A Comparison Of Pain Scores With Or Without Local Anaesthesia
Transcript Of A Comparison Of Pain Scores With Or Without Local Anaesthesia
A COMPARISON OF PAIN SCORES WITH OR WITHOUT LOCAL ANAESTHESIA IN NEONATAL CIRCMCISION USING PLASTIBELL TECHNIQUE AT PLATEAU STATE SPECIALIST HOSPITAL, JOS, NIGERIA A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF
THE COLLEGE IN FAMILY MEDICINE (FMCFM) PART II FINAL EXAMINATION MAY 2010 BY DR.AMINU GANGO FIKIN
DEPARTMENT OF FAMILY MEDICINE PLATEAU STATE SPECIALIST HOSPITAL, JOS, NIGERIA
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ACKNOWLEDGEMENT My heartfelt gratitude goes to DR STEPHEN YOHANNA for his ingenuity, thorough supervision, guidance and encouragement throughout the entire period of my training and this work. I’m also grateful to DR PITMANG, DR LAR, DR LAABES, and DR INYANG for their contribution and criticism. My gratitude goes to all the consultants of Plateau State Specialist Hospital, Jos for contributing in one way or the other during my period of training. My sincere thanks goes to DR ABUBAKAR BALLA who provided me with shelter throughout the period of my training.
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DEDICATION To my children, AHMED, YUSUF, HADIJA, ALHAJI GONI, BA MAINA, AWULU and ABDULMUMINI, my wife, MOGOROM FATI MAINA GORIA, and my Mother and Father. Thank you for everything you are to me.
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CERTIFICATION This is to certify that Dr. Aminu G. FIKIN performed the study reported in this Dissertation at Plateau State Specialist Hospital under our supervision. We also supervised the writing of the dissertation. SUPERVISOR Dr. STEPHEN YOHANNA (BM, BCH; MPH; FMCGP; FWACP) CONSULTANT FAMILY PHYSICIAN EVANGEL HOSPITAL, JOS, NIGERIA SIGNATURE: ………………………………………………….. DATE: …………………………………………………………. HEAD OF DEPARTMENT Dr. INYANG OLUBUKUNOLA (MB, BS; FMCGP) CONSULTANT FAMILY PHYSICIAN PLATEAU STATE SPECIALIST HOSPITAL, JOS, NIGERIA SIGNATURE: …………………………………………. DATE: ………………………………………………………..
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LIST OF ABBREVIATIONS
AAP American Academy of Pediatrics
AMA American Medical Association
BC
Before Christ
CRIES Crying, Requirement, Increased vital signs, facial Expression
and Sleeplessness
FLACC F ace, Legs, Activity, Cry, and Consolability
IASP International Association for Study of Pain
NFCS Neonatal Facial Coding System
NIPS Neonatal/Infant Pain Score
N-PASS Neonatal Pain Agitation and Sedation Scores
PIPP
PREMATURE Infant Pain Profile
US
United States
WHO World Health Organization
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TABLE OF CONTENTS
ACKNOWLEDGEMENT ........................................................................................................................... i DEDICATION .......................................................................................................................................... ii CERTIFICATION .....................................................................................................................................iii LIST OF ABBREVIATIONS .................................................................................................................... iv TABLE OF CONTENTS........................................................................................................................... v LIST OF TABLES ..................................................................................................................................viii LIST OF FIGURES ................................................................................................................................. ix ABSTRACT ............................................................................................................................................. 1 CHAPTER ONE: INTRODUCTION ......................................................................................................... 3 1.1 INTRODUCTION ............................................................................................................................... 3 1.2 STATEMENT OF THE PROBLEM AND PROBLEM ANALYSIS. .................................................... 6 1.3 AIM .................................................................................................................................................... 6 1.4 OBJECTIVES .................................................................................................................................... 6 1.5 RATIONALE FOR THE STUDY......................................................................................................... 7 1.6 RELEVANCE OF THE STUDY TO FAMILY MEDICINE. ................................................................ 7 CHAPTER TWO: LITERATURE REVIEW............................................................................................... 9 2.1 HISTORY OF CIRCUMCISION. ........................................................................................................ 9 2.2 EPIDEMIOLOGY OF CIRCUMCISION............................................................................................ 14 2.3 CIRCUMCISION TECHNIQUES...................................................................................................... 19 2.4 NEONATAL PAIN RESPONSE DURING CIRCUMCISION............................................................. 24
