Does dexamethasone with preemptive analgesia improve pediatric tonsillectomy pain?

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.

Preoperative Administration of Hycet Elixir Reduces Hospital Length of Stay After Pediatric Outpatient Adeno/Tonsillectomy

Background: Postoperative wound pain is commonly observed in the pediatric postanesthesia care unit (PACU) following tonsillectomy, adenoidectomy, and adenotonsillectomy (adeno/tonsillectomy), which contributes to increased medical care costs and delayed facility discharge. The purpose of this study was to review the benefits of preoperative administration of Hycet elixir (2.5 mg hydrocodone and 108 mg acetaminophen per 5 mL) in a pediatric population aged 1 to 9 years following adeno/tonsillectomy.

Methods: Patient demographics, comorbidities, surgical and anesthetic times, need for postoperative rescue therapies, and PACU recovery and length of stay times were measured in pediatric patients who received preoperative administration of Hycet elixir (0.2 mg/kg hydrocodone) for adeno/tonsillectomy in an outpatient setting compared to a control group.

Results: The Hycet elixir group had significant reductions in PACU and hospital lengths of stay and significant reductions in the need for postoperative rescue analgesics. No significant differences were observed in emergence times or in the incidences of unplanned hospital admission between the control and Hycet elixir groups.

Conclusion: These data show that the preoperative administration of Hycet elixir is well tolerated in the pediatric patient population undergoing adeno/tonsillectomy and appears to significantly reduce the need for postoperative rescue analgesics and postoperative care times. These data support the use of preoperative administration of Hycet elixir in this patient population.

Postoperative Nausea and Vomiting in Pediatric Patients

Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

WITHDRAWN: Drugs for preventing postoperative nausea and vomiting

BACKGROUND

Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review.

OBJECTIVES

The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies.

SELECTION CRITERIA

We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted outcome data.

MAIN RESULTS

We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16).

AUTHORS' CONCLUSIONS

Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.

Steroids for Post-Tonsillectomy Pain Reduction: Meta-Analysis of Randomized Controlled Trials

OBJECTIVES: To determine whether meta-analysis supports the use of corticosteroids to reduce post-tonsillectomy pain for pediatric patients.

METHODS: A systematic review of currently available randomized controlled trials using a single-dose, intravenous corticosteroid during pediatric tonsillectomy was performed. Visual analog pain scale (VAS) data was extracted with reviewers blinded to results. Meta-analysis was performed with weighted mean difference and random-effects model using Revman 4.2 software.

RESULTS: Eight randomized trials were included in analysis of post-tonsillectomy pain. A statistically significant reduction in pain as measured by VAS on postoperative day 1 was noted (mean VAS difference = −0.97; CI 95 % = −1.74,−0.19; P = 0.01).

CONCLUSIONS: A single, intraoperative dose of dexamethasone may reduce post-tonsillectomy pain on postoperative day 1, by a factor of 1 on a 10-point pain scale. As the side effects and cost of dexamethasone dose appear negligible, consideration of routine use seems reasonable.

Should We Give Routine Postoperative Intravenous Fluids After Cleft Surgery?

OBJECTIVE

In 2012, the James Lind Alliance, together with the Craniofacial Society of Great Britain and Ireland and the Cleft Lip and Palate Association, set priorities for unanswered questions in cleft management. One of these priorities included postoperative fluid management. The authors' postoperative regimen does not include intravenous fluids unless the child fails to achieve adequate oral intake by the first evening postoperatively. This audit evaluated whether this is appropriate and safe practice.

METHODS

All patients undergoing cleft-related surgery by a single surgeon in a single center during August 2011 to August 2012 were included. Patient age, weight, and surgery type were recorded together with fluid requirement, length of stay, and any returns to theater or readmissions.

