Preoperative ketorolac increases bleeding after tonsillectomy in children

Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

Intravenous Acetaminophen Versus Ketorolac for Prehospital Analgesia: A Retrospective Data Review

BACKGROUND

Parenteral ketorolac and intravenous (IV) acetaminophen have been used for prehospital analgesia, yet limited data exist on their comparative effectiveness.

STUDY OBJECTIVES

To evaluate the comparative effectiveness of IV acetaminophen and parenteral ketorolac for analgesia in the prehospital setting.

METHODS

We conducted a retrospective cross-sectional evaluation of patients receiving IV acetaminophen or parenteral ketorolac for pain management in a large suburban EMS system between 1/1/2019 and 11/30/2021. The primary outcome was change in first to last pain score. Subgroup analysis was performed on patients with traumatic pain. We used inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to estimate the treatment effect of acetaminophen versus ketorolac among all patients and the subgroup of those with traumatic pain.

RESULTS

Of 2178 patients included, 856 (39.3%) received IV acetaminophen and 1322 (60.7%) received parenteral ketorolac. The unadjusted mean change in pain score was -1.9 (SD 2.4) for acetaminophen group and -2.4 (SD 2.4) for ketorolac. In the propensity score analyses, there was no statistically significant difference in pain score change for the acetaminophen group versus ketorolac among all patients (mean difference, IPTW: 0.11, 95% confidence interval [CI] -0.16, 0.37; PSM: 0.15, 95% CI -0.13, 0.43) and among those with traumatic pain (unadjusted: 0.18, 95% CI -0.35, 0.72; IPTW: 0.23, 95% CI -0.25, 0.71; PSM: -0.03, 95% CI -0.61, 0.54).

CONCLUSIONS

We found no statistically significant difference in mean pain reduction of IV acetaminophen and parenteral ketorolac for management of acute pain.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

INTRODUCTION & OBJECTIVE

The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events.

METHODS

A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed.

RESULTS

1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter.

DISCUSSION

The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution.

CONCLUSIONS

The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy?

IMPORTANCE

Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk.

OBJECTIVE

The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk.

DESIGN

Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018.

SETTING

This study was completed at a tertiary-care pediatric referral center.

PARTICIPANTS

1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital.

EXPOSURES

Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk.

MAIN OUTCOME(S) AND MEASURE(S)

Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention.

RESULTS

1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage.

CONCLUSIONS AND RELEVANCE

Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.

Does Intraoperative Ketorolac Increase Bleeding in Oculoplastic Surgery?

PURPOSE

To report adverse hemorrhagic outcomes in patients who received intravenous (IV) ketorolac during oculofacial plastic surgical procedures.

METHODS

The medical records of 111 consecutive patients who underwent lacrimal or orbital surgery, between the years 2016 and 2018, performed by a single surgeon under general anesthesia were retrospectively reviewed. Patients were excluded if they had history of a bleeding coagulopathy, anticoagulant use prior to surgery, or insufficient follow up. Patients were divided into 2 groups based on whether they received intravenous ketorolac. The primary outcome measure was the occurrence of a major postoperative bleeding event, and the secondary outcome measures were the evaluation of postoperative ecchymosis graded at 1 week after surgery and the incidence of persistent ecchymosis beyond 4 weeks.

RESULTS

A total of 111 patients were analyzed further, including 31 patients who received intraoperative IV ketorolac and 80 control patients who did not. The demographic characteristics between the 2 groups were similar. No major bleeding events occurred in either group. And there was no statistically significant difference between the 2 groups in terms of ecchymosis grade and the incidence of development of persistent ecchymosis. Comparing the subgroups of lacrimal and orbital cases, there was also no significance difference between these groups.

CONCLUSIONS

This study suggests that intraoperative ketorolac use does not increase the risk of postoperative bleeding complications in oculofacial procedures. This alternative to opioids may assist with pain control and lessen the narcotic burden.

Postoperative Ketorolac Administration Is Not Associated with Hemorrhage in Cranial Vault Remodeling for Craniosynostosis

Nonsteroidal anti-inflammatory drugs have been used as part of multimodal postoperative analgesic regimens to reduce the necessity of opioids. However, due to its effect on platelet function, there is a hesitation to utilize ketorolac postoperatively. The goal of this study is to analyze our experience utilizing ketorolac in patients who underwent major cranial vault remodeling (CVR) for craniosynostosis with an emphasis on postoperative hemorrhage and complications.

Incidence of bleeding in children undergoing circumcision with ketorolac administration

INTRODUCTION

Circumcision is the most common surgical procedure performed by pediatric urologists. Ketorolac has been shown to have an efficacy similar to morphine in multimodal analgesic regimens without the commonly associated adverse effects. Concerns with perioperative bleeding limit the use of ketorolac as an adjunct for pain control in surgical patients. As such, we sought to evaluate our institutional outcomes with respect to ketorolac and postoperative bleeding.

METHODS

We retrospectively reviewed all pediatric patients undergoing circumcision from January 1, 2014 to December 31, 2015 at the Alberta Children's Hospital. Demographics, perioperative analgesic regimens, and return to emergency department or clinic for bleeding were gathered through chart review.

RESULTS

A total of 475 patients undergoing circumcisions were studied, including 150 (32%) who received perioperative ketorolac and 325 (68%) who received standard analgesia. Patients receiving ketorolac were more likely to return to the emergency department or clinic for bleeding (ketorolac group 19/150 [13%], non-ketorolac group 16/325 [5.0%]; p=0.005). Patients receiving ketorolac were more likely to have postoperative sanguineous drainage (ketorolac group 96/150 [64%], non-ketorolac group 150/325 [46%]; p<0.001). There was no significant difference in the number of patients requiring postoperative admission or further medical intervention.

CONCLUSIONS

Although a promising analgesic, ketorolac requires additional investigation for safe usage in circumcisions due to possible increased risk of bleeding.