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2.5 PAIN ASSESSMENT TOOLS.......................................................................................................... 32 2.6 PAIN MANAGEMENT IN NEONATES. ......................................................................................... 37 2.7 ANAESTHESIA FOR NEONATAL CIRCUMCISION. ...................................................................... 44 2.8 COMPLICATIONS OF NEONATAL CIRCUMCISION. .................................................................... 47 CHAPTER THREE: MATERIALS AND METHODS.............................................................................. 59 3.1 STUDY ENVIRONMENT. ................................................................................................................ 59 3.2. STUDY POPULATION. .................................................................................................................. 59 3.3 STUDY DESIGN.............................................................................................................................. 59 3.4 THE SAMPLE SIZE. ........................................................................................................................ 60 3.5 SAMPLING METHOD...................................................................................................................... 60 3.6 INCLUSION CRITERIA. .................................................................................................................. 61 3.7 EXCLUSION CRITERIA. ................................................................................................................. 61 3.8 METHOD AND INSTRUMENT OF DATA COLLECTION. ............................................................... 61 3.9 METHOD OF DATA ANALYSIS. ..................................................................................................... 65 3.10 ETHICAL CONSIDERATION......................................................................................................... 65 CHAPTER FOUR: RESULTS. ............................................................................................................... 66 4.1 PHYSICAL CHARACTERISTICS OF THE NEONATES.................................................................. 66 4.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARENTS. ............................................. 67 4.3 NEONATAL INFANT PAIN SCORES. ............................................................................................. 68 4.4 COMPARISON OF MEAN NEONATAL INFANT PAIN SCORES. .................................................. 70 4.5 PHYSIOLOGICAL CHANGES DURING CIRUMCISION. ................................................................ 74 4.6 DURATION OF CIRCUMCISION .................................................................................................... 76
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4.7 COMPLICATIONS OF NEONATAL CIRCUMCISION ..................................................................... 77 4.8 REASONS FOR CIRCUMCISION. .................................................................................................. 79 CHAPTER FIVE: DISCUSSION ........................................................................................................... 80 5.1 PHYSICAL CHARACTERISTICS OF NEONATES.......................................................................... 80 5.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARENTS. ............................................. 81 5.3 NEONATAL INFANT PAIN SCORES .............................................................................................. 82 5.4 PHYSIOLOGICAL AND BEHAVIOURAL CHARACTERISTICS ...................................................... 84 5.5 COMPLICATIONS OF NEONATAL CIRCUMCISION ..................................................................... 86 5.6 DURATION OF SURGERY ............................................................................................................. 87 5.7 REASONS FOR NEONATAL CIRCUMCISION............................................................................... 87 5.8 IMPLICATIONS FOR FAMILY PHYSICIANS .................................................................................. 88 5.9 CONCLUSION................................................................................................................................. 89 5.10 RECOMMENTATION. ................................................................................................................... 90 5.11 CONSTRAINT. .............................................................................................................................. 90 REFERENCES. ..................................................................................................................................... 91 APPENDIX A: CONSENT FORM. ....................................................................................................... 102 APPENDIX B: QUESTIONNAIRE ....................................................................................................... 104 APPENDIX C: NEONATAL/INFANT PAIN SCALE (NIPS) .................................................................. 107 APPENDIX D: ETHICAL CLEARANCE ............................................................................................... 108 APPENDIX E: CIRCUMCISION INSTRUMENTS................................................................................ 109
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LIST OF TABLES
Table 1: Physical characteristics of Neonates
66
Table 2: Socio-demographic characteristics of parents
67
Table 3: Neonatal pain scores during surgery
68
Table 4: Mean neonatal pain scores
70
Table 5: Physiological changes during circumcision
74
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LIST OF FIGURES
Figure 1: Comparison of Mean pain scores
73
Figure 2: Comparison Mean of duration of surgery
77
Figure 3: Complications of Neonatal circumcision
78
Figure 4: Reasons for circumcision
79
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THE COLLEGE IN FAMILY MEDICINE (FMCFM) PART II FINAL EXAMINATION MAY 2010 BY DR.AMINU GANGO FIKIN
DEPARTMENT OF FAMILY MEDICINE PLATEAU STATE SPECIALIST HOSPITAL, JOS, NIGERIA
i
ACKNOWLEDGEMENT My heartfelt gratitude goes to DR STEPHEN YOHANNA for his ingenuity, thorough supervision, guidance and encouragement throughout the entire period of my training and this work. I’m also grateful to DR PITMANG, DR LAR, DR LAABES, and DR INYANG for their contribution and criticism. My gratitude goes to all the consultants of Plateau State Specialist Hospital, Jos for contributing in one way or the other during my period of training. My sincere thanks goes to DR ABUBAKAR BALLA who provided me with shelter throughout the period of my training.