RESULTS

Of the 79 patients included, none required readmission or return to theater, and the mean length of stay was 1.72 days. Nineteen patients (24%) required intravenous fluids, but these tended to be the older children in the group (P value .034). In the youngest patients undergoing primary lip repair, only 1 of 20 required intravenous fluids.

CONCLUSIONS

This study demonstrates that, especially in the younger patients, omitting intravenous fluids as a postoperative routine is associated with a shorter length of stay without an increased complication rate. The authors advocate early postoperative feeding and the return to physiological fluid balance.

Comparison of caudal and intravenous dexamethasone as adjuvants for caudal epidural block: A double blinded randomised controlled trial

Background and Aims:

Dexamethasone has a powerful anti-inflammatory action with significant analgesic benefits. The aim of this study was to compare the efficacy of dexamethasone administered through intravenous (IV) and caudal route on post-operative analgesia in paediatric inguinal herniotomy patients.

Methods:

One hundred and five paediatric patients undergoing inguinal herniotomy were included and divided into three groups. Each patient received a single caudal dose of ropivacaine 0.15%, 1.5 mL/kg combined with either corresponding volume of normal saline (Group 1) or caudal dexamethasone 0.1 mg/kg (Group 2) or IV dexamethasone 0.5 mg/kg (Group 3). Baseline, intra- and post-operative haemodynamic parameters, pain scores, time to rescue analgesia, total analgesic consumption and adverse effects were evaluated for 24 h after surgery. Unpaired Student's t-test and analysis of variance were applied for quantitative data and Chi-square test for qualitative data. Time to first analgesic administration was analysed by Kaplan–Meier survival analysis and log-rank test.

Results:

Duration of analgesia was significantly longer (P < 0.001), and total consumption of analgesics was significantly lower (P < 0.001) in Group II and III compared to Group I. The incidence of nausea and vomiting was higher in Group I (31.4%) compared to Group II and III (8.6%).

Conclusions:

Addition of dexamethasone both caudally or intravenously as an adjuvant to caudal 0.15% ropivacaine significantly reduced the intensity of post-operative pain and prolonged the duration of post-operative analgesia with the significant advantage of caudal over IV route.

Efficacy of dexamethasone on postoperative analgesia in children undergoing hypospadias repair

BACKGROUND AND OBJECTIVE

Management of post operative pain in children undergoing hypospadiasis repair, accounts for optimized surgery outcomes and improved patients' satisfaction. Thus, various studies have widely investigated the best approaches for the pain management. In this study our aim was to determine the effect of dexamethasone in combination with penile nerve block on the postoperative pain and complications in the children undergoing hypospadias surgery.

METHODS

In this randomized double-blind placebo controlled trial, after obtaining informed consent from parents or legal guardians, 42 children undergoing surgical treatment of hypospadias were randomized in two groups to receive either IV dexamethasone 0.5 mg/kg (n=23) or placebo (normal saline) (n=19) during the operation. Penile block was performed in both groups using Bupivacaine 0.5% (1mg/kg) at the end of the procedure. By the end of the operation, FLACC (Face, Leg, Activity, Cry, Consolability) pain score was assessed as the primary outcome of the study. Secondary outcomes includes timing and episodes of rescue medication consumption, post operative nausea \vomiting and bleeding. All the outcomes were assessed in the recovery room and after 2, 6, 12, and 24 hours.

RESULTS

The median of FLACC pain scores at the recovery room and 2, 6, 12, and 24 hours post operation was 2, 1, 1, 1, and 2 for the dexamethasone group and 8, 8, 7, 7, and 8 for the placebo group respectively. This were significantly different (P<0.000). The median time of first rescue medication consumption was 8 hours post operation for the dexamethasone group and three hours for the placebo group which was significantly different (z= 4.57, p<0.000). The maximum episode of post operative rescue medication consumption in dexamethasone group was 4 episodes in only one patient and the minimum was one episode in 11 patients. In comparison numbers in placebo group were five episodes in seven patients and three episodes in four patients. The result indicated that there was statistically significant difference between two groups in terms of episodes of rescue medication consumption (Chi2= 31.4, p<0.000).

