Open Journal of Anesthesiology, 2013, 3, 388-392
Published Online November 2013 (
Open Access OJAnes
The Third Year Anesthesiology Residents’ Knowledge
Regarding Pediatric Postoperative Pain Management
Somboon Thienthong1, Jirawadee Seeh a no o1, Wimonrat Sriraj1, Suwannee Suraseranivongse2,
Allen Finley3
1Department of Anesthesia, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 2Department of Anesthesia, Faculty
of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; 3Department of Anesthesia, IWK Health Center, Dalhousie
University, Halifax, Canada.
Received September 15th, 2013; revised October 12th, 2013; accepted October 24th, 2013
Copyright © 2013 Somboon Thienthong et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: There are six Anesthesiology training centers in Thailand that are approved to operate the training pro-
gram. An evidence of residents’ knowledge about pediatric postoperative pain management is needed for improving the
program. Objective: To assess the third year anesthesiology residents’ knowledge about pediatric postoperative pain
management. Materials and Methods: The questionnaire was adapted from previous studies. The questionnaire has 35
questions consisted of 17 multiple choice questions and 18 true or false questions to cover 2 domains: 1) use of
age-appropriate pediatric pain assessment (10 questions) and 2) pediatric pain treatment (25 questions). Minimal pass-
ing level of the questionnaire rated by three young anesthesiology staffs was 76.2%. All 62 participants were the 3rd
year anesthesiology residents from 6 training centers. Data were analyzed by descriptive statistics. Results: The re-
sponse rate was 95.2%. Seventy-one percent of participants reported that they had learned about pediatric pain treat-
ment. Of those, 55.9% rated their remaining knowledg e at median level. The proportion of the correct score was 67.7%
(mean 23.7 ± 2.9 SD) which was lower than the minimal passing level. The highest score was 29 and the lowest score
was 16. For pain assessment domain; the mean proportion of correct score was 65% (range 90% - 40%). For pain
treatment domain; the mean proportion of correct score was 68.8% (range 88% - 44%). Conclusion: Anesthesiology
residents’ knowledge about pediatric postoperative pain management needs to be improved.
Keywords: Anesthesiology Resident; Knowledge; Pediatric; Postoperative Pain Management
1. Introduction
The Faculty of Medicine, Khon Kaen University per-
formed 3725 cases of surgery on childr en and adolescent
age below 20 years in 2010. It is important to provide
adequate pain management to those patients as it can
improve their recovery or decreases complications to
avoid unnecessary prolonged hospital stay which in-
creases the cost of treatment [1,2]. Until now, inadequ ate
postoperative pain management for children continues to
be reported in the literature. W. L. Chen [3] reported that
parents and nurses also concerned about postoperative
pain in children. The same concern was reported, about
45% of Canadian parents [4] and about 78% of Thai
parents [5]. Among the factors influencing the outcomes
of pain management, the age of children is an important
one. For example, a good modality for pain relief like a
patient-controlled analgesia pump could not be used by
small children [6]. Another important factor is the know-
ledge and attitude of health care providers about postop-
erative pain management [7], especially anesthesiology
residents who work closely with those patients. Saroyan
et al. [8] reported that anesthesiology residents per-
formed better than pediatric and orthopedic residents in
answering questions related to their knowledge of acute
pain management. The superior outcomes of anesthesi-
ology residents were related to an opportunity of the di-
rected educational programs. In 2012, there are six anes-
thesiology training centers in Thailand that provide edu-
cation for about 60 - 70 residents every year. All these
training centers have to follow the same 3-year curricu-
lum that is controlled by the Royal Colleg e of Anesthesi-
ology Thailand. Even so, the situation of the six centers
The Third Year Anesthesiology Residents’ Knowl edge Regarding Pediatric Postoperative Pain Management 389
may have some differences. Pain education is an example:
a training center(s) with well-established acute pain ser-
vice unit may provide more ex periences and good know-
ledge to the residents. The objective of this study was to
assess the third year anesthesiology residents’ knowledge
about pediatric postoperative pain management across
the training centers in Thailand.
