection techniques were not compared with different local anesthetic agents. With multi-center study on a larger sample size, the study results can be generalized to the population and better reproducibility of results can be expected.The infiltration technique when compared to IANB is simpler with a shorter and sufficient anesthetic effect. Infiltration injections are easier to administer and more comfortable for patients. They can be utilized to avoid collateral innervations, achieve hemostasis when necessary, and shield the nerve trunks from harm. It can be concluded that local infiltration is less painful for the patient during injection and as efficacious as nerve block for extraction, hence local infiltration can be routinely used for lower premolar orthodontic extractions.


Low back pain is a prevalent public health issue caused by superior cluneal nerve (SCN) entrapment. This study aimed to explore the course of SCN branches, cross-sectional area (CSA) of the nerves, and effects of ultrasound-guided SCN hydrodissection.SCN distance relative to the posterior superior iliac spines was measured and compared with ultrasound findings in asymptomatic volunteers. The CSA of the SCN, pressure-pain threshold, and pain measurements were obtained from asymptomatic controls and patients with SCN entrapment at various time points after hydrodissection  in the short-axis view.2 and did not vary across different segments/branches or pain statuses. Initial treatment success was observed in 77.7% (n = 28) of 36 patients receiving hydrodissection due to SCN entrapment. A group with initial treatment success experienced symptom recurrence in 25% (n = 7) of cases, and those with recurrent pain had a higher prevalence of scoliosis than those without symptom recurrence.Twenty sides of 10 formalin-fixed cadavers were dissected. The SCN locations on the iliac crest did not differ from the ultrasound findings in 30 asymptomatic volunteers. The average CSA of the SCN across different branches and sites ranged between 4.69–5.67 mmUltrasonography effectively localizes SCN branches on the iliac crest, whereby increased nerve CSA is not useful for diagnosis. Most patients benefit from ultrasound-guided dextrose hydrodissection; however, those with scoliosis may experience symptom recurrence and whether structured rehabilitation can reduce recurrence post-injection should be considered as one perspective in future research.Trial registration ClinicalTrials.gov (NCT04478344). Registered on 20 July 2020, https://clinicaltrials.gov/ct2/show/NCT04478344?cond=Superior+Cluneal+Nerve&cntry=TW&draw=2&rank=1.Critical relevance statement Ultrasound imaging accurately locates SCN branches on the iliac crest, while enlargement of the CSA is not useful in diagnosing SCN entrapment; however, approximately 80% of SCN entrapment cases respond positively to ultrasound-guided dextrose hydrodissection.The online version contains supplementary material available at 10.1186/s13244-023-01463-0. Ultrasound imaging accurately locates SCN branches on the iliac crest.Enlargement of the CSA is not useful in diagnosing SCN entrapment.Approximately 80% SCN entrapment cases respond positively to ultrasound-guided dextrose hydrodissection.Scoliosis is associated with symptom recurrence in patients after successful injection.The online version contains supplementary material available at 10.1186/s13244-023-01463-0. Low back pain has become a significant public health issue in recent years, with an age-standardized prevalence between 7.50–8.20% . DespiteHigh-resolution ultrasound allows for the visualization of the SCN and relevant pathologies, such as neuritis, after posterior lumbar interbody fusion surgery , 7. As aUltrasound-guided SCN injections have been described to provide postsurgical analgesia for the upper buttock  or relieCadaver models were investigated with the approval of the Institute of Anatomy, First Faculty of Medicine, Charles University, Prague. Informed consent was obtained from healthy volunteers and patients. The study was approved by the Institutional Review Board of the National Taiwan University Hospital (201912037RINC) and registered at ClinicalTrials.gov (NCT04478344). The study flow is illustrated in Fig. A board-certified physiatrist who had been practicing musculoskeletal ultrasound for > 10 years conducted the scanning and guided injections using a linear probe at 5–18 MHz . Participants were placed in the prone position with their lumbar and gluteal regions exposed Fig. A. First,Once the course of the medial SCN branch was determined, the transducer was shifted laterally and repositioned at the PSIS level. The medial end of the transducer was pivoted toward the S3 or S4 foramen to obtain a better axial view of the intermediate and lateral branches located in the subcutaneous tissue over the gluteus medius muscle. By moving the transducer cranially, the two aforementioned branches could be seen traveling across the iliac crest Fig. E 8]. Th. Th8]. TIn patients who required ultrasound-guided nerve hydrodissection, a mixture of 1 mL 50% of dextrose, 4 mL of 1% lidocaine, and 5 mL of 0.9% normal saline was used primarily for the medial branch. Ultrasound guidance was used with an in-plane approach to target the branches of the SCN over the iliac crest. Additionally, the needle was gradually inserted using the medial-to-lateral approach to completely dissect the space between the thoracolumbar fascia and underlying bony cortex Fig. F. The afAn academic anatomist with > 25 years of experience performed the dissections. Twenty sides of 10 formalin-fixed cadavers  were dissected. Following a transverse skin incision at approximately the 12th thoracic vertebral level, the skin was removed, and the SCNs were identified above the iliac crest by blunt dissection. They were then traced from the lateral margin of the erector spinae muscle, where they penetrated the thoracolumbar fascia to the point where they crossed the iliac crest Fig. B. The poParticipants were enrolled if they were > 20 years and had no lower back or gluteal pain in the past year. Participants were excluded if they had previous trauma or injury to the lumbar or buttock areas. All the participants underwent bilateral clinical assessments and ultrasound scanning of the SCNs in a single session.As the fascicles of the SCN were small, we utilized Image J software  to measure their CSA, encompassing the epineurium, from the archived ultrasound images . HorizonPatients with unilateral symptoms were recruited from the physical medicine and rehabilitation clinic if they were > 20 years and had low back pain that radiates to the ipsilateral gluteal region, as well as unilateral tenderness on the iliac crest. Patients were excluded if they had poor control of their existing medical conditions , rheumatic disorders, lower back injections within the past year, or previous lumbar/pelvic surgery. Plain radiographs of the lumbosacral region were obtained from each patient to exclude the possibility of bony lesions. In our study, spondylosis was operationalized as a Kellgren and Lawrence grade of ≥ 2 , signifiThe ultrasound-derived CSA, pain threshold of the SCNs, and clinical progress were evaluated at baseline