CONCLUSION

Single dose of intravenous dexamethasone (0.5 mg/kg) in combination with penile block decreased the post operative pain measures, and total post operative analgesic requirement. It also increased the onset of the first analgesic requirement compared to penile block alone.

Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis

Summary In children undergoing tonsillectomy, dexamethasone is recommended to reduce the risk of postoperative nausea and vomiting while non-steroidal anti-inflammatory drugs (NSAIDs) are used for pain relief. We aimed to determine whether children who receive dexamethasone or dexamethasone with NSAID are more likely to experience haemorrhage post-tonsillectomy. Randomized and non-randomized studies in which children undergoing tonsillectomy received dexamethasone or dexamethasone and NSAID were sought within bibliographic databases and selected tertiary sources. The risk of bias assessment and evaluation of haemorrhage rate data collection and reporting were assessed using the Cochrane Risk of Bias Tool and McHarm tool. Synthesis methods comprised pooled estimate of the effect of dexamethasone on the risk of haemorrhage rate using the Peto odds ratio (OR) method. The pooled estimate for haemorrhage rate in children who received dexamethasone was 6.2%, OR 1.41 (95% confidence interval 0.89-2.25, P=0.15). There was risk of bias and inconsistent data collection and reporting rates of haemorrhage in many of the included studies. Clinical heterogeneity was observed between studies. The pooled analysis did not demonstrate a statistically significant increase in the risk of post-tonsillectomy haemorrhage with dexamethasone with/without NSAID use in children. However, the majority of the included studies were not designed to investigate this endpoint, and thus large studies which are specifically designed to collect data on haemorrhage rate are needed.

Enhancement of ropivacaine caudal analgesia using dexamethasone or magnesium in children undergoing inguinal hernia repair

BACKGROUND

Caudal analgesia is the most commonly used technique providing intra- and postoperative analgesia for various pediatric infraumbilical surgical procedures but with the disadvantage of short duration of action after single injection. Caudal dexamethasone and magnesium could offer significant analgesic benefits. We compared the analgesic effects and side-effects of dexamethasone or magnesium added to caudal ropivacaine in pediatric patients undergoing inguinal hernia repair.

MATERIALS AND METHODS

A total of 105 (1-6 years) were randomly assigned into three groups in a double-blinded manner. After a standardized sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.15% 1.5 mL/kg combined with either magnesium 50 mg in normal saline 1 mL (group RM), dexamethasone 0.1 mg/kg in normal saline 1 mL (group RD), or corresponding volume of normal saline (group R) according to group assignment. Postoperative analgesia, use of analgesics, and side-effects were assessed during the first 24 h.

RESULTS

Addition of magnesium or dexamethasone to caudal ropivacaine significantly prolonged analgesia duration 8 (5-11) h and 12 (8-16) h, respectively compared with 4 (3-5) h with the use of ropivacaine alone. The incidence of postoperative rescue analgesia was significantly higher in group R compared with groups RM and RD. The time to 1(st) analgesic dose was significantly longer in groups RM and RD (500 ± 190 and 730 ± 260 min) respectively compared with group R (260 ± 65 min). Group R patients achieved significantly higher Children's Hospital of Eastern Ontario Pain Scale and Faces Legs Activity Cry Consolability scores (4(th) hourly) compared with groups RM and RD patients (8(th) and 12(th) hourly, respectively).

CONCLUSION

The addition of dexamethasone or magnesium to caudal ropivacaine significantly prolonged the duration of postoperative analgesia in children undergoing inguinal hernia repair. Also the time to 1(st) analgesic dose was longer and the need for rescue postoperative analgesic was reduced and without increase in incidence of side effects.

