Comparison of bupivacaine and ropivacaine on postoperative pain after tonsillectomy in paediatric patients

Systematic review and meta-analysis of pain management after tonsillectomy

Tonsillectomy is one of the most common operations. Tonsillectomy is also one of the most painful surgical procedures. However, there is still no satisfactory standard for postoperative pain management. Four databases (Cochrane Library, Ovid Technologies, PubMed, Web of Science) were searched for the period from 1908 to 2019. The systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were pooled using random-effects and fixed-effects models. Randomized controlled trials, reviews and meta-analyses were included. Primary outcomes were quantitative pain intensity in the first 24 h after tonsillectomy and on days 1, 3, and 7 postoperatively. The search yielded 1594 publications, of which 111 publications with 7566 patients, both children and adults, could be included. Intraoperative medication with intravenous dexamethasone significantly reduced pain (mean difference [MD] -0.42; 95% confidence interval [CI]: -0.61- -0.24). Among the local anesthetics, only the preoperative injection of levobupivacaine into the tonsillar compartment was able to provide sufficient pain reduction up to three days after tonsillectomy (MD: -1.92; 95% CI: -2.73 - -1.11). Preoperative or intraoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduced pain (MD: -0.75; 95% CI: -0.87- -0.63). Steroids and NSAIDs are an important part of pain management after tonsillectomy.

Comparative Effectiveness of Analgesia for Early Pain Management After Pediatric Tonsillectomy: A Systematic Review and Network Meta-Analysis

BACKGROUND

Timely and effective analgesia after tonsillectomy in children is crucial, but there is currently no consensus on the optimal analgesics. This analysis aimed to identify the most effective for this surgery.

METHODS

We conducted a systematic review and network meta-analysis (random-effects model) of randomized controlled trials comparing analgesics for pediatric tonsillectomy. We searched relevant studies in PubMed, Embase, Cochrane Library, and Web of Science databases from database inception until June 30, 2023. Children (≤18 years old) who underwent tonsillectomy with or without adenoidectomy were eligible for inclusion. Primary outcomes encompassed pain score and postoperative complications; secondary outcomes included postoperative supplementary analgesia, functional evaluation, and sedation score.

RESULTS

In total 82 randomized controlled trials involving 6110 patients were included, forming the primary network that comprised comparative data for 16 different interventions (including placebo) across 6 types of analgesics. The integrated analysis revealed that nonsteroidal anti-inflammatory drugs except ketoprofen had no significant effects in relieving postoperative pain (mean difference [MD], -2.96; 95% confidence interval [CI], -5.59 to -0.32; P = .10). Local anesthetic infiltration (bupivacaine: MD, -2.76; 95% CI, -3.88 to -1.64, P = .01; ropivacaine: MD, -2.49; 95% CI, -4.25 to -0.73, P = .02; lidocaine: MD, -1.86; 95% CI,-3.52 to -0.2, P = .02; levobupivacaine: MD, -1.06; 95% CI, -2.00 to -0.12, P = .01), analgesics (morphine: MD, -2.07; 95% CI, -3.14 to -1.00; P = .02), and glucocorticoids (dexamethasone: MD, -0.45; 95% CI, -0.73 to -0.16; P = .01) were effective in relieving pain after pediatric tonsillectomy. In reducing incidence of postoperative complications, dexamethasone was superior to bupivacaine (relative risk [RR], 0.60; 95% CI, 0.43-0.83; P = .02). Regarding the number of patients needing rescue analgesic, levobupivacaine was superior to lidocaine (RR, 0.51; 95% CI, 0.32-0.81; P = .01). In rescue analgesia requirement, morphine outperformed lidocaine (RR, 0.44; 95% CI, 0.25-0.75; P = .01) and ropivacaine (RR, 0.54; 95% CI, 0.32-0.91; P = .01) in efficacy but not different from bupivacaine (P = .10) and levobupivacaine (P = .12).

CONCLUSIONS

Based on these results, we would recommend local bupivacaine infiltration or local levobupivacaine infiltration for older children and dexamethasone injection for younger children for early analgesia after tonsillectomy. However, clinicians should choose the optimal analgesic based on the individual child's condition and clinical situation.

Analgesic Efficacy of Ropivacaine Infiltration on Early Post-Tonsillectomy Pain in Pediatrics

OBJECTIVE

To assess the analgesic efficacy of ropivacaine infiltration in the tonsillar fossa among pediatric patients undergoing tonsillectomy.

DATA SOURCES

PubMed, Scopus, Web of Science, and CENTRAL.

