Pain Management After Surgical Tonsillectomy: Is There a Favorable Analgesic?

A Systematic Review of the Effectiveness of Non-Pharmacological Therapies Used by Nurses in Children Undergoing Surgery

OBJECTIVE

The aim of this study was to identify non-pharmacological pain relief therapies in children undergoing surgery.

DESIGN AND DATA SOURCES

Using keywords extracted from Medical Subject Headings and "Descriptores en Ciencias de la Salud" we searched for articles in the Web of Science, Scopus, Cuiden, PubMed, and CINHAL databases from the last five years, and performed a reverse search. We assessed the documentary quality of the articles using various standardized instruments.

RESULTS

The final review included eleven studies. In terms of cognitive-behavioral techniques, there is evidence that both music and video therapy are effective in reducing postoperative pain in children in seven studies, and therapeutic play in five studies. Other methods used less frequently but found to be effective included laughter therapy in one study and deep breathing in another. Regarding physical methods of pain relief, massage was found to be an effective non-pharmacological therapy for reducing pediatric postoperative pain in two studies and ineffective in another.

CONCLUSIONS

In this study, we highlight the importance of non-pharmacological therapies in pediatric postoperative pain management. Cognitive-behavioral techniques, especially music therapy, video therapy, and therapeutic play, reduce pediatric postoperative pain. They are therefore effective therapies that nurses can use in this area. Further research into the effectiveness of storytelling is necessary, as the evidence is not entirely conclusive. More evidence is also needed on physical methods of pain relief, particularly massage.

Dexamethasone Decreased Postoperative Complications in Tonsillotomy

PURPOSE

Tonsillotomy (TT) is a new and popular method with partial resection of the tonsils. Dexamethasone is often used during surgery for its anti-inflammatory, antiemetic, and analgesic properties. In this study, we aimed to explore the effect of systemic steroids use on postoperative vomiting, pain, and bleeding in TT.

DESIGN

A randomized controlled trial.

METHODS

We enrolled 240 children aged 2 to 18 years who had undergone TT or adenotonsillotomy at our center from July 2020 to July 2021. Dexamethasone or 0.9% normal saline was administered before the start of surgery. Postoperative hemorrhage, vomiting, and nausea were recorded and compared between groups.

FINDINGS

The dexamethasone group had a 2.5% (3/119) rate of postoperative bleeding, while the rate was 1.6% (2/119) in the control group. No patients required multiple operations for control of bleeding. The degree of postoperative pain (2.1 ± 0.5 vs 3.4 ± 0.9) and the occurrence of postoperative nausea (21% vs 31.9%), as well as vomiting (15% vs 24.4%) in the dexamethasone group, was significantly lower compared with the placebo group.

CONCLUSIONS

The rate of postoperative bleeding between the dexamethasone group and the control group had no significant difference, suggesting the high safety of dexamethasone use in TT. Dexamethasone use in TT improved postoperative pain, nausea, and vomiting significantly.

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the impact of the surgical indication on posttonsillectomy bleed rates.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias.

RESULTS

A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001).

CONCLUSION

Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.

Pain Management in Children Admitted to the Emergency Room: A Narrative Review

Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.

Common Selfcare Indications of Pain Medications in Children

Pain has a multifaceted impact on individuals worldwide, affecting their physical functioning, emotional well-being, and quality of life. Children (age < 18 years) have a high prevalence of conditions associated with pain, such as toothache, headache, earache, sore throat, and respiratory tract infections, many of which may be accompanied by fever. Globally, the pharmacologic treatment of pain in pediatric patients is limited largely to nonopioid analgesics, and dosing must account for differences in age, weight, metabolism, and risk of adverse effects. This narrative review summarizes the findings of a literature search on the pediatric indications, dosing approaches, dosing guidelines, and pharmacokinetics of paracetamol and ibuprofen, which are common pain medications available globally for self-care use in children. The review also discusses the risks and benefits associated with these agents. The current roles of paracetamol and ibuprofen in the symptomatic management of coronavirus disease 2019 (COVID-19) infection and in the management of post-COVID-19 immunization symptoms in children are also discussed. Therefore, while a very large amount of data over several decades is available for paracetamol and ibuprofen, an urgent need exists for well-designed studies of these medications for the management of pain and fever in pediatric patients with COVID-19 to ensure optimal relief with minimal toxicity.