Anaesthetic Management in Obstructive Sleep Apnoea Syndrome for Adenotonsillectomy

The anaesthetic management of adenotonsillectomy in children with obstructive sleep apnoea syndrome is characteristic due to respiratory and cardiac side effects. A detailed physical examination in the preoperative period should be performed, including children's respiratory and cardiac systems. If they have an active infection, surgery should be postponed until the end of medical treatment. Preparation for difficult airway management should be done in the preoperative period. In this case, we presented a report of two children who had obstructive sleep apnoea syndrome, with airway management performed at the right lateral position to prevent the pharyngeal collapse and rapid sequence intubation performed using a short-acting muscle relaxant.

Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children

OBJECTIVES/HYPOTHESIS

To evaluate the risk of post-tonsillectomy hemorrhage associated with perioperative ketorolac use.

STUDY DESIGN

Systematic review and meta-analysis of primary articles reporting individual-level post-tonsillectomy hemorrhage rates in subjects receiving perioperative ketorolac and matched controls. Retrospective and prospective studies were both included.

METHODS

PubMed search was performed for "[ketorolac OR toradol] AND tonsillectomy." Articles fulfilling inclusion criteria were subjected to meta-analysis to determine summary relative risk (RR).

RESULTS

Adults are at five times increased risk for post-tonsillectomy hemorrhage with ketorolac use (RR: 5.64; 95% confidence interval [CI]: 2.08-15.27; P < .001). In contrast, children under 18 are not at statistically significantly increased risk (RR: 1.39; 95% CI: 0.84-2.30; P = .20). Both retrospective and prospective studies yield consistent findings. There is no association of RR with pre- or postoperative administration of ketorolac.

CONCLUSIONS

Ketorolac can be used safely in children, but is associated with a five-fold increased bleeding risk in adults.

Ketorolac tromethamine - routes and clinical implications

Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.

Lornoxicam versus tramadol for post-operative pain relief in patients undergoing ENT procedures

Background:

Pain following ear-nose and throat surgery is one of the most important complaints for which, several drugs are used. This prospective, randomized, double-blind controlled trial was designed to compare the analgesic effect of tramadol versus lornoxicam for post-operative pain relief in patients undergoing ENT surgical procedures.

Methods:

One hundred and twenty patients of ASA class I-II, who had undergone elective ENT surgical procedures under general anesthesia, were assigned in a randomized manner into three equal groups. Group L received lornoxicam8 mg IV, Group T received tramadol 1 mg/kg IV and Group C received IV saline after induction of anesthesia before the start of the surgery. Post-operative pain was assessed using the visual analogue scale (VAS) and sedation level was evaluated during stay in the post-anesthesia care unit with a four-point sedation scale. Intraoperative blood loss was estimated using the Five-Point Scale. Adverse events in the first 24 h post-operative were recorded.

Results:

The VAS pain scores were significantly higher in Group C as compared with those in Groups L and T at 30 min and 1, 2, 4and 6 h post-operatively, with no significant difference between Group L and Group T. The amount of morphine consumption post-operatively was significantly lower in Group L (5.2 ± 2.5 mg) and Group T (5.0 ± 2.0 mg) as compared with that in Group C (7.4 ± 2.3 mg) (P = 0.001). The time for the first analgesic requirement was significantly less in Group L (92.62 ± 24.23 min) and Group T (88 ± 21.43 min) as compared with that in Group C (42.82 ± 25.61 min), with no significant difference between the other two groups. Estimated intraoperative blood loss score by the surgeons showed no significant difference between the three groups. The most frequent side-effects in the three groups were nausea and vomiting, and their incidence was significantly higher in the placebo group as compared with the other two groups.

Conclusion:

Tramadol 1 mg/kg was comparable to lornoxicam 8 mg for post-operative pain relief in patients undergoing ENT surgical procedures; both drugs helped to reduce the post-operative opioid requirement and consequently minimized the related adverse effects of the opioids.

A 2013 updated systematic review & meta-analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy

BACKGROUND

Although the literature suggests that non-steroidal anti-inflammatory drugs (NSAIDs) are effective in controlling post-operative pain in the paediatric population, physicians have been reluctant to utilise these medications after tonsillectomy due to concerns of increased bleeding rates. While many surgeons prescribe opioid analgesics postoperatively, these are associated with a number of potential adverse side-effects including nausea, vomiting, constipation, excessive sedation and respiratory compromise.

OBJECTIVE OF REVIEW

To compare bleeding rates and severity between recipients of NSAIDs versus placebo or opioid analgesics for tonsillectomy.

SEARCH STRATEGY

Two authors independently searched electronic databases including PubMed, OVID, EMBASE and Cochrane Review from inception to July 2012. The keywords used included: Adenotonsillectomy, Tonsillectomy, Analgesia, Bleeding, Perioperative and Postoperative. These were then combined in various combinations with specific NSAIDs.

EVALUATION METHOD

A systematic review and meta-analysis of all randomised control trials comparing bleeding rates and severity between NSAIDs versus placebo or opioids post-tonsillectomy.

RESULTS

A total of 36 studies met our inclusion criteria including 1747 children and 1446 adults. When all of the studies were combined in a meta-analysis using the most severe outcome, there was no increased risk of bleeding in those using NSAIDs after tonsillectomy. Use of NSAIDs in general [1.30 (0.90-1.88)] or in children [1.06 (0.65-1.74)] was not associated with increased risk of bleeding in general, most severe bleeding, secondary haemorrhage, readmission or need of reoperation due to bleeding. Similarly, there was no increased bleeding risk for specific NSAIDs in adults. In the studies looking at paediatric subjects, the overall odds ratio of bleeding was even lower than in the general population and not significant. This result is based on 18 studies, six of which had zero outcomes in either treatment arm. Similar to the general population analysis, there was no significant difference in any of the subanalyses: bleeds treated with reoperation, readmission or bleeds in children that could be managed conservatively. There were also no significant differences in the subanalyses of individual NSAIDs. Similarly, there was no significant difference in rates of bleeding in the subanalysis of studies that gave NSAIDs multiple times, for instance, both before and after surgery.