REVIEW METHODS

Eligible randomized controlled trials (RCTs) were assessed for bias using Cochrane's risk of bias tool (version 2). Our primary outcome was postoperative pain within 24 h, and secondary outcomes included operative time, intraoperative blood loss, time to first analgesia, bleeding, and nausea/vomiting. Data were pooled as mean difference, standardized mean difference, and risk ratio with a 95% confidence interval.

RESULTS

Our review included 11 RCTs, with a total of 712 patients. The quality of studies varied and included low risk (n = 8 RCTs), some concerns (n = 2 RCTs), and high risk (n = 1 RCT) of bias. The primary endpoint of postoperative pain across all time points was significantly reduced in the ropivacaine group compared with the placebo group. Trial sequential analysis (TSA) of the postoperative pain depicted conclusive evidence and unnecessity for further RCTs. The mean operative time was significantly reduced in the ropivacaine group compared with the placebo group. However, there was no significant difference between both groups regarding additional clinical (i.e., mean intraoperative blood loss and mean time to first analgesia) and safety (i.e., rates of bleeding and nausea/vomiting) outcomes.

CONCLUSION

This systematic review and meta-analysis demonstrated the safety and postoperative analgesic efficacy of ropivacaine versus placebo among pediatric patients undergoing tonsillectomy. There was no significant difference between both groups regarding intraoperative blood loss, time to first analgesia, and rate of postoperative bleeding.

LEVEL OF EVIDENCE

1 Laryngoscope, 134:3018-3029, 2024.

To Compare the Effects of Post-tonsillectomy Intra-operative Infiltration of Ropivacaine Versus Bupivacaine in Tonsillar Fossa

Tonsillectomy is one of the most common surgical procedures practiced in Otorhinolaryngology. A significant obstacle for the speedy and smooth recovery is early post- operative pain. Pain leads to negative outcomes such as poor intake, tachycardia, anxiety, delayed wound healing and insomnia. Aim to assess and compare the effect of post-incisional infiltration of 0.75% Ropivacaine v/s 0.5% Bupivacaine on post tonsillectomy pain, the on start of oral intake and stay in hospital and to investigate any complications that can arise due to infiltration of the said drugs. 60 Patients above the age of 5 years were posted for tonsillectomy or adenotonsillectomy under general anesthesia. Patients were blinded about the group in which they will be enrolled. Group A received Inj. ropivacaine (0.75%) 2 ml and Group B: received Inj. Bupivacaine (0.50%) 2 ml in each fossa. After surgery, no analgesics were given & patients were observed for the intensity of post-operative pain in the immediate post-operative period, at 2, 4, 6, 12, 24, 48 h and further if not discharged using VISUAL ANALOGUE SCORE (VAS) and VERBAL RATING SCALE(VRS). Post-operative pain assessment was done using VAS and VRS at 2nd, 4th, 6th, 12th, 24th and 48th hour which was found to be lower in Group 'A'. Patients in Group 'A' also started their oral intake sooner, had lesser hospitalization days than group 'B' patients. Longer time for Rescue analgesic and reduced total dose of analgesic required was seen in Group A compared to Group B. This comparative study on Post-incisional infiltration of 2 ml 0.75% Ropivacaine v/s 2 ml 0.5% Bupivacaine has shown that Ropivacaine is a more effective drug in reducing post-operative pain in comparison to Bupivacaine, proven statistically.

Comparative efficacy of topical lidocaine, tetracaine, and articaine for post-tonsillectomy pain management in children: a prospective, placebo-controlled study

BACKGROUND

The most important problem in tonsillectomy is pain in the early postoperative period.

OBJECTIVE

We purposed to compare the effects of lidocaine, tetracaine, and articaine application to the peritonsillar bed on post-tonsillectomy pain in children.

METHODS

The prospective, placebo-controlled study included 80 patients, ages 3-14, who were scheduled for elective tonsillectomy. Patients were randomly divided into four groups. Group 1 received 0.9% NaCl; group 2 received 2% lidocaine; group 3 received 2% tetracaine; and group 4 received 4% articaine to the tonsillary bed for 5 min just after the operation. All patients were evaluated in terms of pain and pain-related adverse events in the postoperative 24 h.

RESULTS

All groups that used local anesthetics had significantly lower pain levels than the control group in the first eight hours (p < .001). Furthermore, the articaine group had a lower pain score than the tetracaine group at the eighth hour (p < .05). The articaine group had a lower pain score at the 16th hour than both the control and tetracaine groups (p < .05). There was no significant difference between the groups at the 24th hour (p > .05).