and one and three months after injection. Outcome assessment comprised the VAS for the worst pain experienced over the last 24 h and the Oswestry Disability Index (ODI) , which ep-value of < 0.05 was considered statistically significant.Continuous variables are given as mean, standard deviation, and 95% confidence interval (CI); they were compared using the Mann–Whitney U test or visual inspection of their distribution on the blobbogram. If the 95% CIs of two effect size estimates did not overlap, they were considered significantly different . FurtherOn the cadavers, the average distance between the SCN and PSIS on the horizontal axis was 43.10–45.70 mm for the medial branch, 49.20–51.60 mm for the intermediate branch, and 54.20–56.10 mm for the lateral branch. The mean distance on the vertical axis was 63.40–63.70 mm for the medial branch, 69.60–71.10 mm for the intermediate branch, and 73.80–76.20 mm for the lateral branch. The measurements were similar between healthy volunteers and cadavers (Table 2 across different branches and sides (Table p = 0.982) in entrapped SCN CSA at the iliac crest level between individuals responding to injections  and those not responding to injections .The average nerve CSA at baseline ranged between 4.69–5.67 mmes Table . FurtherThere was no significant difference in the pressure threshold for pain between the right and left sides of the three branches of the SCN in asymptomatic volunteers. However, in patients with entrapment, a significantly lower threshold was observed on the painful side than on the asymptomatic side for all three branches  of the patients. Patients with treatment failure had lower baseline VAS scores than those with initial treatment success  of the patients with initial treatment success  was observed in 25.0% (This study yielded several important results. First, the SCN locations crossing the iliac crest did not differ between the cadavers and asymptomatic volunteers, as confirmed by ultrasound imaging and electrical stimulation. Second, the CSA of the SCN did not vary across branches or in the presence of pain. Third, the average pain threshold decreased in all three SCN branches on the painful side. Fourth, approximately 80% of the patients responded successfully to ultrasound-guided 5% dextrose hydrodissection, whereas the rate of symptom recurrence was up to 25% in those with initial injection success.The location of the SCN on the iliac crest has been previously delineated in cadaveric studies. In 2015, Loubser et al.  investigOur study also revealed that ultrasonography-determined CSA has little value in the diagnosis of SCN entrapment. The use of CSA for diagnosing nerve entrapment is most evident in carpal and cubital tunnel syndromes, where the nerves usually become enlarged proximal to the compression site because of obstruction of the axoplasmic flow , 25. HowBecause tenderness over the iliac crest is considered mandatory for diagnosis, a decreased pain pressure threshold over the affected site is expected in SCN entrapment. It is important to note that increased pain sensitivity over the painful site was observed in all three branches of the nerve and not just in the medial branch. Tension of the thoracolumbar fascia is a common cause of SCN entrapment , 28. TheWe observed an approximately 80% response rate to ultrasound-guided nerve hydrodissection, but several factors may have contributed to the remaining failed cases. For instance, the SCN could have been entrapped at multiple levels, such as inside the erector spinae muscle or in the subcutaneous layer, whereas our approach only targeted segments crossing the iliac crest. Additionally, ultrasound-guided intervention may not correct faulty biomechanics, such as excessive lumbar lordosis, which has been found to accentuate SCN entrapment. Finally, the SCN is in proximity to many common pain generators in the lumbosacral region, such as the lumbar facets, sacroiliac joints, and gluteus muscle insertions. Pathologies in these locations can generate symptoms similar to or concurrent with SCN entrapment.Recurrent pain was observed in 25% of the patients who initially responded to the injection, and scoliosis was associated with recurrent pain after the initial treatment success. Scoliosis can cause asymmetry in the tension of the thoracolumbar fascia, which can alter the biomechanics of the spine and the surrounding muscles. An observational study also suggested that continued tightening of the fascial plane due to asymmetrical tension distribution could further increase scoliotic curvature . Our finFor nerve hydrodissection, we used an injectate consisting of 5% dextrose, 1% lidocaine, and normal saline. Various regimens, including corticosteroids, platelet-rich plasma, and 5% dextrose, are commonly used for nerve hydrodissection. In case of carpal tunnel syndrome, a network meta-analysis has demonstrated that 5% dextrose is the most effective injectate for symptom relief . AdditioThis study has several limitations. First, the injection techniques were validated at only two sites on a cadaver. This was due to the fact that if the methylene blue staining was used on the other 10 cadavers, the exact locations of the SCN on the iliac crest might have not been accurately located. Second, we did not administer placebo injections over the subcutaneous layer or other sham treatments for comparison with the patient group. Our clinical objective was to investigate the responsiveness and predictors of ultrasound-guided 5% dextrose hydrodissection for SCN entrapment; therefore, future studies are needed to explore the comparative effectiveness of our approach with other treatment methods. Third, structured rehabilitation was not incorporated after the injection. Considering that scoliosis is associated with symptom recurrence, it may be necessary to include physical therapy and exercise interventions in standard post-injection care to reduce thoracolumbar fascial tension and improve pelvic symmetry. Fourth, our study only followed patients for a period of three months, leaving the long-term effects of ultrasound-guided intervention unknown. Additionally, our strict inclusion criteria excluded patients with nonspecific low back pain who did not exhibit tenderness over the iliac crest. Future studies are necessary to explore the duration of the effect of ultrasound-guided SCN hydrodissection and determine whether the benefits of this intervention can extend to a broader patient population beyond those with SCN entrapment alone. Fifth, we did not routinely arrange all patients with initial injection failure or recurrent pain for EOS imaging , magnetiUltrasound imaging enables the localization of SCN branches on the iliac crest, and the findings are similar to those of cadaveric dissections. Enlargement of the nerve CSA is not useful for diagnosing SCN entrapment, and approximately 80% of cases respond positively to ultrasound-guided dextrose hydrodissection. Scoliosis is associated with symptom recurrence in patients with successful initial injections, and whether structured rehabilitation can reduce recurrence post-injection should be considered as one perspective in future research.Additional file 1. Supplemental tables.