CONCLUSIONS

These results suggest that NSAIDs can be considered as a safe method of analgesia among children undergoing tonsillectomy.

Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. However, as they inhibit platelet aggregation and prolong bleeding time they could cause increased perioperative bleeding. The overall risk remains unclear. This review was originally published in 2005 and was updated in 2010 and in 2012.

OBJECTIVES

The primary objective of this review was to assess the effects of NSAIDs on bleeding with paediatric tonsillectomy. Our secondary outcome was to establish whether NSAIDs affect the incidence of other postoperative complications when compared to other forms of analgesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); MEDLINE (inception until October 2012); EMBASE (inception until October 2012); Current Problems (produced by the UK Medicines Control Agency), MedWatch (produced by the US Food and Drug Administration) and the Australian Adverse Drug Reactions Bulletins (to May 2010). The original search was performed in August 2004. We also contacted manufacturers and researchers in the field.

SELECTION CRITERIA

We included randomized controlled trials assessing NSAIDs in children, up to and including 16 years of age, undergoing elective tonsillectomy or adenotonsillectomy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted the data. We contacted study authors for additional information, where necessary.

MAIN RESULTS

We included 15 studies that involved 1101 children in this updated review. One study was added as a result of our 2012 search, another previously included study was removed due to lack of randomization. Fourteen included studies compared NSAIDs with other analgesics or placebo and reported on bleeding requiring surgical intervention. The use of NSAIDs was associated with a non-significant increase in the risk of bleeding requiring surgical intervention: Peto odds ratio (OR) 1.69 (95% confidence interval (CI) 0.71 to 4.01). Ten studies involving 365 children reported perioperative bleeding requiring non-surgical intervention. NSAIDs did not significantly alter the number of perioperative bleeding events requiring non-surgical intervention: Peto OR 0.99 (95% CI 0.41 to 2.40) but the confidence intervals did not exclude an increased risk. Thirteen studies involving 1021 children reported postoperative vomiting. There was less vomiting when NSAIDs were used as part of the analgesic regime than when NSAIDs were not used: Mantel Haenszel (M-H) risk ratio (RR) 0.72 (95% CI 0.61 to 0.85).

AUTHORS' CONCLUSIONS

There is insufficient evidence to exclude an increased risk of bleeding when NSAIDs are used in paediatric tonsillectomy. They do however confer the benefit of a reduction in vomiting.

Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty

PURPOSE

We conducted a retrospective review following concerns involving a suspected increase in the requirement for surgical re-exploration for hematoma evacuation when ketorolac was administered perioperatively in patients undergoing reduction mammoplasty.

METHODS

Following ethics approval, a retrospective chart review was conducted of all patients who underwent reduction mammoplasty at our two institutions from the time ketorolac became available in 2004 until surgeons requested its use discontinued in 2007. The data we collected included patient demographics, ketorolac administration, requirement for surgical re-exploration, documented hematoma formation not requiring surgical re-exploration, and excessive bleeding in the perioperative period. Three hundred and seventy-nine patient records were reviewed; 127 of the patients received a single intravenous dose of ketorolac (15 or 30 mg), and 252 of the patients did not receive ketorolac.

RESULTS

Patients who received ketorolac were at an increased risk of requiring surgical re-exploration for hematoma evacuation (relative risk [RR] = 3.6; 95% confidence interval [CI], 1.4 to 9.6) and hematoma formation not requiring re-exploration (RR = 2.2; 95% CI, 1.3 to 3.6).

CONCLUSIONS

A single perioperative intravenous dose of ketorolac was associated with a greater than three-fold increase in the likelihood of requirement for surgical hematoma evacuation. Our data suggest that it may be prudent to consider carefully whether the potential risks associated with the use of ketorolac outweigh the potential benefits of using ketorolac in patients undergoing reduction mammoplasty.

The safety and efficacy of intravenous ketorolac in patients undergoing primary endoscopic sinus surgery: a randomized, double-blinded clinical trial

BACKGROUND

Ketorolac (KT) is an intravenous (IV) nonsteroidal anti-inflammatory drug (NSAID) for acute, moderate pain. KT is safe, but may be linked to increased risk of post-tonsillectomy hemorrhage. The safety and efficacy of KT following primary endoscopic sinus surgery (ESS) is unknown.

METHODS

All patients underwent primary ESS and septoplasty. Patients randomly received either IVKT 30 mg or IV fentanyl (IVF) 25 μg postprocedure. Postoperative pain was recorded at 0, 30, and 60 minutes via visual analog scale (VAS), and patients received as needed fentanyl and hydrocodone/acetaminophen for additional pain. Postoperative bleeding questionnaires were completed on postoperative days 1 and 7 (POD 1 and POD 7). Preoperative and POD 7 hemoglobin was assessed.

RESULTS

A total of 34 patients enrolled in the study over 1 year. Sixteen patients received IVKT and 18 patients received IVF. The average time of administration was 23 ± 6 minutes postprocedure. There were no significant differences in preoperative and postoperative hemoglobin levels between groups and bleeding assessments. There were no incidences of postoperative hemorrhage. There was no significant difference in pain VAS between the IVKT and IVF groups (3.5, 3.2, 2.1 vs 3.0, 4.4, 3.8 at 0, 30, and 60 minutes, respectively). There was no significant difference between the number of doses of supplemental analgesics for the IVKT and IVF groups (2.0 vs 3.4 doses IV; 1.0 vs 1.4 doses orally, respectively).