Effect of systemic steroids on post-tonsillectomy bleeding and reinterventions: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the risk of postoperative bleeding and reintervention with the use of systemic steroids in patients undergoing tonsillectomy.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, Cochrane Library, Scopus, Web of Science, Intute, Biosis, OpenSIGLE, National Technical Information Service, and Google Scholar were searched. References from reviews identified in the search and from included studies were scanned.

REVIEW METHODS

Randomised controlled trials comparing the administration of systemic steroids during tonsillectomy with any other comparator were eligible. Primary outcome was postoperative bleeding. Secondary outcomes were the rate of admission for a bleeding episode, reintervention for a bleeding episode, blood transfusion, and mortality.

RESULTS

Of 1387 citations identified, 29 randomised controlled trials (n=2674) met all eligibility criteria. Seven studies presented a low risk of bias, but none was specifically designed to systematically identify postoperative bleeding. Administration of systemic steroids did not significantly increase the incidence of post-tonsillectomy bleeding (29 studies, n=2674 patients, odds ratio 0.96 (95% confidence interval 0.66 to 1.40), I&sup2;=0%). We observed a significant increase in the incidence of operative reinterventions for bleeding episodes in patients who received systemic steroids (12, n=1178, 2.27 (1.03 to 4.99), I&sup2;=0%). No deaths were reported. Sensitivity analyses were consistent with the findings.

CONCLUSIONS

Although systemic steroids do not appear to increase bleeding events after tonsillectomy, their use is associated with a raised incidence of operative reinterventions for bleeding episodes, which may be related to increased severity of bleeding events. Systemic steroids should be used with caution, and the risks and benefits weighed, for the prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their condition of use.

Steroids for improving recovery following tonsillectomy in children

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2003.Tonsillectomy continues to be one of the most common surgical procedures performed worldwide. Despite advances in anesthetic and surgical techniques, post-tonsillectomy morbidity remains a significant clinical problem.

OBJECTIVES

To assess the clinical efficacy of a single intraoperative dose of dexamethasone in reducing post-tonsillectomy morbidity.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN; and additional sources for published and unpublished trials. The date of the most recent search was 29 October 2010, following a previous search in September 2002.

SELECTION CRITERIA

Randomized, double-blind, placebo-controlled trials of a single dose of intravenous, intraoperative corticosteroid for pediatric patients (age < 18 years) who underwent tonsillectomy or adenotonsillectomy.

DATA COLLECTION AND ANALYSIS

The first author extracted data regarding the primary outcome measures and measurement tools from the published studies. The first author also recorded data regarding study design, patient ages, procedures performed, dose of corticosteroid and method of delivery, as well as methodological quality. When data were missing from the original publications, we contacted the authors for more information. We performed data analysis with a random-effects model, using the RevMan 5.1 software developed by the Cochrane Collaboration.

MAIN RESULTS

We included 19 studies (1756 participants). We selected only randomized, placebo-controlled, double-blinded studies to minimize inclusion of poor quality studies. However, the risk of bias in the included studies was not formally assessed. Children receiving a single intraoperative dose of dexamethasone (dose range = 0.15 to 1.0 mg/kg) were half as likely to vomit in the first 24 hours compared to children receiving placebo (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.41 to 0.58; P < 0.00001). Routine use in five children would be expected to result in one less patient experiencing post-tonsillectomy emesis (risk difference (RD) -0.24; 95% CI -0.32 to -0.15; P < 0.00001). Children receiving dexamethasone were also more likely to advance to a soft/solid diet on post-tonsillectomy day one (RR 1.45; 95% CI 1.15 to 1.83; P = 0.001) than those receiving placebo. Finally, postoperative pain was improved in children receiving dexamethasone as measured by a visual analog scale (VAS, 0 to 10) (MD -1.07; 95% CI -1.73 to -0.41; P = 0.001), which correlates clinically to a reduction in pain (on a VAS of 0 to 10) from 4.72 to 3.65. No adverse events were noted in the included studies.