Femoral nerve block (FNB) is a well-established analgesic technique for TKA. However, it associates quadriceps weakness. Therefore, femoral triangle block (FTB) and adductor canal block (ACB) were proposed as effective alternative motor-spearing techniques. The primary objective was to compare quadriceps muscle strength preservation between FNB, FTB and ACB in TKA. The secondary objective was to analyze pain control and functional outcomes.This is a prospective, double-blinded RCT. From April 2018 to April 2019, patients who undergo a primary TKA were randomized into three experimental groups: FNB-G1/FTB-G2/ACB-G3. Quadriceps strength preservation was measured as the difference in maximum voluntary isometric contraction (MVIC) preoperatively and postoperatively.n = 22; G2, n = 26; G3, n = 30) met our inclusion/exclusion criteria. Patients with FNB retained significantly lower baseline MVIC at 6 h postoperatively (p = 0.001), but there were no differences at 24 and 48 h. There were no differences between the groups in functional outcomes at any time point. Patients in the FNB-G1 presented significant lower pain scores at 6 h (p = 0.01), 24 h (p = 0.005) and 48 h (p = 0.01). The highest cumulative opioid requirement was reported in ACB-G3.Seventy-eight patients .This study was registered in clinicaltrials.gov (NCT03518450;  Every year, the number of total knee arthroplasties (TKA) is increasing . Acute pThe anterior innervation of knee joint seems to be the most relevant for postoperative pain after TKA. The femoral nerve provides the anteromedial sensory innervation of the knee; femoral nerve block (FNB) has been shown to be an effective and well-established analgesic technique for TKA . HoweverThe primary objective of this prospective, double-blinded, randomized controlled trial (RCT) was to compare quadriceps muscle strength preservation between three PNB techniques in TKA: FNB vs FTB vs ACB. The secondary objective was to analyze pain control and functional outcomes.This study is a prospective, double-blinded RCT. It was approved by the Ethics Committee (R(AG)299/2017) and it was registered in clinicaltrials.gov . The present trial is reported in compliance with the CONSORT statement.From April 2018 to April 2019, patients who were listed to undergo an elective, unilateral, primary TKA at the Department of Orthopedic Surgery of our center  were screened for the study. The inclusion criteria were: (a) patients older than 18 years of age, (b) elective, unilateral, primary TKA, (c) operated in our center between April 2018 and April 2019 and (d) programmed to be the first surgery of the day. Exclusion criteria included: (a) revision knee surgery, (b) previous diagnosis of unstable psychiatric pathology, (c) dementia, (d) kidney or hepatic disease that contraindicated the use of NSAIDs and/or paracetamol, (e) allergy to any component of multimodal analgesia, (f) use of opioids greater than 30 mg of oral morphine equivalent daily dose (oMEDD) and g) history of drug abuse.Eligible patients were interviewed and provided with a printed information sheet. After written informed consent was obtained, the patient was assigned a participant number and the preoperative battery of tests was performed. Then, the participants were randomized into three experimental groups: FNB group (FNB-G1), distal FTB group (FTB-G2) and proximal ACB group (ACB-G3). The randomization and allocation were computer generated by a statistician not otherwise involved in the study. Sequentially numbered opaque envelopes with each participant intervention group were made. Once in the operating theatre, the assigned anesthesiologist opened the corresponding envelope with the designated group. Excluding the anesthesiologist, all other professionals and the patient were blinded to treatment allocation.The primary outcome was quadriceps muscle strength preservation. It was measured as the difference in quadriceps strength preoperatively and 6 h after surgery, using the maximum voluntary isometric contraction (MVIC). The MVIC was assessed by a Physical Medicine and Rehabilitation specialist at the preadmission consult and at 6, 24 and 48 h postoperatively. A handheld dynamometer (HHD) was used  . In a seThe secondary outcomes were pain control and functionality. Pain was assessed preoperatively and at 6, 24 and 48 h after surgery. Pain measurement was obtained at rest and during 45° passive flexion of the knee on a 0 (no pain) to 100 (pain as bad as it can be) visual analogue scale (VAS). Furthermore, cumulative opioid consumption was calculated at these time points using units of morphine milligram equivalents (MME) to analyze supplementary pain relief requirement. Functional tests were also measured preoperatively and at 6, 24 and 48 h postoperatively using the Timed Up and Go test (TUG), 30-secs-Chair-Stand-Test (30′ CST), 10-Point-Mobility-Scale (10-PMS), Daniels test and passive/active Range of Motion (ROM). Length of hospital stay (LOS) was measured from the surgery day until patient discharge.All PNB were performed by an experienced anesthesiologist under aseptic conditions, using a high-frequency (10–12 MHz) linear US probe , a 100-mm needle  and 30 mL of 0.25% bupivacaine with 4 mg of dexamethasone. Thirty minutes after performing the intervention technique, the efficacy of the nerve block was evaluated by testing for loss to cold sensation in the saphenous nerve innervation area. Then, an IPACK block  was admiPlacing the US probe on the proximal thigh perpendicular to its long axis, the femoral artery was located and followed towards the inguinal ligament. The femoral nerve was identified external to the artery. The injection point was located 1–2 cm distal to the inguinal ligament before the femoral artery bifurcation. Using an in-plane approach, the needle was advanced in a lateral-to-medial direction until the tip was located next to the femoral nerve.The US probe was placed in a transverse orientation over the mid-thigh. The sartorius muscle was identified and followed to the point where its medial border intersected the adductor longus medial border. Once the proximal end of the AC was identified, the distance from this point to the inguinal ligament was divided in thirds. The femoral artery was followed to the point where the distal and medial third of