CONCLUSION AND SIGNIFICANCE

We recommend the immediate application of topical articaine to the tonsillar bed following the procedure to enhance postoperative pain management.

Efficacy of Ropivacaine Administration on Post-tonsillectomy Pain in Adults: A Systematic Review and Meta-analysis of Randomized Placebo-controlled Trials

The objective of this investigation is to assess the efficacy of ropivacaine on intraoperative and postoperative endpoints like operative time, blood loss, pain, and bleeding among adult's patients undergoing for tonsillectomy. PubMed, CENTRAL, Scopus, and Web of Science databases were screened from inception until November 2022. The included RCTs were evaluated for risk of bias via risk of bias tool (second version). All endpoints were summarized as mean difference (MD) or standardized mean difference (SMD) for continues outcomes, and risk ration (RR) for dichotomous outcomes, under random-effect model. Four RCTs met our PICOS criteria, comprising a total of 257 patients. Regarding postoperative pain, there was a significant difference that favor ropivacaine group compared with placebo group within hours (n = 4 RCTs, SMD = -0.92, 95% CI [-1.57, -0.26], p = 0.006), and within days (n = 4 RCTs, SMD = -050, 95% CI [-0.82, -0.18], p = 0.002). However, there were no significant difference between ropivacaine and placebo groups I terms of operative time (n = 3 RCTs, SMD = -0.17, 95% CI [-0.45, 0.11], p = 0.22), intraoperative blood loss (n = 2 RCTs, SMD = -0.37, 95% CI [-1.41, 0.67], p = 0.49), and postoperative bleeding (n = 4 RCTs, RR = 2.27, 95% CI [0.90, 5.73], p = 0.08). In conclusion, administration of ropivacaine was associated with less postoperative pain among adult's patients who undergoing tonsillectomy. However, there were no benefit in term of reduction in operative time, intraoperative blood loss, and postoperative hemorrhage.

A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy

Objectives

To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research.

Data Sources

PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley).

Methods

A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs.

Results

One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons.

Conclusion

Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.

The efficacy and safety of peri-tonsillar administrated agents on pain treatment after pediatric tonsillectomy: A network meta-analysis

OBJECTIVES

We assessed the pain control efficacies and associated morbidities of drugs administered locally (around the tonsils) in pediatric patients undergoing a tonsillectomy.

METHODS

Randomized controlled trials up to April 2022 were retrieved from six databases. The treatment networks featured six interventions (ropivacaine, bupivacaine, levobupivacaine, ketamine, tramadol, and dexamethasone) and a control (placebo). The outcomes were the postoperative pain scores, the time to use of the first analgesic drugs, and postoperative nausea/vomiting. Both pairwise and network meta-analyses were performed.

RESULTS

All treatments controlled pain at 1 h and 1 day postoperatively. Although all agents tended to delay the time to the first analgesic drug, only bupivacaine, dexamethasone, ketamine, and tramadol significantly reduced the need for analgesics. No agent caused significant postoperative nausea or vomiting. The ranking hierarchy revealed that tramadol was superior in terms of pain control 1 h postoperatively, the time to the first analgesic drug, and the number of analgesic doses required; however, it ranked third in terms of operative time.

CONCLUSION

All drugs reduced postoperative pain. Tramadol was optimal in pain control, and dexamethasone also afforded good pain control with low incidences of nausea and vomiting.

Efficacy of bupivacaine infiltration for controlling post-tonsillectomy pain, duration of surgery and post-operative morbidities: A systematic review and meta-analysis

The objective of the present review and meta-analysis was to evaluate the efficacy of bupivacaine during tonsillectomy in terms of reducing the mean operative procedure duration, post-operative pain and the onset of post-operative morbidities. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed to perform a systematic literature search using the MEDLINE, Scopus, EMBASE and CENTRAL databases. The present meta-analysis sought to evaluate the efficacy of bupivacaine administered during tonsillectomy as compared to the administration of normal saline. The efficacy of the intervention was evaluated based on pain scores using the visual analogue scale, the duration of the operation and the occurrence of post-operative morbidities. Out of 1,427 records, 15 articles with 729 participants (mean age, 10.2±6.7 years) were included in the study. The present systematic review supported the use of bupivacaine during tonsillectomy at a level of evidence of 1b and confirmed beneficial effects of bupivacaine intervention by demonstrating small to large effect reductions in the visual analog scale score (Hedge's g, -1.48), the mean duration of the operative procedure (Hedge's g, -1.35) and the incidence of post-operative morbidity (Hedge's g, -0.23) in comparison to the placebo groups treated with normal saline. Based on these results, the administration of bupivacaine is recommended during tonsillectomies to reduce the perceived level of pain, the duration of the operation and the post-operative morbidity.

PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations

Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.

#10-Year Challenge: Local anaesthetic for post-tonsillectomy pain: Update meta-analysis

INTRODUCTION

Adequate management of post-tonsillectomy pain is an important consideration in postoperative management after tonsillectomy. A 2008 meta-analysis showed that the use of local anaesthetic either by infiltration or topical application reduced postoperative pain.

OBJECTIVES

To review the current evidence for the use of local anaesthetic as a means of reducing post-tonsillectomy pain and compare current evidence to the previous meta-analysis 10 years ago.

METHOD

Systematic literature searches of MEDLINE [*"ANESTHETICS, LOCAL"/ AND *TONSILLECTOMY/], EMBASE [*"LOCAL ANESTHETIC AGENT"/ AND *TONSILLECTOMY/] and PubMed [(Tonsillectomy).ti,ab AND (Local Anaesthetic).ti,ab OR (Local Anesthetic).ti,ab]. A meta-analysis of randomised control trials assessing the use of local anaesthetic agents for post-tonsillectomy pain.

RESULTS

Twenty-three studies were included in the meta-analysis. Overall, local anaesthetic, applied topically or infiltrated, significantly reduces pain scores compared with controls at 4-6 hours [-0.65 (95% CI: -0.77; -0.53)]; 24 hours [-0.50 (95% CI: -0.66, -0.35)]; and 5-7 days [-0.78 (95% CI: -0.90, -0.65)] (standardised mean differences).

CONCLUSION

Current studies suggest that use of peri-operative local anaesthetic during tonsillectomy does improve postoperative pain outcomes. The limitations of the analysis are as follows: all studies are small, and a multi-centred larger trial is recommended to guarantee statistical reliability. There was no description of significant adverse side effects from local anaesthetic use.

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Introduction  Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective  To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods  In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results  Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo ( p  < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion  We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Comparing local anesthetic infiltration of the peritonsillar region and glossotonsillar sulcus for post-tonsillectomy pain management

PURPOSE

The objective of this study was to compare the efficacy of peritonsillar and glossotonsillar sulcus infiltration with bupivacaine to manage postoperative pain and odynophagia in children undergoing tonsillectomy.

METHODS

Fifty children (5-10 years of age) undergoing tonsillectomy due to recurrent tonsillar infections were enrolled in the study and assigned into two groups receiving either pre-incisional peritonsillar (Group 1, n = 25) or glossotonsillar sulcus (Group 2, n = 25) infiltration with 1 mg/kg bupivacaine (0.5%) totaling 5 mL in volume. At different time intervals following arrival to the post-anesthesia care unit (PACU), the participants in each group were evaluated for pain using the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) and for odynophagia using a four-point scale (1-none, normal or no difficulty with swallowing, 2-mild, mild difficulty with swallowing, 3-moderate, moderate difficulty with swallowing, and 4-severe, no swallowing or swallowing only with maximal effort). Additional parameters were assessed for 24 h post-surgery, including time to first administration of analgesic, additional analgesic requirements, nausea/vomiting, allergic reaction, and bleeding.

RESULTS

Infiltration of either region with bupivacaine yielded similar analgesic effects at different times following the surgery (P = 0.065). Time to first analgesic treatment and additional analgesic requirements were not significantly different between groups (P = 0.181). Compared to the Group 1, Group 2 was associated with significantly lower odynophagia scores at different times after the surgery (P = 0.020).

CONCLUSION

Present results indicate that the infiltration of local anesthetics to glossotonsillar sulcus is a safe, practical, and effective pain management intervention without risk of significant side effects for children undergoing tonsillectomy.

Comparison of topical ropivacaine with and without ketamine on post-surgical pain in children undergoing tonsillectomy: a randomized controlled double-blind study

PURPOSE

Tonsillectomy in pediatric patients may cause severe postoperative pain. Topical local anesthetics are an easy and safe way to control post-tonsillectomy pain, but there is no benefit during the early postoperative stage. Topical ketamine shows a good effect on early stage postoperative pain. We compared the effect of topical ropivacaine with and without ketamine on post-tonsillectomy pain.