AUTHORS' CONCLUSIONS

The evidence suggests that a single intravenous dose of dexamethasone is an effective, safe and inexpensive treatment for reducing morbidity from pediatric tonsillectomy.

Dexamethasone and Tonsillectomy Bleeding

Objective. To use meta-analytic techniques to examine the effect of dexamethasone on the risk of postoperative bleeding following tonsillectomy.

Data Sources. PubMed and Embase databases accessed on April 23, 2009, and April 28, 2009.

Review Methods. Using principles of meta-analysis, inclusion and exclusion criteria were developed to identify all randomized controlled trials of patients undergoing tonsillectomy in which perioperative intravenous dexamethasone was administered in at least 1 treatment arm and bleeding complications were reported. Electronic databases were searched to identify candidate articles. Two authors independently abstracted data from each article. Discrepancies were resolved by consensus. A fixed-effects model was used to pool relative risks among studies using the Mantel-Haenszel method. Studies were assessed for publication bias using a funnel plot of studies’ effect size vs standard error of the effect size as well as Begg test and Egger test. A P value <.05 was considered significant.

Results. The primary search identified 85 potential studies. Fourteen met inclusion criteria and were selected for meta-analysis. No significant heterogeneity was found among studies (I2< 0.1%; 95% confidence interval [CI], 0%-55%; P = .68). The pooled relative risk (RR) of postoperative bleeding did not differ significantly between patients receiving dexamethasone and controls (RR, 1.02; 95% CI, 0.65-1.61; P = .92). When studies were stratified by age, primary vs secondary hemorrhage, and follow-up duration, no further significant differences in bleeding rate were identified. No evidence of publication bias was found using Begg ( P = .70) or Egger ( P = .73) tests.

Conclusion. The results of this meta-analysis indicate that perioperative dexamethasone does not confer an increased risk of postoperative bleeding in patients undergoing tonsillectomy.

Effect of perioperative perineural injection of dexamethasone and bupivacaine on a rat spared nerve injury model

Background

Neuropathic pain resulting from diverse causes is a chronic condition for which effective treatment is lacking. The goal of this study was to test whether dexamethasone exerts a preemptive analgesic effect with bupivacaine when injected perineurally in the spared nerve injury model.

Methods

Fifty rats were randomly divided into five groups. Group 1 (control) was ligated but received no drugs. Group 2 was perineurally infiltrated (tibial and common peroneal nerves) with 0.4% bupivacaine (0.2 ml) and dexamethasone (0.8 mg) 10 minutes before surgery. Group 3 was infiltrated with 0.4% bupivacaine (0.2 ml) and dexamethasone (0.8 mg) after surgery. Group 4 was infiltrated with normal saline (0.2 ml) and dexamethasone (0.8 mg) 10 minutes before surgery. Group 5 was infiltrated with only 0.4% bupivacaine (0.2 ml) before surgery. Rat paw withdrawal thresholds were measured using the von Frey hair test before surgery as a baseline measurement and on postoperative days 3, 6, 9, 12, 15, 18 and 21.

Results

In the group injected preoperatively with dexamethasone and bupivacaine, mechanical allodynia did not develop and mechanical threshold forces were significantly different compared with other groups, especially between postoperative days 3 and 9 (P < 0.05).

Conclusions

In conclusion, preoperative infiltration of both dexamethasone and bupivacaine showed a significantly better analgesic effect than did infiltration of bupivacaine or dexamethasone alone in the spared nerve injury model, especially early on after surgery.

The effects of levobupivacaine versus levobupivacaine plus magnesium infiltration on postoperative analgesia and laryngospasm in pediatric tonsillectomy patients

BACKGROUND

The aim of this study was to evaluate whether the addition of magnesium to levobupivacaine will decrease the postoperative analgesic requirement or not, and to investigate the possible preventive effects on laryngospasm.