CONCLUSION

In this study, IVKT was a safe analgesic in the setting of primary ESS. There was no increased risk of hemorrhage or acute blood-loss anemia. IVKT did not appear to offer statistically significant pain control over IVF.

Preoperative lornoxicam for pain prevention after tonsillectomy in adults

STUDY OBJECTIVE

To evaluate the efficacy of preoperative lornoxicam on postoperative pain management following tonsillectomy.

DESIGN

Prospective, randomized, double-blinded, placebo-controlled study.

SETTING

King Fahd University Hospital.

PATIENTS

40 adult, ASA physical status I and II patients scheduled for tonsillectomy.

INTERVENTIONS

Patients were randomly allocated to two groups to receive either intravenous (IV) lornoxicam 16 mg (Group L) or saline as control (Group C) preoperatively. Anesthesia was induced using IV fentanyl and propofol, while endotracheal intubation was facilitated with rocuronium, and maintenance was accomplished using nitrous oxide and sevoflurane.

MEASUREMENTS

Pain scores at rest and on swallowing, intraoperative bleeding, interval until first request for rescue diclofenac suppository, and total diclofenac dose given in the first 12 and 24 hours postoperatively were recorded. The frequency of postoperative complications including bleeding, hypoxia, nausea and vomiting also were observed.

MAIN RESULTS

Pain scores at rest were significantly lower in Group L than Group C at all observation times. Similarly, pain scores on swallowing were lower in Group L during the first 4 postoperative hours. The maximum verbal pain scale (VPS) in the control group was 7 (5.75 - 8 median, interquartile range) and in the lornoxicam group, it was 4 (4 - 5 median, interquartile range) (P < 0.001). The total diclofenac dose during the immediate postoperative 12 hours was significantly lower in Group L than Group C (65 ± 24 mg vs. 20 ± 25 mg, respectively; P < 0.001). No significant differences were noted for intraoperative bleeding. The frequency of postoperative nausea and vomiting was similar in both groups.

CONCLUSION

Preoperative 16 mg lornoxicam was effective for immediate postoperative pain relief after tonsillectomy in adults.

Preoperative peritonsillar lornoxicam infiltration is not superior to intravenous lornoxicam for pain relief following tonsillectomy in adults

BACKGROUND AND OBJECTIVE

Nonsteroidal anti-inflammatory drugs have peripheral analgesic effects. We compared the efficacy of peritonsillar infiltration versus intravenous (i.v.) lornoxicam on pain relief after tonsillectomy in adults.

METHODS

Sixty adult patients scheduled for tonsillectomy were randomly assigned into three groups in a double-blind placebo-controlled study. In the control group, the patients received i.v. and peritonsillar saline infiltration; in the infiltration group, they received i.v. isotonic saline and peritonsillar lornoxicam infiltration, whereas in the i.v. group they received i.v. lornoxicam and peritonsillar saline infiltration. Pain verbal analogue scale at rest and on swallowing, the time to the first postoperative analgesic request, the total postoperative analgesic consumption during the first 24 h, intraoperative blood loss and postoperative bleeding were evaluated.

RESULTS

Preoperative lornoxicam administration resulted in a significant reduction in pain scores postoperatively in the infiltration and i.v. groups with no significant difference between them. The time to first postoperative analgesic request was 143 +/- 138 min in the control group compared with 684 +/- 328 and 750 +/- 316 min in the i.v. and infiltration groups, respectively; P value is less than 0.05. Similarly a higher total paracetamol consumption (2632 +/- 1065 mg) during the first postoperative day was recorded in the control group than in both the lornoxicam groups (1300 +/- 733 and 1600 +/- 754 mg), with no significant differences between the i.v. and infiltration groups. Comparable intraoperative blood losses with no posttonsillectomy bleeding were recorded in the three study groups.

CONCLUSION

Peritonsillar infiltration or i.v. lornoxicam enhanced postoperative analgesia after tonsillectomy in adults. However, the analgesic efficacy of locally applied lornoxicam is not superior to the i.v. administration.

Acute pain management in children

The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal.

The effects of paracetamol, ketorolac, and paracetamol plus morphine on pain control after thyroidectomy

BACKGROUND

The aim of this study was to compare the efficacy of ketorolac, paracetamol, and paracetamol plus morphine on pain relief after thyroidectomy.

METHODS

Eighty patients were randomly allocated to one of the 4 groups: normal saline (group C), ketorolac 30 mg (group K), paracetamol 1 g (group P), and paracetamol 700 mg plus morphine 3 mg (group PM). Each regimen was administered intravenously (IV) 30 min. before the end of surgery. If pain was not relieved, patients received an IV bolus of pethidine hydrochloride 25 mg. Pain intensity using a visual analogue scale (VAS) was recorded at 0.5, 1, 2, 4, and 6 hr after the end of surgery.

RESULTS

VAS at 0.5 and 1 hr after the end of surgery were significantly lower in group K, group P, and group PM than in group C (P < 0.05). The number of patients receiving pethidine hydrochloride at 0.5 and 1 hr after the end of surgery was significantly lower in group K, group P, and group PM than in group C (P < 0.05). There was no significant difference among the groups in the incidences of adverse events associated with study medications and patient satisfaction (P > 0.05).

CONCLUSIONS

Paracetamol 1 g IV possesses a similar analgesic efficacy to ketorolac 30 mg IV after thyroidectomy. Paracetamol may represent an alternative to ketorolac for pain prevention after mildly to moderately painful surgery in situations where the use of NSAIDs is unsuitable.

Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing

Nonspecific and COX-2 selective nonsteroidal anti-inflammatory drugs (NSAIDs) function by inhibiting the cyclooxygenase isoenzymes and effectively reduce pain and inflammation attributed to acute or chronic musculoskeletal pathologies. However, use of NSAIDs as an analgesic is thought to negatively contribute to bone healing. This review strived to provide a thorough unbiased analysis of the current research conducted on animals and humans regarding NSAIDs and their effect on bone healing. Specifically, this review discusses the role of animal models, dosing regiments, and outcome parameters when examining discrepancies about NSAIDS and their effects on bone regeneration. The role of COX-2 in bone regeneration needs to be better defined in order to further elucidate the impact of NSAIDs on bone healing.