METHODS

Patients aged 3-7 years undergoing tonsillectomy were selected to participate in the study. Our study was performed in a randomized, placebo-controlled, double-blind manner. Patients were randomly assigned to one of two groups using computer-generated random numbers. The researchers who assessed the pain score, the caregivers, and the patient were blinded to group assignment. One group received topical ropivacaine with saline (RS group) and the other group received topical ropivacaine with 20 mg ketamine (RK group) on the tonsillar bed. Pain scores using the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 15 min and 30 min, and at 1, 2, 4, 8, 16 and 24 h were recorded. Rescue analgesic requirement and complications were also recorded.

RESULTS

A total of 66 patients were randomly assigned to the RS group (n = 33) and the RK group (n = 33). The mCHEOPS scores were significantly lower in the RK group at 15 min (P = 0.046). The mCHEOPS scores of the two groups decreased with time, but there was no intergroup interaction. The RS group received more analgesics until 1 h after surgery and the RK group received more analgesics during 1-24 h after surgery. There were no differences in adverse outcomes.

CONCLUSIONS

Topical ropivacaine with ketamine can reduce immediate postoperative pain and analgesic requirement better than ropivacaine alone.

The comparison of preincisional peritonsillar infiltration of ketamine and tramadol for postoperative pain relief on children following adenotonsillectomy

OBJECTIVE

To investigate and compare the effectiveness of preincisional peritonsillar infiltration of ketamine and tramadol for post-operative pain on children following adenotonsillectomy.

STUDY DESIGN

Prospective randomized double blind controlled study.

METHODS

Seventy-five children aged 3-10 years undergoing adenotonsillectomy were included in study. Patients received injections in peritonsillar fossa of tramadol (2 mg/kg-2 ml), ketamine (0.5 mg/kg-2 ml) or 2 ml serum physiologic. During operation heart rate, oxygen saturation, average mean blood pressures were recorded in every 5 min. Operation, anesthesia and the time that Alderete scores 9-10, patient satisfaction, analgesic requirements were recorded. Postoperatively nausea, vomiting, sedation, dysphagia, bleeding scores were recorded at 0, 10, 30, 60 min and 2, 4, 8, 12, 18, 24h postoperatively. Pain was evaluated using modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at fixed intervals after the procedure (15 min and 1, 4, 12, 16, and 24h postoperatively).

RESULTS

The recordings of heart rate, mean arterial pressure, nausea, vomiting, sedation and bleeding scores were similar in all groups (p>0.05). The mCHEOPS scores at 10 min, 30 min, 1h, 8h were significantly lower in both tramadol and ketamine group when compared with control (p<0.05). Use of additional analgesia at 10 min and 18 h were higher in control group than ketamine, tramadol group (p<0.05). Dysphagia scores were significantly lower for both ketamine and tramadol group when compared with control group (p<0.05). mCHEOPS, additional analgesia, dysphagia, patient satisfaction scores were similar in tramadol, ketamine groups (p>0.05).

CONCLUSIONS

Preincisional injection of ketamine and tramadol prior to tonsillectomy is safe, effective method and equivalent for post-tonsillectomy pain, patient satisfaction, postoperative nausea, vomiting, dysphagia.

The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial

BACKGROUND

The purpose of this single-blinded, randomized, controlled trial was to compare the analgesic efficacy of intra-articular injections of bupivacaine or ropivacaine with that of no injection for postoperative pain control after the operative treatment of supracondylar humeral fractures in a pediatric population.

METHODS

Subjects (n=124) were randomized to treatment with 0.25% bupivacaine (Group B) (n=42), 0.20% ropivacaine (Group R) (n=39), or no injection (Group C) (n=43). The opioid doses and the times of administration as well as child-reported pain severity (Faces Pain Scale-Revised) and parent-reported pain severity (Total Quality Pain Management survey) were recorded.

RESULTS

The proportion of subjects who required morphine and/or fentanyl injections was significantly (p=0.004) lower in Group B (10%) as compared with Group R (36%) and Group C (44%). On the basis of the log-rank test, the opioid-free survival rates were significantly greater in Group B as compared to Groups C and R. Total opioid consumption (morphine equivalent mg/kg) in the first seventy-two hours postoperatively was significantly less in Group B as compared with Group C (mean difference, 0.225; [95% confidence interval (CI), 0.0152 to 0.435]; p=0.036). Parent-reported pain scores were also significantly lower in Group B as compared with both Group C (mean difference, 1.81 [95% CI, 0.38 to 3.25]; p=0.014) and Group R (mean difference, 1.66; 95% CI, 0.20 to 3.12; p=0.027). There were no significant differences across the three groups in terms of self-reported pain. Differences between Groups R and C were not significant for any of the outcome variables.