the FT met. A lateral-to-medial in-plane approach was used to advance the needle and locate its tip in the lateral aspect of the femoral artery.After the US identification of the proximal end of the AC, the transducer was moved distally to identify the adductor hiatus, where the femoral artery diverges from the sartorius muscle and goes through the adductor magnus tendon. Once the two ends of the AC were located, the distance between them was divided in thirds. The injection point was located where the proximal and medium thirds met. The needle was inserted from the lateral aspect of the thigh until locating the tip laterally to the femoral artery.During surgery, patients had standard monitors and intravenous access. All surgeries were performed by specialized orthopaedic surgeons from the knee unit. Patients were placed in the supine position. A medial parapatellar approach, under tourniquet, was used to implant a tricompartmental prosthesis (TKA). Local infiltration of analgesia (LIA) was not used.After surgery, all patients were transferred to the post-anesthesia care unit (PACU), where they remained until meeting the discharge criteria. Postoperative pain was assessed every 15 min. Patients with VAS scores of 40/100 or higher were managed with 2–4 mg of IV morphine every 10 min as needed. If the patient continued experiencing severe pain at the anterior aspect of the knee after the administration of 0.2 mg/kg of morphine within the first 6 h post-surgery, the PNB would be considered to have failed and a rescue FNB would be performed.Once out of the PACU, for the first 48 postoperative hours, the analgesic regimen consisted of 50 mg of IV dexketoprofen every 8 h and 1 g of IV paracetamol every 8 h. If the patient requested more analgesics and VAS score was 40/100 or higher, 1 mg/kg of IV tramadol was administered and repeated every 8 h if needed. IV morphine (2 mg/h) was used as second line rescue agent.The primary endpoint of this study was quadriceps muscle strength preservation (MVIC). In order to have an 80% chance of detecting 1.5 units of differences, with α = 0.05, a sample size of 38 participants per treatment group was needed for this study. Assuming a 10% dropout rate, a total sample size of 126 subjects (42 per group) was planned.X2 test or Fisher’s exact test were used as appropriate. To study the relationship between continuous data, Student’s T test or Mann–Whitney U test were used. The Kruskal–Wallis test was used to compare outcomes between the three groups. When significant differences were found, the test was followed by pairwise comparison using the Dunn’s multiple comparisons post hoc test with Bonferroni correction for multiple tests (three comparisons).The Kolmogorov–Smirnov test was used to assess normality. Normally distributed data were reported as mean (standard deviation [SD]). Non-normally distributed and ordinal data were reported as median (inter-quartile range [IR]), and categorical data were presented as number (percentage [%]). To study the possible relationship between categorical variables, Pearson p-values were two-tailed and a p-value < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS 14.0 .Analysis of data was performed by intention to treat analysis. All n = 4; G2, n = 4; G3, n = 4) were considered lost to follow-up due to unavailability to assess their postoperative outcomes. The three groups were comparable in terms of baseline demographic data (Table p = 0.02).Seventy-eight patients met our inclusion/exclusion criteria and were recruited for the study. An interim analysis was performed and significant differences in analgesic outcomes were noticed; recruitment was stopped as it was unethical to continue. The CONSORT diagram is presented in Fig. ta Table , except p = 0.001). However, there were no significant differences at 24 and 48 h.The quadriceps strength preservation assessment Table  showed tp = 0.01), 24 h (p = 0.005) and 48 h (p = 0.01) , , 24 (p = 0.005) and 48 h (p = 0.02), and at 6 h for passive flexion (p = 0.005).There were no observed group differences in VAS pain scores before surgery. However, patients in the FNB-G1 presented statistically significant lower median pain scores during rest at 6 h (6), Fig. . No pairp = 0.001) and 24 h (p = 0.01), , . This branch of the femoral nerve importantly contributes to the innervation of the anteromedial knee joint . BurcketIn our study, we did not use perioperative corticosteroids nor LIA. Both of them could be useful tools to enhance pain control in a multimodal analgesia setting. It has been reported that intravenous dexamethasone reduces postoperative pain, opioid consumption and nausea . HoweverOur study is subjected to several limitations. First, an interim analysis detected significant differences in analgesic outcomes between the three groups and recruitment was stopped. Therefore, the minimum sample size was not reached. The interim analysis was not planned in advance; however, it was carried out due to an apparent highly heterogeneity in pain control among patients. Second, there was an uneven distribution of participants between the three groups. It could have been better controlled by using a block randomization design. However, the study groups were comparable in terms of baseline demographic data . Third, the study did not contain a control group without PNB . On the other hand, it is a double-blinded RCT, which may allow to provide the highest level of evidence. Another strength of our work is that all the PNB were performed by an experienced anesthesiologist, using strict injection point location through anatomic and US landmarks. Furthermore, to homogenize the three groups, we used a 30 mL volume for all the PNB and an iPACK block was added to all participants.For patients undergoing TKA, distal FTB and proximal ACB preserve quadriceps strength better than FNB at 6 h postoperatively, but there are no differences at 24 and 48 h. Moreover, this early inferiority in strength preservation do not translate to worse functional outcomes at any time point nor longer LOS. FNB is associated with better pain control at 6, 24 and 48 h after TKA surgery, while ACB presents the highest cumulative opioid requirement. More RCTs comparing multiple PNB are necessary to clearly elucidate the role of each block in the TKA surgery.