A novel classification and grading scale of palatine tonsil anatomy in children

PURPOSE

The influence of tonsil anatomical differences on post-tonsillectomy hemorrhage and pain has not been studied yet. This study aimed to establish a classification and grading scale of palatine tonsil anatomy, not size, for personalized post-tonsillectomy care.

METHODS

Between August 2020 and August 2021, 337 children who underwent extracapsular tonsillectomy were recruited. The images of tonsil anatomy during the surgery were recorded and then classified and graded. Postoperative hemorrhage was recorded, and the degree of pain was measured using a visual analog scale (VAS). The primary outcomes were the associations between postoperative hemorrhage, pain, and the classification and grade of tonsil anatomy, analyzed by univariable and multivariable analyses.

RESULTS

186 of the 337 patients (55.2%) were male and 151 (44.8%) were female; the mean age was 5.59 years. The overall postoperative hemorrhage rate was 4.1%. The mean postoperative VAS score was 4.96. By univariable analysis with logistic regression model, significant associations were found between postoperative hemorrhage and the grade 2 and grade 3 tonsillar lower pole, and grade 3 tonsillar bed. Multivariable analysis with binary logistic regression model also revealed significant associations between postoperative hemorrhage and the grade 2 and grade 3 lower pole (OR: 8.23, 95% CI 1.01-67.37, P = 0.049; OR: 23.86, 95% CI 2.22-56.47, P = 0.009, respectively) and grade 3 tonsillar bed (OR: 14.25, 95% CI 1.46-18.75, P = 0.022). Linear regression analysis showed the associations between postoperative pain and grade 2 and grade 3 lower pole (β: 0.88, 95% CI 0.31-1.32, P = 0.002; β: 1.56, 95% CI 1.29-3.29, P = 0.001, respectively) and grade 3 anterior surface (β: 0.85, 95% CI 0.30-3.07, P = 0.004). Age and upper pole were not associated with the postoperative hemorrhage and pain neither.

CONCLUSION

In the present study, we established a novel classification and 3-grade scale of palatine tonsil anatomy, based on upper pole, anterior surface, lower pole, and tonsillar bed. Furthermore, we revealed for the first time that some anatomical characteristics of tonsils were associated with post-tonsillectomy complications.

Evaluation of the Efficacy of Paracetamol in the Control of Pain After Adenotonsillectomy in the Pediatric Population

Introduction Adenotonsillectomy is a common surgical procedure in otolaryngology. Over the years, several techniques have been developed and modified in order to reduce mortality and morbidity. Postoperative pain control remains controversial. The aim of this study was to evaluate the efficacy of paracetamol alone in the control of postoperative pain. Methods A prospective study was conducted between May 2018 and February 2019, including 76 pediatric patients (age < 18 years), who underwent adenotonsillectomy. The surgeries were performed by the lead author with the same surgical technique. Patients were evaluated one week and one month after surgery through the application of the visual analog pain scale and the number of days of pain was assessed by the need for medication. Results Seventy-six total adenotonsillectomy were performed, with a total of 152 tonsils removed. The majority of patients were male (n=39, 51.3%), with an average age of 6.9 years (min 5, max 15 years). The most frequent surgical indication was sleep breathing disorders, present in 86.9% of the cases. The average duration of postoperative pain was 3 days, with no significant difference between groups (p>0.05). The average intensity of postoperative pain was 3.36 and was higher in patients with infectious criteria as surgical indications (p<0.05). Postoperative bleeding occurred in 3.9% (n=3) of the children, self-limited, without the need for readmission or surgical revision. Conclusion Pain after adenotonsillectomy was more intense in patients undergoing surgery for infectious criteria. Paracetamol used in monotherapy has shown safety and efficacy in controlling postoperative pain.