2. Materials and Methods
The protocol was approved by the ethical committee of
Khon Kaen University, Thailand. This survey was done
between December 2011 and August 2012. All partici-
pants were the third year anesthesiology residents in the
six training centers across Thailand. The survey was con-
ducted during the last three months of the training pro-
gram to make sure that all participants had experienced
all clinical areas including pediatric postoperative pain
The pediatric postoperative pain management ques-
tionnaire was adapted from the Pediatric Nurses Know-
ledge and Attitude Survey Regarding Pain (PNKAS-P)
developed by Manworren in 2001 [9] and some parts
were adapted from the “assessing resident knowledge of
acute pain management in hospitalized children” devel-
oped by Saroyan in 2008 [8]. The validity of the contents
of questionnaires was proved by three experts in the field
of pain management and it was screened by few immedi-
ate graduated anesthesiology staffs to clarify all ques-
The questionnaire has two parts: part one is about de-
mographic of participants, e.g., gender, institution, aca-
demic training curriculum about pediatric pain manage-
ment, knowledge seeking behavior and self evaluation
about their knowledge; Part two is about the knowledge
on pediatric postoperative pain management; there were
17 multiple choice questions and 18 true or false ques-
tions to cover 2 domains: 1) use of age-appropriate pedi-
atric pain assessment (10 questions) and 2) pediatric pain
treatment (25 questions).One score for one right answer
and total scores were 35.
The questionnaires were sent to the pain clinic staffs of
six training centers to distribute to all the 3rd year resi-
dents, collect and send them back to the researchers. Par-
ticipants were asked to answer all questions according to
their knowledge and not allowed to open any book. In
case, questionnaire was not returned within one week
they will receive a reminding note, a period of one month
was allowed to return the last questionnaire. Data were
analyzed by descriptive statistics; scores were presented
as mean ± standard deviation (SD) or percentage.
3. Results
Sixty-two questionnaires were sent to all 3rd year resi-
dents in the six institutes and the response rate was
95.2%. The number of participants from each institution,
gender, self evaluation about pediatric pain knowledge
and knowledge seeking behavior were presented in Ta-
ble 1. Seventy-one percent of participants from all cen-
ters stated that pain education was provided and most of
them (71.4%) recalled that they learn ed it in th e first year
of anesthesiology training program.
For the total of 35 questions, the mean correct score
Table 1. Demographic of the participants (N = 59).
Demographic data N (%)
10 (16.9)
RH 9 (15.2)
SH 24 (40.7)
KU 7 (11.9)
CU 8 (13.6)
SU 1 (1.7)
Male:Female 14:45 (23.7:76.3)
Level of knowledge about pediatric pain
management by self evaluation:
33 (55.9)
Low 23 (39.0)
None 3 (5.1)
Pediatric pain management was taught in the
anesthesiology training curriculum:
42 (71.2)
No 17 (28.8)
Academic year which teaching pediatric pain
management: (N = 42)
1st year
30 (71.4)
2nd year 11 (26.2)
3rd year 1 (2.4)
Seeking behavior for pediatric pain
management from other sources:
50 (84.8)
No 9 (15.2)
Source of learning:
30 (50.9)
Text book 33 (55.9)
Internet 24 (40.7)
Conferences 6 (10.2)
Others 2 (3.4)
Frequency of knowledge seeking about
pediatric pain management:
High (Every 2 - 3 week)
3 (5.1)
Modest (Every month) 18 (30.5)
Seldom (More than a month) 38 (64.4)
Open Access OJAnes
The Third Year Anesthesiology Residents’ Knowledge Regarding Pediatric Postoperative Pain Management
was 23.7 ± 2.9 (67.7%). The highest score was 29 and
the lowest score was 16. The proportion of participants
who had correct answer for each question was presented
in Table 2.
Table 2. The proportion of participants who had correct
answer for each question (N = 59).
Questions Number
of correct
answer Percent
The first domain
1 Observable changes in vital signs must be relied
upon to verify a child’s/adolescent’s statement
that he has severe pain 49 83.1
2 Because of an underdeveloped neurological
system, children under 2 years of age have de-
creased pain sensitivity and limited memory of
painful experiences
38 64.4
3 If the infant/child/adolescent can be distracted
from his pain this usually means that he is not ex-
periencing a high level of pain 20 33.9
4 Infants/children/adolescents may sleep in spite
of severe pain 10 17.0
5 Comparable stimuli in different people produce
the same intensity of pain 54 91.5
6 Children less than 8 years cannot reliably report
pain intensity and therefore, the nurse should rely
on the parents’ assessment of the child’s pain in-
55 93.2
7 A three-year-old child, who is developmentally
normal, is in the postoperative care unit following
a tonsillectomy. She is awake and alert. The mo-
ther states that her child is in pain. What is the
best measure of this child’s pain?