To investigate health-related quality of life (HRQoL) of patients with knee osteoarthritis (KOA) in Guangzhou, China, and examine its association with selected sociodemographic characteristics as well as knee function.This multicenter cross-sectional study included 519 patients with KOA in Guangzhou from April 1 to December 30, 2019. Data on sociodemographic characteristics were obtained using the General Information Questionnaire. The disability was measured using the KOOS-PS, resting pain using the Pain-VAS, and HRQoL using the EQ-5D-5L. The association of selected sociodemographic factors, KOOS-PS and Pain-VAS scores with HRQoL (EQ-5D-5L utility and EQ-VAS scores) were analyzed using linear regression analyses.The median (interquartile range [IQR]) of EQ-5D-5L utility and EQ-VAS scores were 0.744 (0.571–0.841) and 70 (60–80) respectively, lower than the average HRQoL in the general population. Only 3.661% of KOA patients reported no problems in all EQ-5D-5L dimensions, with Pain/Discomfort being the most frequently affected dimension (78.805%). The correlation analysis showed that the KOOS-PS score, Pain-VAS score and HRQoL were moderately or strongly correlated. Patients with cardiovascular disease, no daily exercise, and high KOOS-PS or Pain-VAS scores had lower EQ-5D-5L utility scores; and patients with body mass index (BMI) > 28 ,high KOOS-PS or Pain-VAS scores had lower EQ-VAS scores.Patients with KOA had relatively low HRQoL. Various sociodemographic characteristics as well as knee function were associated with HRQoL in regression analyses. Providing social support and improving their knee function through methods such as total knee arthroplasty might be crucial to improve their HRQoL. Osteoarthritis (OA) is a common and disabling chronic musculoskeletal disease worldwide, imposing heavy social and economic burdens on patients and healthcare systems in numerous countries . So far,The HRQoL is a subjective assessment of the physical, psychological and social dimensions of health . To dateDespite the potentially large impact of KOA on people's health, so far relatively few studies have assessed the impact on HRQoL and its determinants –41. PrevThis cross-sectional study included patients before total knee arthritis (TKA) at one of four tertiary hospitals in four districts of Guangzhou, China, from April 1 to December 30, 2019. We used the following inclusion criteria to filter these patients: (1) diagnosed as KOA according to the 2018 clinical guidelines for the diagnosis of osteoarthritis in China  and (2) 2) was calculated using height and weight for each patient. According to the guidelines of the Working Groups on Obesity in China [Sociodemographic characteristics of patients were collected using the General Information Questionnaire developed by the International Consortium for Health Outcomes Measurement (ICHOM) for KOA. The survey content included sex, age, height, weight, marital status, smoking status, alcohol consumption, monthly family income, medical insurance, frequency of physical activity, history of knee surgery, and history of KOA. Body mass index , a simplified version of the original KOOS, is a measure of impairment, handicap and disability after knee injury . It inclThe Visual Analogue Pain Scale (Pain-VAS) score is mostly used for the subjective feelings of the respondents on pain. It uses a 10-point scale, with higher scores indicating greater pain intensity, such as 0 for no pain and 10 for severe pain .alpha coefficient of the EQ-5D-5L utility score in this study was 0.78, representing that the internal consistency of this scale is good. This EQ-5D-5L scale also includes a visual analogue scale , which records the patient's self-rated health status [The European Quality of Life Five-Dimensional Five-Level (EQ-5D-5L) scale is a standardized tool developed by the EuroQol Group to measure HRQoL . Becauseh status . The EQ-p-value < 0.05 (two-sided) was considered statistically significant. The database was established using EpiData 3.1 software, and R software (version 4.1.2) was used for data cleaning, statistical description, and statistical analysis.Descriptive summary statistics were performed for sociodemographic characteristics, KOOS-PS score, Pain-VAS score, EQ-5D-5L dimensions , EQ-5D-5L utility score, EQ-VAS score, and the top 20 most frequent EQ-5D-5L health status . Univarip < 0.05) Furthermore, the average KOOS-PS and Pain-VAS scores were 33.920 (sd = 14.739) and 3.894 sd = 2.601 respectively.Table The violin plots in Fig. mentclass2pt{minimTable Figure Next, we explored the impacts of the statistically significant sociodemographic characteristics in univariate analyses , as well as knee function (KOOS-PS and Pain-VAS scores) on HRQoL using the linear regression models. Table KOA is the most common clinical OA and imposes a severe burden on patients and healthcare systems. The clinical symptoms of patients with KOA are mainly knee joint swelling, pain, and mobility impairment, which severely limit the patient's mobility and self-care ability, and greatly reduce the patient's health-related quality of life (HRQoL) . HRQoL iOur findings demonstrated that KOA patients in Guangzhou had a relatively poor HRQoL compared with the general population, which needs attention. In this study, the median (IQR) of EQ-5D-5L utility scores was 0.744 (0.571–0.841), lower than that of the general populations in China (0.96) , AustralThe results of this study showed the correlations among EQ-5D-5L dimensions, EQ-5D-5L utility score, EQ-VAS score, KOOS-PS score, and Pain-VAS score. Specifically, we observed strong positive correlations among Mobility, Self-care and Usual activities; strong negative correlations between EQ-5D-5L utility score and EQ-5D-5L dimensions, indicating that the EQ-5D-5L has high content consistency. In addition, there were moderate positive correlations between the KOOS-PS score and EQ-5D-5L dimensions, and a strong negative correlation between the KOOS-PS score and EQ-5D-5L utility score, suggesting that the KOOS-PS score may affect the EQ-5D-5L utility score by having effects on EQ-5D-5L dimensions. Finally, the Pain-VAS score was moderately correlated with Pain/Discomfort and EQ-5D-5L utility score, indicating that the Pain-VAS score may influence the EQ-5D-5L utility score through the Pain/Discomfort dimension.The results of multivariate linear regression analysis also showed that there were differences