Postoperative pain, pain management, and recovery at home after pediatric tonsil surgery

Telephone Counseling for Children Recovering from Tonsil Surgery-A Randomized Controlled Feasibility Study

BACKGROUND

Even though children after tonsil surgery experience pain and other limitations in their daily lives, nursing care is transferred to parents after tonsil surgery, and they might need some kind of support. The aim of the study was to test the design of a randomized controlled trial intended to evaluate a nurse-led telephone follow-up after tonsil surgery on postoperative symptoms and quality of life.

METHODS

Of the seventeen children aged 3-17 years scheduled to tonsil surgery, nine were randomized to the intervention group and eight to the control group using a randomization list. The parents in the intervention group were contacted by telephone on days 1, 3, 5, and 10 postoperatively for counseling by a nurse. The instruments Postoperative Recovery in Children (PRiC) and the health-related quality of life instrument (EQ-5 D-Y) were used to evaluate postoperative symptoms and quality of life, respectively.

RESULTS

Eight participants in the intervention group reported throat pain compared to five participants in the control group on the operation day and four days after, possibly due to an uneven distribution of the type of surgery between the study groups. The parents appreciated the telephone counseling, and there were no unplanned revisits in the intervention group. However, it was difficult to recruit participants and the assessment tools were not always fully completed.

CONCLUSIONS

No explicit conclusions can be drawn from this feasibility study due to the low number of participants and the study design needs adjustments.

Postoperative Analgesic Regimens and Their Satisfaction Rates-Data from the Swedish Quality Register for Tonsil Surgery

OBJECTIVE

To describe postoperative analgesic regimens and patient-reported pain-related outcomes after tonsil surgery.

METHODS

Cohort study including perioperative data (n = 9274) and patient-reported outcome measures (n = 5080) registered in the Swedish Quality Register for Tonsil Surgery during 2023.

RESULTS

After tonsil surgery, 92.7% received at least paracetamol and a NSAID/COX inhibitor, while 6.8% received no NSAID/COX inhibitor. Opioids were prescribed after tonsillectomy to 62.9% of adults and less often to adolescents and children (13-17-year-olds: 48.2%, 6-12-year-olds: 8.8%, 0-5-year-olds: 4.0%). Clonidine was frequently prescribed to 0-5-year-olds after tonsillectomy (54.4%). Overall, 11.7% reported dissatisfaction with the pain treatment, with the highest dissatisfaction rate after tonsillectomy in adolescents (20.6%) and adults (20.0%), and the lowest after tonsillotomy in children (4.9-6.8%). The most common complaint among dissatisfied patients was analgesics not being sufficiently helpful. Adult patients who received addition of opioids were less dissatisfied with the pain treatment (15.9% vs. 25.9%, p < 0.001), but also reported more side effects (5.7% vs. 2.7%, p = 0.039), compared with patients who received only paracetamol and NSAID/COX inhibitors.

CONCLUSION

Tonsil surgery patients in Sweden receive various analgesic regimens. Although most are satisfied with pain treatment, there is room for improvement, particularly among adolescents and adults undergoing tonsillectomy. Paracetamol and a NSAID/COX inhibitor seem advisable as basic treatment. However, many patients need more effective treatment. The addition of opioids in adults results in greater satisfaction with pain treatment, but safety issues with opioid prescriptions must be taken into consideration.

LEVELS OF EVIDENCE

Level 4 Laryngoscope, 2024.

Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery

OBJECTIVE

The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS).

MATERIALS & METHODS

A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries).

RESULTS

Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy.

CONCLUSION

The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.

Long-term complications after tonsil surgery: an analysis of 54,462 patients from the Swedish Quality Register for Tonsil Surgery

Objective

This study aims to evaluate long-term complications after tonsil surgery using an exploratory retrospective cohort study design based on data from the Swedish Quality Register for Tonsil Surgery (SQTS).