ii
DEDICATION To my children, AHMED, YUSUF, HADIJA, ALHAJI GONI, BA MAINA, AWULU and ABDULMUMINI, my wife, MOGOROM FATI MAINA GORIA, and my Mother and Father. Thank you for everything you are to me.
iii
CERTIFICATION This is to certify that Dr. Aminu G. FIKIN performed the study reported in this Dissertation at Plateau State Specialist Hospital under our supervision. We also supervised the writing of the dissertation. SUPERVISOR Dr. STEPHEN YOHANNA (BM, BCH; MPH; FMCGP; FWACP) CONSULTANT FAMILY PHYSICIAN EVANGEL HOSPITAL, JOS, NIGERIA SIGNATURE: ………………………………………………….. DATE: …………………………………………………………. HEAD OF DEPARTMENT Dr. INYANG OLUBUKUNOLA (MB, BS; FMCGP) CONSULTANT FAMILY PHYSICIAN PLATEAU STATE SPECIALIST HOSPITAL, JOS, NIGERIA SIGNATURE: …………………………………………. DATE: ………………………………………………………..
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LIST OF ABBREVIATIONS
AAP American Academy of Pediatrics
AMA American Medical Association
BC
Before Christ
CRIES Crying, Requirement, Increased vital signs, facial Expression
and Sleeplessness
FLACC F ace, Legs, Activity, Cry, and Consolability
IASP International Association for Study of Pain
NFCS Neonatal Facial Coding System
NIPS Neonatal/Infant Pain Score
N-PASS Neonatal Pain Agitation and Sedation Scores
PIPP
PREMATURE Infant Pain Profile
US
United States
WHO World Health Organization
v
TABLE OF CONTENTS
ACKNOWLEDGEMENT ........................................................................................................................... i DEDICATION .......................................................................................................................................... ii CERTIFICATION .....................................................................................................................................iii LIST OF ABBREVIATIONS .................................................................................................................... iv TABLE OF CONTENTS........................................................................................................................... v LIST OF TABLES ..................................................................................................................................viii LIST OF FIGURES ................................................................................................................................. ix ABSTRACT ............................................................................................................................................. 1 CHAPTER ONE: INTRODUCTION ......................................................................................................... 3 1.1 INTRODUCTION ............................................................................................................................... 3 1.2 STATEMENT OF THE PROBLEM AND PROBLEM ANALYSIS. .................................................... 6 1.3 AIM .................................................................................................................................................... 6 1.4 OBJECTIVES .................................................................................................................................... 6 1.5 RATIONALE FOR THE STUDY......................................................................................................... 7 1.6 RELEVANCE OF THE STUDY TO FAMILY MEDICINE. ................................................................ 7 CHAPTER TWO: LITERATURE REVIEW............................................................................................... 9 2.1 HISTORY OF CIRCUMCISION. ........................................................................................................ 9 2.2 EPIDEMIOLOGY OF CIRCUMCISION............................................................................................ 14 2.3 CIRCUMCISION TECHNIQUES...................................................................................................... 19 2.4 NEONATAL PAIN RESPONSE DURING CIRCUMCISION............................................................. 24
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2.5 PAIN ASSESSMENT TOOLS.......................................................................................................... 32 2.6 PAIN MANAGEMENT IN NEONATES. ......................................................................................... 37 2.7 ANAESTHESIA FOR NEONATAL CIRCUMCISION. ...................................................................... 44 2.8 COMPLICATIONS OF NEONATAL CIRCUMCISION. .................................................................... 47 CHAPTER THREE: MATERIALS AND METHODS.............................................................................. 59 3.1 STUDY ENVIRONMENT. ................................................................................................................ 59 3.2. STUDY POPULATION. .................................................................................................................. 