CONCLUSIONS

The intra-articular injection of 0.25% bupivacaine significantly improves postoperative pain control following the closed reduction and percutaneous pinning of supracondylar humeral fractures in pediatric patients.

The efficiacy of anterior and posterior archs suturation at inferior tonsillar pole for posttonsillectomy pain control

The aim of our study was to investigate the efficiacy of the suturation technique after completing the tonsillectomy procedure for posttonsillectomy pain control in adult patients. August 2010-February 2011, 44 adult patients, ages ranged from 16 to 41 years old who underwent tonsillectomy at Elaziğ Training and Research Hospital Otorhinolaryngology Clinic were included to the study. After tonsillectomy procedure, anterior and posterior tonsillar archs were sutured each other and so, the area of tonsillectomy lodges which covered with mucosa were increased. Twenty two patients who applied posttonsillectomy suturation were used as study group and remnant 22 patients who did not applied posttonsillectomy suturation were used as control group. The visual analogue score (VAS) was used to evaluate the postoperative pain degree (0 no pain, 10 worst pain). ANOVA test (two ways classification with repeated measures) was used for statistical analysis of VAS values. P < 0.05 was accepted as statistically significant. The effect of time (each post-operative day) on VAS values was significant. The mean VAS values between study and control group on post-operative day 1st, 3rd, 7th, and 10th were statistically significant (P < 0.05). The severity of posttonsillectomy pain was less in study group patients than control group patients. The suturation of anterior and posterior tonsillar archs after tonsillectomy procedure was found effective to alleviate the posttonsillectomy pain in adult patients.

Effects of levobupivacaine versus bupivacaine infiltration on postoperative analgesia in pediatric tonsillectomy patients: a randomized, double-blind, placebo-controlled study

OBJECTIVES

We compared the effects of levobupivacaine hydrochloride, bupivacaine hydrochloride, and saline injections in alleviating posttonsillectomy pain.

METHODS

Between November 2009 and April 2010, we recruited 60 patients (36 male and 24 female) between 2 and 12 years of age into the study. After informed consent was obtained from the parents, patients admitted for tonsillectomy were randomized into 3 groups by means of sealed envelopes. Group 1 (20 patients; mean age, 6.45+/-2.78 years) received 0.9% sodium chloride (saline solution), group 2 (20 patients; mean age, 5.60+/-2.70 years) received 0.25% levobupivacaine hydrochloride, and group 3 (20 patients; mean age, 5.85+/-2.43 years) received 0.5% bupivacaine hydrochloride infiltrated around each tonsil. Pain was evaluated with McGrath's face scale.

RESULTS

The postoperative pain scores at 1 and 5 hours were similar among the groups (p>0.05). The pain scores in the levobupivacaine group were lower than those in the saline group at 13 hours (p<0.017). The pain scores in the bupivacaine and levobupivacaine groups were significantly lower than those in the saline group from 17 to 21 hours until day 6 (p>0.017). There was no difference between the levobupivacaine and bupivacaine groups (p>0.017).

CONCLUSIONS

Local infiltration of levobupivacaine is a relatively safe and effective method and is equivalent to use of bupivacaine for posttonsillectomy pain.

Comparison of peritonsillar levobupivacaine and bupivacaine infiltration for post-tonsillectomy pain relief in children: placebo-controlled clinical study

OBJECTIVES

To compare the effects of preincisional peritonsillar infiltration of levobupivacaine and bupivacaine on post-tonsillectomy pain in children.

METHODS

Sixty children undergoing elective tonsillectomy or adenotonsillectomy were randomly allocated into three groups before tonsillectomy: peritonsillar infiltrations with 0.25% levobupivacaine with 1:200,000 epinephrine (group levobupivacaine, n=20), 0.25% bupivacaine with 1:200,000 epinephrine (group bupivacaine, n=20), and normal saline (group saline, n=20) were applied. Pain was evaluated by using a modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS). Choice of additional analgesic was acetaminophen for all patients.

RESULTS

mCHEOPS values at 0th (immediately) and 30th minute after arrival the PACU were lower in both the local anesthetics groups than the saline group (p<0.001, p<0.01 for the group levobupivacaine; p<0.001, p<0.05 for the group bupivacaine, respectively). In addition, mCHEOPS values at 1st hour in the ward was lower in the group bupivacaine when compared to the group saline (p<0.05). Analgesic requirements and the time to first analgesia required, were also significantly different between the local anesthetic and saline groups (p<0.05 for both local anesthetics groups). Time to first mobilization was shorter in both local anesthetic groups when compared to the saline group (p<0.05 for both local anesthetic groups).