Methods

All patients registered in the SQTS between 1 January 2009 and 31 May 2021 were eligible for the study. In this study, a long-term complication is defined as any complication persisting for a minimum of 6 months after surgery. The definition of a complication was based on individual patient reports, provided in a free text format, of any remaining issues 6 months after tonsil surgery. Complications were categorized as follows: disturbed taste or sense of smell, dysphagia, miscellaneous and general symptoms and signs, miscellaneous throat problems, pain or discomfort in the mouth or throat, problems with jaws or teeth, problems with the ears or hearing, problems with the nose or sinuses, problems with throat secretions or throat clearing, problems with voice or speech, and sensory symptoms. A multivariable logistic regression analysis was used to identify independent predictors of long-term complications.

Results

In total, 54,462 patients were included in the study. A total of 3,780 patients (6.9%) reported one or more long-term complications. The most frequent long-term complications, with a plausible connection to the surgery, were found in the following categories: pain or discomfort in the mouth or throat (1.9%), problems with throat secretions or throat clearing (0.8%), dysphagia (0.6%), and problems with voice or speech (0.6%). Tonsillotomy was associated with a lower risk of long-term complications than tonsillectomy.

Conclusion

This study suggests that subjective long-term complications after tonsil surgery, in general, are relatively common (6.9%). However, complications with a plausible connection to the surgery were less common (4.0%), and specific complications seemed to be relatively rare, with no single specific problem reaching a prevalence of ≥0.6%.

Pain Management in Pediatric Burns: A Review of the Science behind It

Pediatric burns are a significant medical issue that can have long-term effects on various aspects of a child's health and well-being. Pain management in pediatric burns is a crucial aspect of treatment to ensure the comfort and well-being of young patients. The causes and risk factors for pediatric burns vary depending on various factors, such as geographical location, socioeconomic status, and cultural practices. Assessing pain in pediatric patients, especially during burn injury treatment, poses several challenges. These challenges stem from various factors, including the age and developmental stage of the child, the nature of burn injuries, and the limitations of pain assessment tools. In pediatric pain management, various pain assessment tools and scales are used to evaluate and measure pain in children. These tools are designed to account for the unique challenges of assessing pain in pediatric patients, including their age, developmental stage, and ability to communicate effectively. Pain can have significant physical, emotional, and psychological consequences for pediatric patients. It can interfere with their ability to engage in daily activities, disrupt sleep patterns, and negatively affect their mood and behavior. Untreated pain can also lead to increased stress, anxiety, and fear, which can further exacerbate the pain experience. Acute pain, which is short-term and typically associated with injury or illness, can disrupt a child's ability to engage in physical activities and impede their overall recovery process. On the other hand, chronic pain, which persists for an extended period, can have long-lasting effects on physical functioning and quality of life in children. The psychological consequences of burns can persist long after the physical wounds have healed, leading to ongoing emotional distress and impaired functioning. Multimodal pain management, which involves the use of multiple interventions or medications targeting different aspects of the pain pathway, has gained recognition as an effective approach for managing pain in both children and adults. However, it is important to consider the specific needs and considerations of pediatric patients when developing evidence-based guidelines for multimodal pain management in this population. Over the years, there have been significant advances in pediatric pain research and technology, leading to a better understanding of pain mechanisms and the development of innovative approaches to assess and treat pain in children. Overall, pain management in pediatric burns requires a multidisciplinary approach that combines pharmacologic and nonpharmacologic interventions.

Effects of Early Exposure to Isoflurane on Susceptibility to Chronic Pain Are Mediated by Increased Neural Activity Due to Actions of the Mammalian Target of the Rapamycin Pathway