Safety and efficacy of ketorolac in children after cardiac surgery

OBJECTIVE

To evaluate the nephrotoxic and opioid-sparing effects of ketorolac in children after cardiac surgery.

DESIGN

A retrospective cohort study.

SETTING

A Cardiac Critical Care Unit in a university-affiliated children's hospital.

SUBJECTS

Children less than 18 years of age who underwent low-risk cardiac surgery from July 2002 to December 2005.

RESULTS

Among 248 children studied, 108 received ketorolac and 140 did not. The ketorolac group was older, included a larger proportion of atrial septum defect repairs and a smaller proportion of ventricular septum defect repairs compared to the control group. The median change in serum creatinine did not differ between the ketorolac group and the control group (% change [IQR]); 12% [1-25] increase versus 12% [-3 to 31] increase, P = 0.86. On postoperative day 0 or 1, the ketorolac group received less opioids than control group. There was no difference in duration of mechanical ventilation or in length of stay between groups.

CONCLUSION

Ketorolac started in the first 12 h after a low-risk cardiac surgery in children is not associated with a measurable difference in renal function. The data suggest that ketorolac may be effective in reducing the exposure to opioids. Further studies are required to define subsets of children after cardiac surgery who could safely benefit from ketorolac therapy to reduce pain.

Safety in paediatric clinical trials--a 7-year review

AIM

The safety of clinical trials in children has not been previously studied. We aimed to identify how safety is monitored and the extent of adverse drug reactions (ADRs).

METHODS

A literature review of the Medline Database for therapeutic clinical trials involving oral and intravenous medicines in children from 1996 to 2002. Papers were read to determine the safety monitoring and the presence of adverse events (AEs) or ADRs.

RESULTS

Seven hundred thirty-nine trials were identified. Thirteen (2%) had safety monitoring committees (SMCs). Five hundred twenty-three (71%) trials reported AEs and 151 (20%) of these trials reported a serious AE. ADRs were present in 270 (36.5%) trials, with 80 (11%) of trials having a moderate or severe ADR. Six clinical trials were terminated early because of significant drug toxicity. All of these had SMCs. There were deaths in 83 (11%) trials. In the majority of trials, mortality was thought to be unrelated to the investigational drug; however, in two trials mortality was higher in the treatment group.

CONCLUSIONS

About 11% of trials have a moderate or severe ADR. All paediatric clinical trials should have a SMC.

Sequential clot strength analyses following diclofenac in pediatric adenotonsillectomy

BACKGROUND

Tonsillectomy is a common pediatric surgical procedure resulting in significant postoperative pain. There is ongoing controversy as to the most satisfactory analgesic regimen. Nonsteroidal antiinflammatory drugs (NSAIDs) are an alternative to opioids in this setting. NSAID use in tonsillectomy has been shown to be opioid sparing in the recovery period and to have similar analgesic effects to opioids in pediatric patients. Because of their nonspecific action on the enzyme cyclo-oxygenase there is potential for increased bleeding which has led many practitioners to avoid NSAIDs completely in this patient population potentially resulting in suboptimal pain control. Our aim in this study was to assess the effect of preoperatively administered diclofenac on the blood clot strength in children undergoing (adeno-) tonsillectomy.

METHODS

Twenty patients undergoing (adeno-) tonsillectomy were recruited into this prospective observational study. All patients received 2 mg.kg(-1) of diclofenac rectally immediately preoperatively. Blood was taken for thromboelastograph analysis pre-diclofenac and 1 and 4 h post-diclofenac administration.

RESULTS

There was a statistically significant increase in maximal clot strength (MA) at 1 and 4 h after diclofenac. Similarly there was a statistically significant reduction in time to initial fibrin formation (R time) post-diclofenac. There was no primary or secondary hemorrhage.

CONCLUSIONS

Diclofenac when given preoperatively does not adversely affect clot strength in the immediate postoperative period when the risk of primary hemorrhage is greatest.

Use of nonsteroidal anti-inflammatory drugs in infants. A survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as perioperative analgesics. Many are currently used off label. Diclofenac is currently licensed for use in children over 1 year of age for the treatment of juvenile rheumatoid arthritis, while ibuprofen is licensed for use in children weighing over 7 kg. The dose and interval in children is currently extrapolated from adult studies, as the pharmacokinetic (PK) and pharmacodynamic (PD) data are lacking in infants.

METHODS

A postal questionnaire was sent to members of the Association of Paediatric Anaesthetist of Great Britain and Ireland seeking to clarify members' prescribing patterns of NSAIDs, especially in infants. Information regarding the choice of NSAIDS, route of administration, lower age limit, dose interval, dose and practice in two specific perioperative contexts (adenotonsillectomy and open heart surgery) was sought.

RESULTS

The response rate was 80%. NSAIDs are used by 86% of responders in infants. Diclofenac is most commonly used intraoperatively (78%); while ibuprofen (73%) was used more frequently postoperatively. NSAIDs are used by 21% of respondents in ICU. Commonest routes of administration were oral (81%) and rectal (80%), rarely intravenously (9%). The commonest dose for diclofena is 1 mg x kg(-1) (59%); the dosing schedule employed being 8 hourly in 53% of cases. NSAIDs are used by 57% of responders as part of their analgesic regime for adenotonsillectomies.

CONCLUSION

Members of the Association of Paediatric Anaesthetists of Great Britain and Ireland commonly prescribe NSAIDs in infants. This is despite the dearth of PK and PD data in this age group.

Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis

Postoperative vomiting (POV) remains one of the commonest causes of significant morbidity after tonsillectomy in children. A variety of prophylactic anti-emetic interventions have been reported, but there has only been a limited systematic review in this patient group. A systematic search was performed by using Cochrane Controlled Trials Register, MEDLINE and EMBASE to identify double-blind, randomized, placebo-controlled trials of prophylactic anti-emetic interventions in children undergoing tonsillectomy, with or without adenoidectomy. The outcome of interest was POV in the first 24 h. Summary estimates of the effect of each prophylactic anti-emetic strategy were derived using fixed effect meta-analysis. Where appropriate, dose-response effects were estimated using logistic regression and 22 articles were identified. Good evidence was found for the prophylactic anti-emetic effect of dexamethasone [odds ratio (OR) 0.23, 95% CI 0.16-0.33], and the serotinergic antagonists ondansetron (OR 0.36, 95% CI 0.29-0.46), granisetron (OR 0.11, 95% CI 0.06-0.19), tropisetron (OR 0.15, 95% CI 0.06-0.35) and dolasetron (OR 0.25, 95% CI 0.1-0.59). Metoclopramide was also found to be efficacious (OR 0.51, 95% CI 0.34-0.77). There is not sufficient evidence to suggest that dimenhydrinate, perphenazine or droperidol, in the doses studied, are efficacious, nor were gastric aspiration or acupuncture. In conclusion, dexamethasone and the anti-serotinergic agents appear to be the most effective agents for the prophylaxis for POV in children undergoing tonsillectomy.

Critical care clotting catastrophies

Coagulation problems are very common in intensive care patients. It is important to recognize potential problems, perform a rapid assessment, and start therapy. The author reviews general clinical and laboratory approaches to diagnosis and treatment of the bleeding patient and to correction of coagulopathies. This review outlines a set of often catastrophic coagulation problems, which may present both thrombotic and bleeding challenges. These include heparin induced thrombocytopenia, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation.

The effect of non-steroidal anti-inflammatory drugs on bleeding during periodontal surgery

BACKGROUND

With the increasing prevalence of individuals taking non-steroidal anti-inflammatory drugs (NSAIDs), there is concern as to whether low-dose NSAIDs cause bleeding problems during periodontal surgery.

METHODS

A controlled, single-blind study was designed to measure the effect of ibuprofen at peak plasma levels on intraoperative bleeding. Fifteen medically healthy subjects (seven males and eight females), each having two sites requiring periodontal surgery of similar complexity, type, and duration, were selected for the study. The subjects were instructed to take ibuprofen prior to one of the surgeries. A standard bleeding time and papillary bleeding index score were recorded at initial consultation, and prior to the first and second surgeries. The volume of aspirated blood was measured during each surgery by subtracting the amount of water used for irrigation from the total volume of fluid (blood + irrigation water) collected at 15-minute intervals during the surgery.

RESULTS

An analysis of the results showed an increase in intraoperative bleeding when ibuprofen was taken prior to surgery (31.93 +/- 15.72 versus 17.80 +/- 9.57 ml; P <0.01). Ibuprofen appeared to have its greatest effect on bleeding mid-surgery. The average bleeding time also increased significantly (P <0.01) when ibuprofen was preadministered (4.17 +/- 0.96 versus 3.8 +/- 0.92 minutes), although the bleeding remained within the normal range. Papillary bleeding did not show a significant difference between the two surgeries. Surgeries involving osseous resection showed a significant increase in bleeding when ibuprofen was preadministered.

CONCLUSION

Taken prior to periodontal surgery, ibuprofen increases intraoperative blood loss in patients up to almost two times that of those who did not take ibuprofen.

Postoperative pain management in children

There is increased awareness of the need for effective postoperative analgesia in infants and young children. A multi-modal approach to preventing and treating pain usually is used. Mild analgesics, local and regional analgesia, and opioids when indicated, frequently are combined to minimize adverse effects of individual drugs or techniques.

Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. However, as they inhibit platelet aggregation and prolong bleeding time, they could cause increased perioperative bleeding. The overall risk remains unclear.

OBJECTIVES

The primary objective of this review was to assess the effects of NSAIDs on bleeding for paediatric tonsillectomy. There is good evidence (Kokki 2003; Romsing 1997) to show that NSAIDs are effective analgesics in children. It was not the remit of our review to question this, but rather to assess the risk of bleeding when NSAIDs are used for pain relief following paediatric tonsillectomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2004); MEDLINE (inception until August 2004); EMBASE (from inception until August 2004), Current Problems (produced by the UK Medicines Control Agency); MedWatch (produced by the US Food and Drug Administration) and the Australian Adverse Drug Reactions Bulletin in December 2001. The Cochrane Anaesthesia Review Group's handsearch co-ordinator performed handsearching as required. We also contacted manufacturers and researchers in the field.

SELECTION CRITERIA

We included randomized controlled trials assessing NSAIDs in children up to and including 16 years of age, undergoing elective tonsillectomy or adenotonsillectomy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted the data. We contacted study authors where necessary for additional information. We also collected information on adverse effects from the trials.

MAIN RESULTS

We included 13 trials involving 955 children. All included trials compared NSAIDs with other analgesics or placebo and looked at bleeding requiring surgical intervention. NSAIDs did not significantly alter number of perioperative bleeding events requiring surgical intervention; Peto odds ratio 1.46 (95% confidence interval 0.49 to 4.40). Seven trials involving 471 children looked at bleeding not requiring surgical intervention. NSAIDs did not significantly alter number of perioperative bleeding events not requiring surgical intervention; Peto odds ratio 1.23 (95% confidence interval 0.44 to 3.43). Ten trials involving 837 children looked at post-operative nausea and vomiting. There was less nausea and vomiting when NSAIDs were used as part of the analgesic regime, compared to when NSAIDs were not used; Odds ratio 0.40 (95% confidence interval 0.23 to 0.72).