59 3.3 STUDY DESIGN.............................................................................................................................. 59 3.4 THE SAMPLE SIZE. ........................................................................................................................ 60 3.5 SAMPLING METHOD...................................................................................................................... 60 3.6 INCLUSION CRITERIA. .................................................................................................................. 61 3.7 EXCLUSION CRITERIA. ................................................................................................................. 61 3.8 METHOD AND INSTRUMENT OF DATA COLLECTION. ............................................................... 61 3.9 METHOD OF DATA ANALYSIS. ..................................................................................................... 65 3.10 ETHICAL CONSIDERATION......................................................................................................... 65 CHAPTER FOUR: RESULTS. ............................................................................................................... 66 4.1 PHYSICAL CHARACTERISTICS OF THE NEONATES.................................................................. 66 4.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARENTS. ............................................. 67 4.3 NEONATAL INFANT PAIN SCORES. ............................................................................................. 68 4.4 COMPARISON OF MEAN NEONATAL INFANT PAIN SCORES. .................................................. 70 4.5 PHYSIOLOGICAL CHANGES DURING CIRUMCISION. ................................................................ 74 4.6 DURATION OF CIRCUMCISION .................................................................................................... 76
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4.7 COMPLICATIONS OF NEONATAL CIRCUMCISION ..................................................................... 77 4.8 REASONS FOR CIRCUMCISION. .................................................................................................. 79 CHAPTER FIVE: DISCUSSION ........................................................................................................... 80 5.1 PHYSICAL CHARACTERISTICS OF NEONATES.......................................................................... 80 5.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARENTS. ............................................. 81 5.3 NEONATAL INFANT PAIN SCORES .............................................................................................. 82 5.4 PHYSIOLOGICAL AND BEHAVIOURAL CHARACTERISTICS ...................................................... 84 5.5 COMPLICATIONS OF NEONATAL CIRCUMCISION ..................................................................... 86 5.6 DURATION OF SURGERY ............................................................................................................. 87 5.7 REASONS FOR NEONATAL CIRCUMCISION............................................................................... 87 5.8 IMPLICATIONS FOR FAMILY PHYSICIANS .................................................................................. 88 5.9 CONCLUSION................................................................................................................................. 89 5.10 RECOMMENTATION. ................................................................................................................... 90 5.11 CONSTRAINT. .............................................................................................................................. 90 REFERENCES. ..................................................................................................................................... 91 APPENDIX A: CONSENT FORM. ....................................................................................................... 102 APPENDIX B: QUESTIONNAIRE ....................................................................................................... 104 APPENDIX C: NEONATAL/INFANT PAIN SCALE (NIPS) .................................................................. 107 APPENDIX D: ETHICAL CLEARANCE ............................................................................................... 108 APPENDIX E: CIRCUMCISION INSTRUMENTS................................................................................ 109
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LIST OF TABLES
Table 1: Physical characteristics of Neonates
66
Table 2: Socio-demographic characteristics of parents
67
Table 3: Neonatal pain scores during surgery
68
Table 4: Mean neonatal pain scores
70
Table 5: Physiological changes during circumcision
74
ix
LIST OF FIGURES
Figure 1: Comparison of Mean pain scores
73
Figure 2: Comparison Mean of duration of surgery
77
Figure 3: Complications of Neonatal circumcision
78
Figure 4: Reasons for circumcision
79
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