Patients who have undergone surgery in early life may be at elevated risk for suffering neuropathic pain in later life. The risk factors for this susceptibility are not fully understood. Here, we used a mouse chronic pain model to test the hypothesis that early exposure to the general anesthetic (GA) Isoflurane causes cellular and molecular alterations in dorsal spinal cord (DSC) and dorsal root ganglion (DRG) that produces a predisposition to neuropathic pain via an upregulation of the mammalian target of the rapamycin (mTOR) signaling pathway. Mice were exposed to isoflurane at postnatal day 7 (P7) and underwent spared nerve injury at P28 which causes chronic pain. Selected groups were treated with rapamycin, an mTOR inhibitor, for eight weeks. Behavioral tests showed that early isoflurane exposure enhanced susceptibility to chronic pain, and rapamycin treatment improved outcomes. Immunohistochemistry, Western blotting, and q-PCR indicated that isoflurane upregulated mTOR expression and neural activity in DSC and DRG. Accompanying upregulation of mTOR and rapamycin-reversible changes in chronic pain-associated markers, including N-cadherin, cAMP response element-binding protein (CREB), purinergic P2Y12 receptor, glial fibrillary acidic protein (GFAP) in DSC; and connexin 43, phospho-extracellular signal-regulated kinase (p-ERK), GFAP, Iba1 in DRG, were observed. We concluded that early GA exposure, at least with isoflurane, alters the development of pain circuits such that mice are subsequently more vulnerable to chronic neuropathic pain states.

Pain management in hospitalized children: A cross-sectional study

OBJECTIVE

To characterize pain management in hospitalized children.

METHOD

This is an observational, cross-sectional, retrospective and descriptive study of quantitative approach, carried out in a secondary hospital in the city of São Paulo, through analysis of 1,251 medical records of children admitted to the pediatric department. Data were tabulated and analyzed through descriptive statistics.

RESULTS

A total of 88.8% of children were assessed for pain with standardized instruments and 86% had analgesia prescribed. Among the assessments, 37.8% of the children had pain; of these, 26% had severe pain, greater in orthopedic conditions; 18.3% were not medicated, even with the presence of pain and prescribed analgesia; 4.3% had no analgesics prescribed; only 0.4% received non-pharmacological measures, and 40.3% had a report of reassessment. Professionals provided greater analgesia to children with surgical and orthopedic conditions compared to clinical conditions (p < 0.05).

CONCLUSION

Pain management in hospitalized children is ineffective, from initial assessments to reassessments after interventions, with prioritization of medication actions guided by professional judgment in the face of pain complaints.

Manejo da dor em crianças hospitalizadas: Estudo transversal

RESUMO Objetivo: Caracterizar o manejo da dor em crianças hospitalizadas. Método: Estudo observacional do tipo transversal, com abordagem quantitativa, de caráter retrospectivo e descritivo, realizado em um Hospital secundário do Município de São Paulo, por meio de análise de 1.251 prontuários de crianças internadas na divisão pediátrica. Os dados foram tabulados e analisados por meio de estatística descritiva. Resultados: Um total de 88,8% das crianças foi avaliado para dor com instrumentos padronizados e 86% tinham analgesia prescrita. Dentre as avaliações, 37,8% das crianças apresentaram dor; dessas, 26% apresentaram dor intensa, maior nas afecções ortopédicas; 18,3% não foram medicadas, mesmo com presença de dor e analgesia prescrita; 4,3% não tinham analgésicos prescritos; apenas 0,4% receberam medidas não farmacológicas e 40,3% tinham registro de reavaliação. Os profissionais propiciaram maior analgesia a crianças com afecções cirúrgicas e ortopédicas em comparação às afecções clínicas (p < 0,05). Conclusão: O manejo da dor em crianças hospitalizadas mostra-se ineficaz, desde as avaliações iniciais até as reavaliações após intervenções, com priorização de ações medicamentosas guiadas pelo julgamento profissional frente a queixa álgica.

Researchers' choice of pain scales in trials of children undergoing surgery: A cross-sectional analysis of systematically searched randomized controlled trials and survey of authors

BACKGROUND

Many pain scales are used post-operatively in pediatric trials, making the comparison of trials, and the pooling of data for meta-analyses difficult. The Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) statement, published in 2008, attempted to address this issue. We aimed to investigate the reasons for authors' choice of pain scales and the potential impact of PedIMMPACT.

METHODS

We performed a cross-sectional analysis of systematically searched randomized controlled trials testing tramadol in children (up to 16 years) undergoing surgery, published between 2000 and 2020 (9 years prior to and 12 years following the publication of PedIMMPACT).

