S. J. Farrelly, A. O'Donoghue, R. O'Connor

Cork University Hospital, Ireland


Inadequate treatment of pain can result in hyperaesthesia, increased risk of post operative infection and delayed discharge.  There is no standardised treatment pathway for children with abdominal pain in our hospital.  We reviewed our current standard of treatment and compared it to the GIRFT best practice guideline “Acute paediatric abdominal pain pathway”. (1)


A retrospective chart review was conducted over 18 months in Cork University Hospital (CUH) to identify all emergency laparoscopic appendicectomies undertaken in the paediatric population. The sample size obtained was 75 cases.

There was no formal documentation of pain scores in the emergency department (ED).  Allowing for pre-hospital analgesia (38%), the mean time to first analgesia in the ED was 3.6 hours.

66% of patients received perioperative diclofenac and nearly 20% of that cohort had subtherapeutic drug administration. Paracetamol administration was appropriate. 98% of patients received intraoperative morphine however 56% were administered less than 0.1mg/kg.  Local anaesthetic was infiltrated at the surgical site in 72% of cases.

Pain scores were reliably recorded in theatre recovery (95%).  18% of the patients had a pain score of 5-10 in the immediate post operative phase requiring rescue analgesia.  Patients who experienced higher pain scores had either subtherapeutic morphine, subtherapeutic diclofenac, no local anaesthetic administration or a combination of the above.  A further 10% had pain scores of 3-4 in theatre recovery.  15% of patients had a pain score > 4 in the 24 hour period post operatively.

Strategy for change

We presented the findings of our audit to our Anaesthesia department and provided education meetings on paediatric analgesia prescribing to trainees.  We have engaged with ED staff to promote the use of validated pain scores and highlighted the time to first analgesia administration.

These findings are being used for a business case to employ a dedicated paediatric pain CNS.

Measure of improvement

We will re-audit the pain management of our cohort of paediatric laparoscopic appendicectomies after the above interventions have been fully instituted to determine if our interventions have been successful.

Lessons learnt

Our results suggest that the analgesia administered to patients in the peri and post operative period is suboptimal, only 72% achieving pain scores of 0-2 in the immediate post operative phase.  We also note a prolonged time to administration of first analgesia compared to best practice (20 minutes) in the ED.

Message for others

CUH is not a dedicated paediatric hospital but has a paediatric caseload across of a range of acute and elective surgery of over 2500 children per year.  Optimum delivery of care in our centre is centred on education of staff regarding paediatric analgesic needs and the introduction of standardised, validated treatment algorithms.


Ref. 1. “Acute paediatric abdominal pain pathway”. Getting it Right First Time 2022

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