in the EQ-5D-5L utility and EQ-VAS scores in different hospitals, suggesting that there was a certain center specificity. Possible explanations included: the relatively small number of patients in the Hospital D (only 22), heterogeneity among the four districts, or differences in the ways the researchers asked questions. Although univariate analysis showed that age may have an effect on EQ-5D-5L. However, we did not find statistically significant association of age with HRQoL after adjusting for knee function Table . We alsop < 0.0001). Thus, it is crucial to improve the knee function of patients with KOA. Unicompartmental knee arthroplasty, osteotomy, arthroscopic surgery and total knee arthroplasty (TKA) can all improve the functional scores of KOA patients. Follow-up studies have shown that TKA is superior to other interventions in improving knee function and relieving knee pain in the long term [Furthermore, our findings found that the higher the KOOS-PS or Pain-VAS score, the lower the EQ-5D-5L utility and EQ-VAS scores, which is consistent with the previous studies , 41, 60.ong term . Additioong term . In lighong term .Although investigating the HRQoL of KOA patients in China is important, more studies should be conducted in this research area –40. ThisSeveral limitations also need to be acknowledged. First, we only included 519 patients with advanced KOA who were going to TKA at one of four tertiary hospitals in Guangzhou, China. Those who were not planning to go to the hospital for TKA were not included in the study. These individuals may have different health indices, and this limitation may have introduced some bias in our estimates and somewhat affected the extrapolation of our study. Second, future studies should consider the impact of satisfaction subscores and patient expectations on HRQoL . In addiIn this paper, we investigated the HRQoL among patients with KOA in Guangzhou, and analyzed the influence of selected sociodemographic characteristics as well as knee function on HRQoL. In summary, the HRQoL of KOA patients in Guangzhou is relatively low, and comprehensive measures should be taken to control the occurrence and development of KOA. The HRQoL of patients with KOA is related to some sociodemographic characteristics  as well as knee function and pain scores . These findings may support policymakers in maintaining the HRQoL of the Chinese population when designing community-based mental health care and health policies.


As the evidence showed, despite the magnitude of the effects that pain can have on a child, it is often inadequately assessed and treated. However, whether pain is adequately treated or not, evidence is lacking in the study setting.This study assessed pain management adequacy among hospitalized pediatric patients at the University of Gondar Comprehensive Specialized Hospital, Ethiopia.p-value <0.05 at a 95% CI was considered statistically significant.An institution-based cross-sectional study was conducted among pediatric patients admitted to the University of Gondar Comprehensive and Specialized Hospital between June and August 2021. Eligible patients were enrolled in the study using consecutive sampling techniques. Data were collected using a structured interview-based questionnaire and a review of the patient's medical records that were prepared after reviewing earlier studies. Pain management adequacy was determined using the pain management index (PMI) score. Statistical Software for Social Sciences (SPSS) version 22 was used for data entry and analysis. Descriptive statistics such as frequencies, percentages, and means with standard deviation were used to describe the respective variables. Logistic regression was used to assess predictor variables of pain management adequacy. A Of the 422 participants enrolled in the study, most (58.1%) were males, with a mean age of 3.9 ± 0.8 years. Pain medication was prescribed to 62.8% (95% CI: 57.3–68.2) of the participants. About 63.3% (95% CI: 58.8%–68%) received inadequate analgesics. The type of painkillers administered also did not match the severity of the pain. Pediatric patients less than 1 month and between 1 month and 1 year , respectively, and patients with severe and moderate levels of pain , respectively, were found to have inadequate pain medication compared with their counterparts.This study revealed that pain was hardly managed based on its severity. Overall, two-thirds of pediatric patients received inadequate pain medication. This indicates majority of patients experienced pain did not manage appropriately. Pain is an unpleasant emotion and sensory complaint associated with actual or potential tissue damage, as defined by the International Association for the Study of Pain –3. Pain Pediatric pain treatment protocols have made great progress recently with the advancement and validation of pain valuation tools for pediatric patients , 13. WitData from children's hospitals around the world reveal that pain in pediatric patients from infancy to adolescence is common, under-recognized, and undertreated compared with adult patients –7, 21. PA cross-sectional observational study in Toronto hospitals shows that out of the total 265 children, only 58.9% received a minimum of one documented intervention in pain management. Out of the 66 children with recognized pain, 55 received an intervention for their pain . The AmeGenerally, in consideration of the above challenges, management of pain in pediatric encompasses the use of pharmacological and non-pharmacological interventions to control the patient's identified pain. Studies on the adequacy of pain management and prevention among hospitalized paediatric patients are limited in resource-limited settings, particularly in Ethiopia. Therefore, this study assessed pain management and its adequacy in pediatric patients admitted to UoGCSH, Northwest Ethiopia. The study findings will add to the body of knowledge of both healthcare providers and patients and carers and will serve as the baseline for further study.An institutional-based cross-sectional study was conducted among paediatric patients admitted to the University of Gondar Comprehensive and Specialised Hospital (UoGCSH) from June 17 to August 20, 2021. The hospital is among the largest teaching hospitals in the country and has provided both teaching and clinical services for different specializations, including pediatric. It serves more than five million