METHODS

Seventy-five children undergoing elective tonsillectomy and/or adenoidectomy surgery. The drug was prepared as only NaCl 0.9% for the first group (Group S, n=25), levobupivacaine 0.25% for the second group (Group L, n=25), and levobupivacaine 0.25% plus magnesium sulphate 2mg/kg for the third group (Group M, n=25). Pain was recorded at 15th minute, 1st, 4th, 8th, 16th, and 24th hour postoperatively. Pain was evaluated using a modified Children's Hospital of Eastern Ontario pain scale (mCHEOPS). Incidence of postoperative nausea and vomiting (PONV) was assessed at various time intervals (0-2, 2-6, 6-24h) by numeric rank score. Patients were followed for laryngospasm for 1h in recovery room after extubation. Other complications appeared within 24h postoperatively were recorded.

RESULTS

All postoperative CHEOPS values were lower than control in both groups. Analgesic requirement was decreased significantly in both groups in comparison with control patients, but this requirement was significantly lower in Group M (p<0.05). Although laryngospasm was not observed in Group M, the difference between groups was not statistically significant. PONV was similar in both groups.

CONCLUSIONS

Levobupivacaine and Levobupivacaine plus magnesium infiltration decrease the post-tonsillectomy analgesic requirement. Insignificant preventive effect of low doses of magnesium infiltration on laryngospasm observed in this study needs to be clarified by larger series.

[Steroids for reduction of morbidity following tonsillectomy]

BACKGROUND

Of the morbidities that follow tonsillectomy, nausea and vomiting, fever, pain and inadequate oral intake are the most commonly encountered. The incidence of postoperative nausea and vomiting (PONV) has been reported as between 40% and 85%. In children, the risk of dehydration is increased owing to the delay in oral intake of fluids in the early postoperative period. In efforts to reduce postoperative morbidity, numerous modifications and adjuncts to the surgical procedure have been suggested, including the use of steroids.

PATIENTS AND METHODS

Reduction in PONV, pain and early return to a normal diet were studied as separate end-points in a review of the current literature.

RESULTS

A total of 31 studies matched our search criteria and involved paediatric and adult patient populations. Only 15 studies evaluated pain, PONV and diet. The lack of standardised surgical and anaesthetic techniques and the variations in length of follow-up, concentration of steroids administered and patient age distribution weaken the impact of the results recorded in several studies. However, two-thirds show that a single intravenous dose of dexamethasone reduces pain, although this was limited to the early postoperative period. Moreover, 15 studies confirmed a beneficial effect of dexamethasone on both PONV and early oral intake.

CONCLUSIONS

Preoperative administration of a single dose of dexamethasone to reduce postoperative morbidity resulting from tonsillectomy is supported by several studies. Adverse events have never been reported. However, further studies are warranted to determine the optimum dose required and the effect in adult tonsillectomy patients. In addition, the data should be based on standardised surgical and anaesthetic techniques to allow reliable evaluation of the significance of all outcome measures.

Evaluation of early postoperative morbidity in pediatric tonsillectomy with the use of sucralfate

OBJECTIVE

The objective of this study is to evaluate the efficacy of sucralfate in alleviating posttonsilectomy morbidity in a pediatric group of patients.

METHODS

A prospective, double-blind, randomized, and placebo-controlled study comparing the irrigation of a solution containing either 1g of sucralfate (study group) or 1g of lactulose (control group) was performed on 69 children aged 3-12 years, who underwent tonsillectomy at the University Hospital of Brasilia Medical School. The children were randomly assigned and each one used a solution containing sucralfate or lactulose to swish and swallow four times daily during 7 days. Eleven patients were excluded. The anesthetic was standardized and no premedication was used. Pain magnitude using an "Oucher" scale, nausea, vomiting, bleeding, earache, analgesic drug intake, changes in the interincisor teeth distance, and changes in the weight and temperature were assessed by the surgeon 6, 24h, and 7 days after the surgery.