AUTHORS' CONCLUSIONS

NSAIDs did not cause any increase in bleeding requiring a return to theatre. There was significantly less nausea and vomiting when NSAIDs were used compared to alternative analgesics.

Ketorolac after congenital heart surgery: does it increase the risk of significant bleeding complications?

BACKGROUND

The routine use of ketorolac after congenital heart surgery in infants and children is limited by concerns for postoperative bleeding complications. The object of this study was to determine if the use of ketorolac is associated with an increased risk of significant postoperative bleeding after congenital heart surgery in infants and children.

METHODS

A retrospective chart review was performed. The exposure of interest was postoperative use of ketorolac after congenital heart surgery in infants and children. The outcome measured was postoperative bleeding requiring surgical exploration. The patients who received ketorolac were compared with an age- and diagnosis-matched comparison group who did not receive ketorolac.

RESULTS

Records of 842 infants and children who underwent congenital heart surgery between July 2001 and October 2002 were reviewed. 94 (11.1%) patients were treated with ketorolac postoperatively. The comparison group consisted of 94 matched subjects selected from the patients that did not receive ketorolac. The mean age of patient in the ketorolac group was 8.5 (+/-6.1) years. No (0%) patients in the ketorolac group and four (4.2%) patients in the nonketorolac group developed postoperative bleeding requiring surgical exploration. The relative risk for postoperative bleeding that required surgical exploration in the ketorolac group compared with the nonketorolac group was 0.2 (95% CI 0.02-1.67).

CONCLUSIONS

The use of ketorolac after congenital heart surgery in infants and children does not significantly increase the risk of bleeding complications requiring surgical exploration.

Rofecoxib administration to paediatric patients undergoing adenotonsillectomy

BACKGROUND

Rofecoxib is a selective COX-2 inhibitor that does not interfere with platelet function and is associated with fewer bleeding complications than other nonsteroidal anti-inflammatory agents (NSAIDs). Our aims were to evaluate the safety and the efficacy of rofecoxib administration to paediatric patients undergoing adenotonsillectomy (T&A).

METHODS

We conducted a double-blind, randomized, placebo-controlled study of rofecoxib in 45 ASA 1-2 patients > or = 4 years of age undergoing outpatient T&A. All patients received midazolam 0.5 mg x kg(-1) (max 15 mg) p.o. and either rofecoxib 1 mg x .kg(-1) (max 25 mg) or placebo p.o. 30 min preoperatively. All patients had a standardized anaesthetic and were extubated awake in the operating room at the conclusion of surgery. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores were obtained on arrival in the postanaesthetic care unit (PACU). Morphine 25 microg x kg(-1) i.v. were administered up to six times for pain in the PACU. Wong-Baker FACES Scales were obtained at discharge from the PACU and the day surgery unit (DSU). Outcome measures included intraoperative estimated blood loss (EBL), pain scores, PACU morphine requirements and discharge times.

RESULTS

There were 23 patients in the rofecoxib group and 22 patients in the placebo group. There were no differences between the rofecoxib and placebo groups in terms of bleeding, pain scores, PACU morphine requirements, PACU times or DSU times.

CONCLUSION

Rofecoxib administration to paediatric patients undergoing T&A did not result in increased bleeding. Rofecoxib, however, was not found to decrease morphine use or improve pain scores prior to hospital discharge in T&A patients who received intraoperative morphine and acetaminophen.

Analgesic effect of clonidine added to bupivacaine 0.125% in paediatric caudal blockade

BACKGROUND

Caudals are a common method of providing pain relief in children undergoing surgery. Clonidine, an alpha(2) agonist, exhibits significant analgesic properties. The current investigation sought to determine whether caudal clonidine added to caudal bupivacaine would decrease pain in paediatric patients undergoing surgery.

METHODS

Thirty-six children undergoing elective surgery were studied. Following anaesthetic induction, a caudal was placed (1 mg.kg(-1) bupivacaine 0.125%) with an equal volume of either clonidine (2 microg.kg(-1)) or saline. Perioperative analgesic requirements in the postanaesthesia care unit (PACU) and at home following hospital discharge, and parental pain scores were evaluated.

RESULTS

There were no significant demographic, haemodynamic, or pain score differences between the groups. There was no difference in analgesic duration between groups. There were significantly more children who vomited during the first 24 postoperative hours in the clonidine group than in the saline group (eight in clonidine, two in saline; P < 0.05).

CONCLUSION

We do not recommend adding clonidine (2 microg.kg(-1)) to a bupivacaine (0.125%) caudal block in children undergoing surgery.

Intraoperative ketorolac is an effective substitute for fentanyl in children undergoing outpatient adenotonsillectomy

BACKGROUND

In this prospective randomized double-blind study, we compared the incidence of emesis and 48-h recovery profiles after a single dose of ketorolac vs fentanyl in dexamethasone-pretreated children undergoing ambulatory adenoidectomy and laser-assisted tonsillectomy (ADLAT). We evaluated the hypothesis that avoiding the use of opioids and replacing them with an equianalgesic dose of ketorolac, a nonsteroidal anti-inflammatory drug, would reduce the incidence of postoperative nausea and vomiting (PONV).

METHODS

Fifty-seven ASA I and II children aged 1.710 years who underwent ADLAT were randomized to receive either intravenous ketorolac (1 mg.kg(-1)) or fentanyl (2 microg.kg(-1)) for pain control during a standardized general anaesthetic with propofol infusion. The early (postanaesthesia care unit, day surgical area) and late postoperative courses were compared between the groups.

RESULTS

The incidence of PONV was low and equal in both groups. Postoperative pain scores were equal at all stages of followup. Agitation scores in the postanaesthesia care unit were significantly higher in the ketorolac group, but this had no effect on the late variables of behaviour studied.

CONCLUSIONS

Ketorolac showed no advantage over fentanyl in reducing the incidence of PONV in children undergoing ADLAT.