people from its surroundings . This stPediatric patients less than 18 years of age who had experienced pain during their hospital stay in the UoGCSH were used as a source population. Pediatric admitted patients experienced pain during the data collection period were study participants and included in the study. Terminally ill patients, patients with neurological disorders, and individuals who refused to participate in the study were excluded.p of 50%, as there were no previous studies found in the study area and a 10% non-response rate. The sample size was calculated as follows:n is the minimum sample size required.The sample size was determined using the single population proportion formula with the assumption of a 5% margin of error, a 95% confidence interval, and a proportion Zα/2 = the standard at the 95% confidence interval; p = proportion = 50%; d = margin of error, i.e., = 0.05.The pain management index (PMI) was used to assess the adequacy of pain treatment in pediatric patients. PMI was calculated by subtracting the pain scores from the analgesics scores. The pain scores are classified as follows: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain. The analgesic scores derived from the WHO ladder are classified into the following: 0 = no analgesics, 1 = WHO I , 2 = WHO II (weak opioid), and 3 = WHO III (strong opioid). The Pain Management Index (PMI) ranges from −3 to 3; negative scores indicate undertreatment, but positive scores do not necessarily represent overtreatment.Adequate pain management: it is indicated for the PMI score greater than or equal to zero, while inadequate pain management refers for the PMI score less than zero. Pain management: is an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain .A structured face-to-face interview-based questionnaire was developed for the participants interviews, while a semi-structured data extraction format was used for the collection of data from the participants’ medical records. The general data collection instrument was developed in English after an extensive literature review. It was translated to a local language, Amharic, to make the data collection procedure easy, then translated to English to maintain consistency. Different pain severity assessment tools were used to assess the level of pain. The revised Faces, Legs, Activity, Cry, and CONSOL Ability Scale (r-FLACC) tool was used to assess the severity of pain among pediatric who can't report pain by themselves (for those less than 5 years), while self-reporting pain assessment tools like the Faces Pain Scale-Revised tool  and Numerical Pain Rating scales were used for participants who could report their pain by themselves, particularly, children aged greater than 5 years are capable of self-reporting their pain intensity , 32.The data was collected by four graduating pharmacy students voluntarily. The participants’ interview method was employed using structured questionnaires for assessing pain and its management adequacy. Sociodemographic variables, diagnoses, comorbidities, and medications were collected variables. The prescribed analgesics, medication regimens, physician diagnosis, nursing care, and different pharmacological and non-pharmacological treatments were obtained from the patient's medical records. Before the data collection, both verbal and written consent was obtained from participants or carers. A parental consent form was signed for children less than or equal to 8 years old, while those aged above 8 years gave direct consent by themselves. Then, data collection procedures were conducted accordingly.Before the actual data collection period, the questionnaire was pretested on 5% of the study participants. A pretest was conducted at Debark General Hospital. Data collectors received a half-day training regarding the objectives, data collection producers, and ethical aspects. Then, data were collected after the enrolled participants were informed about the purpose of the study, the importance of their participation, and the ethical procedures. The collected data were checked for completeness, accuracy, and consistency at every step during and after data collection. The supervisors explicitly followed the data producers during the data collection period.p-value <0.2 in the bivariable logistic regression were further analyzed in the multivariable logistic regression. The Hosmer-Lemeshow model was fitted and adjusted for variables. A p-value <0.05 at a 95% CI was considered as statistically significant.Data was entered into SPSS version 22 for data processing and analysis. After the data was checked for its cleanliness, completeness, and consistency, analysis was carried out. The normal distribution of continuous variables was examined using a histogram, a Q-Q plot and the Shapiro-Wilk test. Categorical variables were presented using frequencies and percentages, while continuous variables were described by mean (standard deviation). Logistic regression was used to assess predictor variables of pain medications adequacy. Variables with a A total of 422 pediatric patients were enrolled in this study (100% response rate). The mean ± SD age of the study participants was 3.9 ± 0.8 years. Most of the study participants (58.1%) were males, with a higher proportion (37.4%) being toddlers or preschool age groups (1–5 years) . The detA higher proportion of patients (30%) experienced a dull type of pain. Detailed patient pain descriptions are illustrated in Less than two-thirds (62.8%) of the participants received pain medication. A higher proportion of the participants (39.6%) received a single acetaminophen analgesia. The most common routes of administration of the prescribed medications were oral (28.0%) followed by a suppository (20.6%). Most of the participants (58.8%) received pre-procedural pain medications. A higher proportion of the participants (30.1%) reported that they required an added dose or additional analgesics medication for the undertreated pain.Beyond the pharmacologic interventions, participants were managed by non-pharmacological means, such as cold application (37.2%) followed by heat application (19.4%). The previously tried treatments for pain relief were prescription medications (15.6%) followed by OTC drugs (8.5%) and non-pharmacological (7.3%) .Although all children with severe pain received at least one pain medication, only a lower proportion (0.70%) of patients with severe pain received