RESULTS

Patients in the study group had significantly lower pain scores in the initial 6 postoperative hours (p<0.05). The difference between the two groups was not statistically significant for the other periods following the procedure or on the evaluation of the other indices.

CONCLUSIONS

The use of the sucralfate in pediatric patients undergoing tonsillectomy was not effective in reducing the postoperative morbidity according to the parameters used in this study. The surgical technique with careful mucosal dissection associated with postoperative caries could be more important in the reduction of posttonsilectomy morbidity.

Drugs for preventing postoperative nausea and vomiting

BACKGROUND

Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review.

OBJECTIVES

The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies.

SELECTION CRITERIA

We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted outcome data.

MAIN RESULTS

We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16).

AUTHORS' CONCLUSIONS

Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.

Systematic review on analgesics given for pain following tonsillectomy in children

In this systematic review effectiveness of analgesics for pain after tonsillectomy in children was evaluated and trial methodology of the included studies explored. Databases were searched for randomised, controlled studies on systemic paracetamol, NSAIDs and opioids. Eighty-four studies were evaluated for inclusion. Thirty-six studies were included and 48 excluded. Only in two studies investigated analgesics were given postoperatively for pain. All other studies investigated prophylactic administration of analgesics. Only five studies were truly placebo controlled. Trial methodology of the included studies varied greatly in respect to analgesics and doses used, duration of follow-up periods, methods of pain measurement, rescue analgesics and criteria for administrating rescue analgesia used. Sensitivity of studies was often unclear. Only 16 out of 36 studies were considered to be sensitive. Because of highly variable methodology and lack of sensitivity only limited conclusions on clinical efficacy of analgesics investigated can be drawn. No analgesic in single prophylactic dose provided analgesia for day of operation. Further studies are needed to find the optimal analgesic(s) for pain after tonsillectomy in children.

Role of Analgesic Adjuncts in Postoperative Pain Management

Postoperative pain remains a major problem. A multi-modal analgesic approach is recommended to optimize pain management and reduce opiate-related adverse effects. Several analgesic adjuncts have been investigated, and many have proved to have a useful analgesic effect. This article reviews the literature regarding use of analgesic adjuncts in the perioperative period.

Current practice patterns in tonsillectomy and perioperative care

OBJECTIVES

Tonsillectomy is one of the most commonly performed otolaryngologic procedures in the United States. Many options and controversies exist regarding techniques and peri-operative management. The purpose of the study was to examine current practice patterns among otolaryngologists regarding tonsillectomy.

METHODS

A 13 question survey regarding tonsillectomy techniques and peri-operative management was mailed to 10% of randomly selected board certified otolaryngologists of the AAO-HNS in the spring of 2002. Four hundred and eighteen anonymously completed questionnaires were returned, for a response rate of 58.5%. Statistical analysis of survey data was performed by means of cross tabulation and Pearson Chi-Square Calculation.

RESULTS

Monopolar electrocautery was the most common technique used among those surveyed (53.5%). There was a significant correlation between choice of monopolar electrocautery and the cited reason for choice of technique being decreased blood loss (P < 0.001). There was no relationship between pediatric fellowship training and choice of technique. 97.7% routinely admitted sleep apnea patients for post-operative observation. There was no significant correlation between practice setting (tertiary versus community) and type of post-operative monitoring for sleep apnea patients, with patients most commonly admitted to an intermediate care setting.

CONCLUSION

In our survey, the most common surgical technique for tonsillectomy was monopolar electrocautery, chosen for the reason of decreased blood loss.

Pulsed Mode Radiofrequency Lesioning to Treat Chronic Post-tonsillectomy Pain (Secondary Glossopharyngeal Neuralgia)

Glossopharyngeal neuralgia (GPN) is an uncommon orofacial pain syndrome. Primary GPN is idiopathic, whereas secondary GPN has identifiable causes: tonsillectomy, peritonsillar abscesses, invasive cancer, and trauma. Despite these differences, both types of GPN present similarly and can recur. Pulsed mode radiofrequency lesioning is a safe, non-destructive treatment method and hence, useful in neuropathic pain conditions. We present the first case of chronic post-tonsillectomy pain (secondary glossopharyngeal neuralgia), that was successfully managed with pulsed radiofrequency lesioning.