Optimising postoperative pain management in the ambulatory patient

Over 60% of surgery is now performed in an ambulatory setting. Despite improved analgesics and sophisticated drug delivery systems, surveys indicate that over 80% of patients experience moderate to severe pain postoperatively. Inadequate postoperative pain relief can prolong recovery, precipitate or increase the duration of hospital stay, increase healthcare costs, and reduce patient satisfaction. Effective postoperative pain management involves a multimodal approach and the use of various drugs with different mechanisms of action. Local anaesthetics are widely administered in the ambulatory setting using techniques such as local injection, field block, regional nerve block or neuraxial block. Continuous wound infusion pumps may have great potential in an ambulatory setting. Regional anaesthesia (involving anaesthetising regional areas of the body, including single extremities, multiple extremities, the torso, and the face or jaw) allows surgery to be performed in a specific location, usually an extremity, without the use of general anaesthesia, and potentially with little or no sedation. Opioids remain an important component of any analgesic regimen in treating moderate to severe acute postoperative pain. However, the incorporation of non-opioids, local anaesthetics and regional techniques will enhance current postoperative analgesic regimens. The development of new modalities of treatment, such as patient controlled analgesia, and newer drugs, such as cyclo-oxygenase-2 inhibitors, provide additional choices for the practitioner. While there are different routes of administration for analgesics (e.g. oral, parenteral, intramuscular, transmucosal, transdermal and sublingual), oral delivery of medications has remained the mainstay for postoperative pain control. The oral route is effective, the simplest to use and typically the least expensive. The intravenous route has the advantages of a rapid onset of action and easier titratibility, and so is recommended for the treatment of acute pain.Non-pharmacological methods for the management of postoperative pain include acupuncture, electromagnetic millimetre waves, hypnosis and the use of music during surgery. However, further research of these techniques is warranted to elucidate their effectiveness in this indication. Pain is a multifactorial experience, not just a sensation. Emotion, perception and past experience all affect an individual's response to noxious stimuli. Improved postoperative pain control through innovation and creativity may improve compliance, ease of delivery, reduce length of hospital stay and improve patient satisfaction. Patient education, early diagnosis of symptoms and aggressive treatment of pain using an integrative approach, combining pharmacotherapy as well as complementary technique, should serve us well in dealing with this complex problem.

Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children

Pain is a common symptom after surgery in children, and the need for effective pain management is obvious. For example, after myringotomy, despite the brief nature of the procedure, at least one-half of children have significant pain. After more extended surgery, such as tonsillectomy, almost all children have considerable pain longer than 7 days. Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for postoperative pain management because surgery causes both pain and inflammation. Several pediatric studies indicate NSAIDs are effective analgesics in the management of mild and moderate pain. In the treatment of severe pain, NSAIDs should be given with acetaminophen (paracetamol) or opioids, and the use of an appropriate regional analgesic technique should be considered. NSAIDs are more effective in preventing pain than in the relief of established pain. Pain following surgery is best managed by providing medication on a regular basis, preventing the pain from recurring. This proactive approach should be implemented for any procedure where postoperative pain is the likely outcome. In children, the choice of formulation can be more important than the choice of drug. Intravenous administration is preferred for children with an intravenous line in place; thereafter mixtures and small tablets are feasible options. Children dislike suppositories, and intramuscular administration should not be used in nonsedated children. Ibuprofen, diclofenac, ketoprofen and ketorolac are the most extensively evaluated NSAIDs in children. Only a few trials have compared different NSAIDs, but no major differences in the analgesic action are expected when appropriate doses of each drug are used. Whether NSAIDs differ in the incidence and severity of adverse effects is open to discussion. Because NSAIDs prevent platelet aggregation they may increase bleeding. A few studies indicate that ketorolac may increase bleeding more so than other NSAIDs, but the evidence is conflicting. Severe adverse effects of NSAIDs in children are very rare, but it is important to know about adverse effects in order to recognize and treat them when they do occur. NSAIDs are contraindicated in patients in whom sensitivity reactions are precipitated by aspirin (acetylsalicylic acid) or other NSAIDs. They should be used with caution in children with liver dysfunction, impaired renal function, hypovolemia or hypotension, coagulation disorders, thrombocytopenia, or active bleeding from any cause. In contrast, it seems that most children with mild asthma may use NSAIDs.

Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after tonsillectomy: a quantitative systematic review

The use of nonsteroidal antiinflammatory drugs (NSAIDs) for analgesia after tonsillectomy is controversial because NSAIDS, through platelet inhibition, may increase the risk of perioperative bleeding. We systematically searched for randomized, controlled trials that reported on the incidence of perioperative bleeding attributable to the use of NSAIDs in patients undergoing tonsillectomy. As secondary outcome measures, we analyzed the quality of pain relief and the incidence of postoperative nausea and vomiting. Twenty-five studies with data from 970 patients receiving a NSAID and 883 receiving a non-NSAID treatment or a placebo were analyzed. Data were combined using a fixed-effect model. Of four bleeding end points (intraoperative blood loss, postoperative bleeding, hospital admission, and reoperation because of bleeding), only reoperation happened significantly more often with NSAIDs: Peto-odds ratio, 2.33 (95% confidence interval [CI], 1.12-4.83) and number-needed-to-treat, 60 (95% CI, 34-277). Compared with opioids, NSAIDs were equianalgesic, and the risk of emesis was significantly decreased (relative risk, 0.73; 95% CI, 0.63-0.85; numbers-needed-to-treat, 9; 95% CI, 5-19).

IMPLICATIONS

The evidence for nonsteroidal antiinflammatory drugs to increase the risk of bleeding after tonsillectomy is equivocal, and the risk-benefit ratio is not straightforward. There is some evidence for an increased likelihood of reoperation because of bleeding. The agenda must be one of further research rather than of clinical recommendations.