Comparison of Conventional Curettage Adenoidectomy Versus Endoscopic Powered Adenoidectomy: A Randomised Single-Blind Study

Globally adenoidectomy is increasingly being performed in isolation for children who have middle ear effusion or chronic otitis media, chronic rhinosinusitis and nasopharyngeal obstruction causing sleep apnoea and mouth breathing. Several techniques have been described lately including endoscopic powered adenoidectomy with debrider. The present study was undertaken to compare the effectiveness of endoscopic powered adenoidectomy (EA) with respect to conventional adenoidectomy (CA). It is a prospective study of 60 patients requiring adenoidectomy consisting of 33 males and 27 females randomized into group A with 30 patients undergoing conventional adenoidectomy with curette and 30 patients undergoing endoscopic powered adenoidectomy with micro-debrider. The demographic data (age, sex, adenoid hypertrophy grade assessed by Clemens and Mcmurray scale) in both groups were not statistically significant (p > 0.05). However, significant differences were observed in mean operative time of both groups (CA-29.12 ± 6.70, EA-37.80 ± 6.90 min, p < 0.05). The intra-operative blood volume loss was 21.30 ± 5.80 ml, 28.24 ± 6.93 ml in CA and EA respectively. No significant difference was seen in post-operative pain assessed by Visual Analogue Scale (VAS) (p-0.39). Complete removal of adenoids was seen in 83.3% cases with EA versus 53.3% with CA (p < 0.05). The residual adenoids noted after the CA and EA in Grade I was 23.3% and 13.3% respectively while in CA, grade II with 16.7% and grade III with 6.7% cases had residual adenoids. Injury to surrounding structure was seen in 16.7% and 10% of CA and EA respectively. However, no difference in complication rate was observed between the study groups (p > 0.05). We conclude that endoscopic powered adenoidectomy is more complete, accurate, with less post-operative pain and lower incidence of recurrence in comparison with conventional adenoidectomy.

Analgesic Effects and Safety of Dexmedetomidine Added to Nalbuphine or Sufentanil Patient-Controlled Intravenous Analgesia for Children After Tonsillectomy Adenoidectomy

Tonsillectomy is a frequently performed surgical procedure in children, requiring post-operative analgesia. This study evaluated the efficacy and safety of nalbuphine or sufentanil combined with dexmedetomidine for patient-controlled intravenous analgesia (PCIA) after pediatric tonsillectomy adenoidectomy. A total of 400 patients undergoing tonsillectomy with and without adenoidectomy were included in the study. Patients received a PCIA pump (0.5 mg/kg nalbuphine, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group ND (n = 200). Patients received a PCIA pump (2 μg/kg sufentanil, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group SD (n = 200). More stable hemodynamic changes were noted in Group ND than Group SD from 1 h to 48 h after operation. At 6, 12, 24, and 48 h after operation, the children in Group ND had higher Ramsay sedation scores than those in Group SD. The times to push the PCIA button in Group ND and Group SD were 2.44 ± 0.74 and 2.62 ± 1.00, showing significant differences (p = 0.041). The VASR scores of children in Group ND were significantly lower within 6, 12, and 24 h than those in Group SD (p &lt; 0.05). The VASC scores of children in Group ND were significantly lower within four time points (2, 6, 12, and 24 h) than those in Group SD (p &lt; 0.05). At 1st day after surgery, the children in Group ND had lower levels of serum ACTH, IL-6, and COR levels than those in Group SD (p &lt; 0.001). The incidence rates of nausea and vomiting, and pruritus were significantly higher in Group SD than Group ND (5.00% vs. 11.00%, p = 0.028; 1.00% vs. 4.50%, p = 0.032). The total incidence rate of adverse reactions was significantly higher in Group SD than Group ND (15.00% vs. 31.00%, p = 0.0001). The study demonstrated that dexmedetomidine added to nalbuphine PCIA enhanced the analgesic effects, attenuated the postoperative pain, and reduced the stress response after pediatric tonsillectomy adenoidectomy.

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.

Effects of Intraoperative Auditory Stimulation on Pain and Agitation on Awakening After Pediatric Adenotonsillectomy: A Randomized Clinical Trial

Importance

Severe pain on awakening (POA) and emergence delirium (ED) are common following pediatric adenotonsillectomy. Effective preventive interventions are lacking.