WHO III (strong opioid) management. Moreover, a higher proportion (4.7% and 14%) of patients with moderate and mild pain, respectively, did not receive any medication to relieve their pain . The perOverall, only 36.7% (95% CI: 32%–41.2%) of the pediatric patients received adequate analgesia. The association of pain management adequacy and potential predictor variables was assessed using a logistic regression model. As a result, a multivariable logistic regression analysis showed that the age of patients and intensity of pain have a significant association with pain treatment adequacy. After taking other variables constant, pediatrics patients aged less than 1 month and those from 1 month to 1 year were found more likely to have inadequate pain management compared with those aged greater than 5 years , respectively. Similarly, patients with severe and moderate levels of pain were found to be more likely to have inadequate pain management than those with mild levels of pain intensity , respectively .Based on the authors’ best searching strategy, no single study that assessed pain management in the paediatric population in the study setting has been published yet. The current finding is fundamental to highlighting the extent of pain management adequacy. This hospital-based cross-sectional study assessed pain management adequacy among admitted paediatric patients. The findings from this study highlighted the management pattern and whether the pain is adequately treated or not based on its WHO class of severity. Additionally, the findings explored potential predictor variables associated with pain management inadequacy. The study revealed that about two-thirds of the patients received inadequate pain medication. Paediatric patients younger than 1 year and patients with severe and moderate levels of pain, respectively, were found to have inadequate pain medication compared with patients older than 5 years and patients with mild pain.Pain is among a common symptoms in hospitalized children . AssessmIn this study, the prevalence of moderate to severe pain was high among hospitalized children, and its management was suboptimal. This is consistent with previous studies , 41–43. In the management of pain, a multimodal approach with two or more medications has been recommended in pediatric patients with persistent underlined pain , as wellIn line with the previous studies , 44, 45,The other interesting aspect that this study demonstrated is the association between pain management adequacy and predictor variables of inadequate pain management. Although the educational background of caregivers, health insurance status, and monthly household income had an association with pain management adequacy in bivariable regression, only the age of the patients and severity of pain were found to have a significant association with pain management adequacy with further analysis using multivariable logistic regression. Consequently, the study found that pediatric patients aged less than 1 year were more likely to have pian management inadequacy compared with those patients with an age greater than 3 years. This might be related to a lower pain assessment in infants because of their difficulty self-reporting their symptoms and pains. Children of a lower age, particularly infants, couldn't report their pains comprehensively. As a result, they sustain the inadequacy of management unless there is a comprehensive pain assessment and management practice. The findings may imply that pediatrics patients, particularly infants, might require special attention towards assessing and managing their pains. Therefore, clinicians could be motivated in the manner of pain management practices. They should adhere to standard tools and guidelines while managing pediatric patients, in particular infant patients.Consistent with previous studies , 41, 47,Generally, the current study highlighted the adequacy of pain management and the extent of pediatric patient pain treatment in a resource-limited setting. Furthermore, it also demonstrated the need to explore the factors associated with pain medications inadequacy. Therefore, we also hope to give some insight into and add to the body of knowledge for practitioners and patients related to the adequacy of pain treatment and prevention in pediatric patients.This study is the first of its kind to assess the adequacy of pain management in paediatric patients and can be a fundamental tool to highlight the extent of pain management. As a limitation, pain was not assessed under different conditions, such as at rest, during movement, and during sleeping time. Because of the nature of the study design, we took the data at the appointed time, but we could not assess the response to pain management and were unable to follow undertreated patients. Point prevalence does not adequately describe the quality of pain management in a population because of these reasons. The PMI is also limited by assessing adequacy based on type of analgesics for severity of pain rather than dose, which results in a very crude measure of treatment adequacy according to the WHO guidelines. The PMI also does not distinguish adherence to the guidelines or the quality of the prescribers. A mixed study method, including a qualitative study, might be important and welcomed for future research. Despite these limitations, this study can provide insight regarding the extent of pain management practice among pediatric patients in a resource-limited setting.This study concluded that the majority of pediatric patients received inadequate pain management. Patients’ age and level of severity of pain were found to be significantly associated with pain management inadequacy. Pain management in pediatric patients could include compliance with guidelines, focusing on the severity of pain, and age-based assessment and management. Since pain is linked to different systems and has multifactorial causes, a combination of pain medications can provide a better outcome to relieve the pediatric patients from persistent pain. Therefore, patients could be assessed according to their severity, and adequate management should be tailored accordingly. Clinicians could also be highly vigilant and motivated towards adherence to pain assessment and management practices in pediatric patients. Additionally, nurses who care for pediatric patients could become familiar with the assessment tools and management modalities.