A randomized, placebo controlled, trial of preoperative sustained release Betamethasone plus non-controlled intraoperative Ketorolac or Fentanyl on pain after diagnostic laparoscopy or laparoscopic tubal ligation [ISRCTN52633712]

BACKGROUND: Gynecological laparoscopic surgery procedures are often complicated by postoperative pain resulting in an unpleasant experience for the patient, delayed discharge, and increased cost. Glucocorticosteroids have been suggested to reduce the severity and incidence of postoperative pain. METHODS: This study examines the efficacy of a sustained release betamethasone preparation to reduce postoperative pain and the requirement for pain relief drugs after either diagnostic laparoscopy or tubal ligation. Patients were recruited, as presenting, after obtaining informed consent. Prior to surgery, patients were randomly selected by a computer generated table to receive either pharmacy-coded betamethasone (12 mg IM Celestone trade mark ) or an optically identical placebo injection of Intralipid trade mark and isotonic saline mixture. The effect of non-controlled prophylactic intraoperative treatment with either fentanyl or ketorolac per surgeon's orders was also noted in this study. Blood samples taken at recovery and at discharge times were extracted and analyzed for circulating betamethasone. Visual analog scale data on pain was gathered at six post-recovery time points in a triple blind fashion and statistically compared. The postoperative requirement for pain relief drugs was also examined. RESULTS: Although the injection achieved a sustained therapeutic concentration, no beneficial effect of IM betamethasone on postoperative pain or reduction in pain relief drugs was observed during the postoperative period. Indeed, the mean combined pain scores during the 2 hour postoperative period, adjusted for postoperative opioids as the major confounding factor, were higher approaching statistical significance (P = 0.056) in the treatment group. Higher pain scores were also observed for the tubal ligation patients relative to diagnostic laparoscopy. Intraoperative fentanyl treatment did not significantly lower the average pain score during the 2 hour postoperative period. Intraoperative ketorolac treatment significantly lowered (P = 0.027) pain scores and reduced the postoperative requirement for additional pain relief drugs. CONCLUSIONS: There was a lack of efficacy of preoperative sustained release betamethasone in reducing postoperative pain despite maintaining a therapeutic concentration during the postoperative period. Intraoperative Ketorolac did afford some short-term pain relief in the postoperative period and reduced the need for additional pain relief drugs.

Treating pediatric patients with obstructive sleep disorders: an update

Obstructive sleep apnea syndrome in children continues to be an important subject for otolaryngologists because of the high prevalence of the disease. The evaluation of a child with OSAS remains controversial, although there is little controversy that T&A is the optimal treatment for these children. The search for the optimal T&A technique is ongoing, although now either "cold" tonsillectomy or "hot" tonsillectomy is standard. Quality-of-life studies confirm the significant benefit gained after a child undergoes a T&A.

Pain management for pediatric ambulatory anesthesia

PURPOSE OF REVIEW

New developments in analgesic drugs and techniques are being applied to the pediatric population. Appropriate pain management for ambulatory surgery patients helps to facilitate early discharge and minimize postoperative morbidity.

RECENT FINDINGS

A variety of opioid-related drugs, as well as novel delivery routes for opioids, have been reported in the pediatric population. New pharmacokinetic information for acetaminophen has resulted in revised dosage recommendations; applications of the nonsteroidal antiinflammatory agents are also discussed. Furthermore, regional anesthesia and adjuncts are useful in the pediatric ambulatory surgery patient.

SUMMARY

Recent data on techniques for pain management after pediatric ambulatory surgery will help the anesthetist develop a comprehensive plan for the postoperative period.