Objective

To determine the effects of intraoperative auditory stimulation on reduction of POA and ED after pediatric adenotonsillectomy.

Design, Setting, and Participants

Single-center, double-blinded, 4-armed, randomized clinical trial of children undergoing adenotonsillectomy from March 2018 to May 2019 at a tertiary care pediatric referral center.

Interventions

Children were randomized to 1 of the following groups: auditory stimulation with music, auditory stimulation with noise, ambient noise insulation with masking earplugs, and a control group receiving no intervention. Ear inserts were placed in the operating room once general anesthesia was administered. Stimulation parameters were based on the preoperative audiological evaluation and the appropriate fitting of the transduction system, including ambient noise level monitoring.

Main Outcomes and Measures

The primary outcome was POA levels measured on 10-point scales according to age-appropriate validated tools. The secondary outcome was ED levels assessed according to the Pediatric Anesthesia Emergence Delirium 20-point scale.

Results

A total of 104 consecutive healthy children (median [interquartile range] age at surgery, 5.0 [3.8-6.4] years) were included in the analysis. Music had a large effect size on POA (0.63; 98% CI, 0.43-0.84) and a medium effect size on ED (0.47; 98% CI, 0.21-0.75), while noise had a medium effect size on POA (0.47; 98% CI, 0.22-0.73) and a large effect size on ED (0.63; 98% CI, 0.44-0.85) compared with controls. The earplugs group showed a small effect size on POA and ED. Considering a clinically meaningful threshold of greater than 4 for POA and 10 or greater for ED at dichotomized analysis, a large effect size was achieved by music (1.39; odds ratio [OR], 0.08; 98% CI, 0.02-0.29; and 0.84; OR, 0.22; 98% CI, 0.06-0.75, respectively) and noise (0.97; OR, 0.17; 98% CI, 0.05-0.6; and 1.48; OR, 0.07; 98% CI, 0.02-0.26, respectively), while earplugs resulted in a small effect size.

Conclusions and Relevance

In this randomized clinical trial, children undergoing adenotonsillectomy who received intraoperative auditory stimulation demonstrated a clinically meaningful decrease in POA and ED in the immediate postoperative period. Further research is needed to assess whether intraoperative auditory stimulation may decrease POA and ED in children undergoing other types of surgical procedures.

Trial Registration

ClinicalTrials.gov Identifier: NCT04112979.

Single dose of intraoperative intravenous morphine for analgesia in children undergoing tonsillectomy: Randomized, double-blind clinical trial

INTRODUCTION

Children undergoing tonsillectomy have severe pain in the postoperative period. One of the pharmacological options for analgesia is opioids, such as morphine. However, the risks of adverse effects, such as increased recovery time from anesthesia and respiratory depression, can limit its use.

OBJECTIVES

To evaluate the use of intraoperative intravenous morphine to reduce immediate postoperative pain in children undergoing tonsillectomy.

METHODS

In this double-blind randomized study, children aged 3-10 years were submitted to tonsillectomy, with or without adenoidectomy, and divided into two groups. Children in group M received 0.1 mg/kg of intravenous morphine during anesthetic induction, while those in the control group received conventional anesthesia without morphine. Postoperative pain perceptions were assessed at 30, 60, 120, 180 and 240 min after recovery from anesthesia, by the children themselves and also by their parents or guardians, using a facial pain scale.

RESULTS

A total of 57 children were included, 30 in the group with morphine and 27 in the group without morphine. According to the children themselves, the postoperative pain was less at the evaluations performed at 30 min after awakening from anesthesia (p =  0.023), while according to their parents/guardians, the pain was less intense in the evaluations performed at 30 (p =  0.002), 60 (p =  0.006) and 180 min (p =  0.007) after awakening. Moreover, postoperative analgesics were less requested by children in the morphine group. No observed side effects were associated with the use of morphine.

CONCLUSION

A single dose of intravenous morphine during anesthetic induction reduced the intensity of immediate postoperative pain in children undergoing tonsillectomy, without increasing the time of awakening from anesthesia and with lower consumption of rescue analgesics.