25 42.4
8 A one-year-old child had surgery on her
stomach. Her face looks grimace with occasional
restless and tense, get improved after hugging.
Her FLACC score is:
30 50.9
9 The most accurate judge of the intensity of the
child’s/adolescent’s pain is 53 89.8
10 Which of the following describes the best
approach for cultural considerations in caring for
child/adolescent in pain: 47 79.7
The second domain
11 Non-drug interventions (e.g. heat, music,
imagery, etc.) are very effective for mild-mode-
rate pain control but are rarely helpful for more
severe pain
8 13.6
12 Children who will require repeated painful
procedures (ie. Daily blood draws), should re-
ceive maximum treatment for the pain and anxie-
ty of the first procedure to minimize the develo-
pment of anticipatory anxiety before subsequent
55 93.2
13 Respiratory depression rarely occurs in
children/adolescents who have been receiving
opioids over a pe riod of months 32 54.2
14 Acetaminophen 650 mg per oral is appro-
ximately equal in analgesic effect to codeine 32
mg per oral 18 30.5
15 The World Health Organization (WHO) pain
ladder suggests using single analgesic agents ra-
ther than combining classes of drugs (e.g. com-
bining an opioid with a non-steroidal agent)
55 93.2
16 The usual duration of analgesia of Morphine
IV is 4 - 5 hours 28 47.5
17 Parents should not be present during painful
procedures 40 67.8
18 Adolescents with a history of substance abuse
should not be given opioids for pain because they
are at high risk for repeated addiction. 48 81.4
19 Young infants, less than 6 months of age, can
not tolerate opioids for pain relief 47 79.7
20 Anxiolytics, sedatives, and barbituates are ap-
propriate medications for the relief of pain during
painful procedures 27 45.8
21 After the initial recommended dose of opioid
analgesic, subsequent doses should be adjusted in
accordance with the individual patient’s response 57 96.6
22 The child/ adolescent should be advised to use
non-drug techniques alone rather than concur-
rently with pain medications 45 76.3
23 The maximum accepted daily dose of Ketoro-
lac for a school-age child is: 36 61.0
24 The maximum accepted daily dose of me-
toclopramid e (IV.) for a school -age child is: 37 62.7
25 NSAIDs that not recommended for using in
children is: 48 81.4
26 The recommended route of administration of
opioid analgesics to children with severe po-
stoperative pain is 58 98.3
27 The recommended route of administration of
opioid analgesics to children with brief, severe
pain of sudden onset, e.g. trauma or postoperative
pain, is
59 100
28 Which of the following analgesic medications
is considered the drug of choice for the treatment
of moderate to severe postoperative pain 52 88.1
29 Which of the following IV doses of morphine
administered would be equivalent to15 mg of oral
morphine 50 84.8
30 Analgesics for post-operative pain should ini-
tially be given 34 57.6
31 The most likely explanation for why a child/
adolescent with pain would request increased do-
ses of pain med i c a t i o n i s 12 20.3
32 Which of the following analgesic medications
can be regularly used for the treatment of pos-
toperative pain 45 76.3
33 Which of the following is the most effective
treatment modalities for upper abdominal surgery 55 93.2
34 You wish to administer morphine sulfate 4 mg
by intravenous (IV) push. Morphine is not imme-
diately available but pethidine is. The equianal-
gesic dose of pethidine IV is:
37 62.7
35 An appropriate dose of morphine to mix with
0.08% bupivacaine solution for continuous epi-
dural infusion in 50 kg children is: 21 35.6
Mean 39.6 67.1
Open Access OJAnes
The Third Year Anesthesiology Residents’ Knowl edge Regarding Pediatric Postoperative Pain Management 391
For 10 questions about the use of age-appropriate pe-
diatric pain assessment domain, the mean correct score
was 6.5 (65%). The highest score was 9 (90%) and the
lowest score was 4 (40%). There were 3 questions from
this domain that less than 50% of participants gave cor-
rect answers.
For 25 questions about the pediatric pain treatment
domain; the mean correct score was 17.2 (68.8%). The
highest score was 22 (88%) and the lowest score was 11
(44%). There were 5 questions from this domain that less
than 50% of participants gave correct answers.