CONCLUSION

Preincisional peritonsillar infiltration with levobupivacaine or bupivacaine before tonsillectomy, are effective than saline, in reducing early post-tonsillectomy pain, where as bupivacaine had slightly longer effect. Compared to saline, with both anesthetic infiltrations, lesser medication for analgesia is required. The clinical trial registration number (Research Ethics Committee of Medical Faculty, Uludag University): 2008-4/36, 19 February 2008.

Topical bupivacaine compared to lidocaine with epinephrine for post-tonsillectomy pain relief in children: a randomized controlled study

OBJECTIVE

To compare the topical administration of bupivacaine hydrochloride, lidocaine hydrochloride with epinephrine and saline in alleviating post tonsillectomy pain.

STUDY DESIGN

A double-blind prospective randomized controlled clinical study.

METHODS

Between November 2008 and March 2009, 60 patients (32 males and 28 females) between ages of 1.5 and 15 years were recruited into the study. After informed consent was obtained from the parents, patients, admitted for tonsillectomy, were randomized into three groups using sealed envelops. Group 1 (20 patients, mean age 5.2±1.7) received topical lidocaine hydrochloride (20 mg/ml) with 0.00125% epinephrine. Group 2 (20 patients, mean age 6±3.7) received topical 0.5% bupivacaine hydrochloride and group 3 (20 patients, mean age 6.7±3.6) received topical saline.

RESULTS

The post-operative pain scores at 1h were similar among the groups (p=0.29). Pain scores in bupivacaine hydrochloride group were significantly lesser than the saline group at 5th, 13th, 17th and 21st hours, until the sixth day (p<0.017). Moreover, pain scores of bupivacaine hydrochloride group were superior to lidocaine hydrochloride group starting at 17 h, until fourth day (p<0.017). Pain scores of lidocaine hydrochloride group were lesser than saline group in the first and fifth days (p<0.017), whereas, there was no significant difference at other times.

CONCLUSION

Topical administration of bupivacaine hydrochloride proved to provide more efficient pain control than both saline and lidocaine without any drug related complication.

Bupivacaine versus normal saline for relief of post-adenotonsillectomy pain in children: a meta-analysis

OBJECTIVE

A meta-analysis was performed to explore the role of peri-operative bupivacaine infiltration in the relief of pain in adenotonsillectomy.

METHODS

Data from Medline, EMBase, Springer and the Cochrane Collaboration database were searched. Reference lists from identified publications were scanned. RevMan 5.0 software was used for statistical analysis.

RESULTS

7 random controlled tests (a total of 286 cases) were included. Pain intensity was evaluated by VAS score or Cheops score. The pain of group bupivacaine (Group B) was less severe than group placebo (Group P). Analgesic requirement of Group B was less than Group P. Nevertheless the difference of complication between bupivacaine and placebo had no statistical difference.

CONCLUSION

Bupivacaine infiltration is a safe and effective method for relief of pediatric post-adenotonsillectomy pain.

The effects of topical levobupivacaine on morbidity in pediatric tonsillectomy patients

OBJECTIVE

To reduce the post-tonsillectomy morbidity by swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml).

STUDY DESIGN

A double-blind prospective randomized controlled clinical study.

METHODS

In this randomized double-blind study in group I (30 children, mean age 7.5+/-2.6) we tightly packed swab soaked with 5 ml levobupivacaine hydroclorur (25mg/10 ml) and in group II (21 children, mean age 7.9+/-3.7) we used 5 ml saline swabs into each of the two tonsillar fossae after tonsillectomy for 5 min. We used McGrath's face scale to compare the two groups in respect of pain control.

RESULTS

There was statistically significant pain relieving effect in the levobupivacaine group in the first 24h (p<0.05). But after 24h pain relieving effect of levobupivacaine was not significant (p>0.05). We did not see any serious complications for both groups. Postoperative morbidity mean results (nausea, vomiting, fever, bleeding, halitosis and ear pain) were not statistically different between the two groups (p>0.05).

CONCLUSION

Topical levobupivacaine seems to be a safe and easy medication for postoperative pain control in pediatric tonsillectomy patients.

Comparison of intravenous and peritonsillar infiltration of tramadol for postoperative pain relief in children following adenotonsillectomy

BACKGROUND AND OBJECTIVE

The aim of this study was to compare the postoperative analgesic efficacy and side-effects of intravenous tramadol with peritonsillar infiltration of tramadol in children undergoing adenotonsillectomy.