RESULTS

Among 76 trials (6211 children), 49 unique pain scales were used. The choice of the scales was explained in 18 trials (24%); in 13 of them, authors at least partly justified their choice by the fact that the pain scale was validated. In 52 trials (68%), the pain scales were referenced, with a total of 59 unique references, most often to prior studies using the same scale (36%) or to studies validating the chosen scale (31%). Twenty-three trials (30%) provided no explanation nor reference. One single trial referenced PedIMMPACT. There was no evidence of a change in the choice of pain scales after the publication of PedIMMPACT.

CONCLUSIONS

A large variety of pain scales are still used in pediatric post-operative pain trials 12 years after the publication of PedIMMPACT. Only a minority of trials provided an explanation for their choice of pain scale. The reasons given most often included that the scale was validated or it was justified by a reference to a prior study using that scale. The impact of the publication of the PedIMMPACT seems limited. The ethics of the ongoing usage of large numbers of pain scales in pediatric pain trials must be challenged.

Pain in children undergoing tonsillotomy with alternating ibuprofen and paracetamol - a prospective observational study

BACKGROUND

The optimal pain therapy for children undergoing tonsillotomy remains unknown. Our aim was to evaluate a standard pain therapy including the alternating application of ibuprofen and paracetamol.

METHODS

Pain intensity of 81 in-patients after tonsillotomy aged 2-12 years was evaluated three times daily (mean observation 3.85 days) using the Children's and Infants' Postoperative Pain Scale (CHIPPS) in children <5 years, or with the Faces Pain Scale-Revised (FPS-R) in older children. Parents completed the Parents' Postoperative Pain Measure (PPPM-D) in addition. Exceeding the cut-off value in one of the scores implied the indication for an opioid rescue medication (RM). Endpoints were number of children with indication for the RM, course of pain, concordance between pain scales, and adverse events.

RESULTS

Overall, 45.7% of children needed the RM either in the recovery room or on the ward. The rate of children having an indication for RM on the ward was 30.9%. The highest proportion of affected children was identified on the day of surgery (32.1%). Most indications were detected with the PPPM-D only. A comparison with an earlier study showed less affected children compared to ibuprofen monotherapy on the day of surgery and the first postoperative day. Eleven children (13.6%) developed fever.

CONCLUSION

Although our pain therapy concept was effective from postoperative day 1 onwards, it needs improvement for the day of surgery. The overall concordance between the PPPM-D and CHIPPS or FPS-R was low. Fever might be a confounder for the pain intensity measurement with the PPPM-D.

Pharmacologic management of post-tonsillectomy pain in children

Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.

Establishment of resilience in a challenging recovery at home after pediatric tonsil surgery-Children's and caregivers' perspectives

The objective of this study was to explore children's and caregivers’ experiences and management of postoperative recovery at home after tonsil surgery. The study had an explorative qualitative design with an inductive approach. Twenty children (5‐12 years of age) undergoing tonsillectomy or tonsillotomy with or without adenoidectomy participated along with their caregivers in semi‐structured interviews at a mean time of 28 days after surgery. The interviews were analyzed with content analysis. One main category emerged from the interviews: children and caregivers struggle to establish resilience in a challenging recovery. The families’ resilience relied on their situational awareness and capacity to act, which in turn formed a basis for the ability to return to normal daily life. Children and caregivers described the recovery as an evident interruption of daily life which had an impact on the children's physical and psychological well‐being. Both children and caregivers described the pain as a central concern. The families used different pharmacological and complementary strategies to manage the pain, which in some cases were complex. Some families said that the analgesics were insufficient in preventing breakthrough pain, and spoke about a lack of support as well as inadequate and contradictory information from healthcare staff. Caregivers also expressed uncertainty, ambivalence, or anxiety about the responsibility associated with their child's recovery. To optimize and support the recovery after tonsil surgery, it is crucial to obtain knowledge of children's and caregivers’ perspectives of postoperative recovery at home. The results indicate that the postoperative period included several troublesome experiences for which neither the children nor the caregivers were informed or prepared. The experience of pain was significant, and often complex to manage. To increase families’ resilience, the information provided by healthcare professionals needs to be broadened. Multidisciplinary teamwork is necessary to achieve this goal.