4. Discussion
Children’s pain is often underestimated and undertreated.
Our previou s survey found that pediatric health care pro-
viders in the Northeastern Thailand needed to improve
their knowledge and skills about pediatric pain manage-
ment [10]. It is common that knowledge and skills gra-
dually decrease after learning so mething, especially, when
the knowledge is not integrated into practice. Therefore,
adequate knowledge and skills about pediatric pain ma-
nagement are necessary for anesthesiology residents be-
fore their graduation. Although many numbers of ques-
tions in this study were adapted from the nurses’ knowl-
edge and attitudes regarding pediatric pain [9], those
questions were the general knowledge and were inte-
grated well in the qu estionnaire. Thus, it is ap propriate to
use those questions to evaluate any pediatric care provi-
ders’ competency in pain management. In the present
study, 71% of the participants from 6 centers recalled
that pain education was provided during the anesthesiol-
ogy training program. In addition to the training program,
about 50% of the residents continued their self-study
either by reading books (55.9%), internet based learning
(40.7%) or other ways. The level of knowledge evaluated
by the residents themselves was modest and was corre-
lated with the mean correct score (67.7%) of the test.
The present study assessed only th e anesthesiology re-
sidents’ knowledge but not compared with that of the
residents in other disciplines. Saroyan et al. [8] assessed
pediatric pain knowledge among 3 residency training pro-
grams and found that anesthesiology residents had better
knowledge compared to orthopedic or pediatric residents.
The mean correct score of anesthesiology residents in the
present study was not different from the study on radio-
therapy residents done by Porzio et al. [11] in 2005
(67.7% vs 63.7%). Although the questionnaire in their stu-
dy had less number of items compared to the present stu-
dy (16 items vs 35 items) and they had only 3 questions
that specific to pediatric pain management. Hameedand
Sweedan [12] assessed the knowledge of 101 pediatric
resident doctors in 3 training centers in Baghdad about
neonatal pain and found that knowledge is increasing by
the year of training (21.7% in the 1st year, 55.2% in the
2nd year and 57.1% in the 3rd year) but their knowledge
was still inadequate when compared to other studies in
developing countries [13,14].
There were 8 questions in the present study that the
correct answer was given by less than 50% of partici-
pants. The reasons for this poor performance were not
clear because it might be related to the questions them-
selves (difficult questions or unclear questions) or related
to students’ factor or other factors. We knew that all 6
training centers had both pain specialists and pediatric
anesthesia specialists to con tribute to give knowledge for
their residents. If the training program provides more
time for residents to rotate in the pediatric area, the qual-
ity of knowledge about pediatric postoperative pain ma-
nagement would be improved further.
A know-do gap of physicians was another aspect that
should be concerned because it played a major role in
pediatric pain management. The present study did not
assess directly about attitudes and practices of the resi-
dents. In the previous study by V. R. Breakey et al. [15],
the attitudes and practices for analgesia and sedation
during lumbar puncture to pediatric patients were com-
pared between pediatric residents and emergency medi-
cine residents, and they found that pediatric residents
used less injectable local anesthetic and used more seda-
tion for lumbar puncture than did emergency medicine
There were some limitations in the present study: fir-
stly, one of the six training centers, there was only one
3rd year resident. Therefore his score might not represent
a real mean score of that center. Secondly, the question-
naires were evaluated for content validity and did a few
cases pilot surveys but the coefficient of validity was no t
calculated. The reasons to explain 8 questions with low
proportion of correct answer remain un clear and may re-
quire further modification.
In conclusion, Pain education has been provided dur-
ing Anesthesiology training programs in Thailand. How-
ever, the third year anesthesiology residents’ knowledge
about pediatric postoperative pain management needs to
be improved.
5. Acknowledgements
The authors would like to thank anesthesiology residents
who had participated in this survey, pain clinic staffs
whose supported data collection and Professor Yukifumi
Nawa for assistance in manuscript preparation. This re-
searchwas made possible by a Teasdale-Corti Team
Grant from the Global Health Research Initiative, admi-
nistered by the International Development Research
Centre (IDRC), Canada.
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The Third Year Anesthesiology Residents’ Knowledge Regarding Pediatric Postoperative Pain Management
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