METHODS

Sixty-six children were randomized into two groups: group I received 2 mg kg(-1) tramadol intravenously and group II received 2 mg kg(-1) tramadol in 2 ml of normal saline (1 ml per tonsil) via peritonsillar infiltration. Modified Hannallah pain scale, nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at the 1st, 15th, 30th and 60th minute postoperatively. The Aldrete score was used to determine the postanaesthesia care unit discharge criteria. Patients were evaluated for the analgesic requirement, nausea and vomiting, bleeding and sedation.

RESULTS

There were no differences between groups during the first 1 h. In the postanaesthesia care unit, groups I and II had comparable pain scores that were not statistically significant (P > 0.05). But during the first 24 h the additional analgesic requirement of group I (141.81 mg) was more than group II (83.63 mg) (P = 0.002). Pain scores in the postoperative ward at 6, 12 and 24 h were significantly higher in group I than in group II (P < 0.001). Also four patients (12.12%) from group I and one patient (3.05%) from group II had nausea and vomiting in the postanaesthesia care unit and none of the patients had rescue analgesics. There were no differences between groups regarding nausea and vomiting, sedation and bleeding in the postoperative ward.

CONCLUSION

In adenotonsillectomy cases, peritonsillar infiltration of tramadol maintains efficient pain relief with lower incidence of nausea and vomiting.

Does topical ropivacaine reduce the post-tonsillectomy morbidity in pediatric patients?

OBJECTIVES

To determine whether post-operative administration of topical ropivacaine hydrochloride decreases morbidity following adenotonsillectomy.

STUDY DESIGN

Prospective, randomized, double-blind clinical trial.

SETTING

University referral center; ENT Department.

PARTICIPANTS

Fourty one children, aged 4-16 years, undergoing tonsillectomy.

METHODS

Patients received 1.0% ropivacaine hydrochloride soaked swabs packed in their tonsillar fossae while the control group received saline-soaked swabs. Mc Grath's face scale was used to compare the two groups in respect of pain control. Chi-square and two-tailed unpaired Student's t-tests or Mann-Whitney-U-tests were used to compare the two independent groups. As 10 we made 11 comparison between groups, for Bonferroni correction, p<0.005 was accepted as statistically significant.

RESULTS

Only first hour there was no significant pain-relieving effect seen in the ropivacaine group (p>0.05). The other hours and days there were statistically significance between the two groups (p<0.001). Also, the other post-operative parameters such as nausea, fever, vomiting, odor, bleeding, otalgia and trismus were not statistically different between the two groups. There were no complications associated with ropivacaine hydrochloride. No patients in this study suffered systemic side effects related to the use of this medication.

CONCLUSION

Locally 1.0% ropivacaine administration significantly relieves the pain of pediatric tonsillectomy and, it is a safe and effective method. High concentrations of ropivaciane may produce clinically significant pain relief. It is more effective to reduce of post-operative analgesic requirement after first hour.

Peritonsillar infiltration with bupivacaine and pethidine for relief of post-tonsillectomy pain: a randomised double-blind study

Previous studies of infiltration of local anaesthetics in children undergoing tonsillectomy resulted in conflicting results. The aim of this study was to evaluate the effect of the peritonsillar injection of bupivacaine and pethidine on postoperative pain in children undergoing snare-dissection tonsillectomy. In a double-blind study, 80 children (aged 7-15 years) were randomly divided into two groups receiving peritonsillar injection of either bupivacaine (1 mg x kg(-1)) and pethidine (1 mg x kg(-1)) in adrenaline 1:200,000 (treatment group) or an equivalent volume of saline (placebo group) pre-operatively. The time needed for first demand of analgesia and analgesic consumption to reduce the visual analogue scale (VAS) for resting throat pain to < or = 30, the VAS for pain on swallowing, drinking liquid and eating a soft diet, incidence of nausea and vomiting, and the need for rescue anti-emetics in the first 24 h after operation were compared in both groups. The combination of bupivacaine and pethidine could significantly decrease the consumption of analgesics for resting pain at 4, 6, 8, 12, and 24 h after operation but did not reduce pain on swallowing, drinking liquid and eating a soft diet. The times to demand of first dose of analgesic and to first oral intake were not significantly different. The overall satisfaction of patients in relation to relief of postoperative pain was not significantly different between the two groups. Although peritonsillar injection of pethidine and bupivacaine in children reduces the analgesic consumption, it does not affect the dynamic pain state in the first 24 h after snare-dissection tonsillectomy.