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Roskvist M, Alm F, Nerfeldt P, Ericsson E. 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. PLoS One 2024; 19:e0298011. [PMID: 38451952 PMCID: PMC10919603 DOI: 10.1371/journal.pone.0298011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/16/2024] [Indexed: 03/09/2024] Open
Abstract
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.
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Affiliation(s)
- Maria Roskvist
- Ear-, Nose- and Throat Clinic, County Hospital Mälarsjukhuset Eskilstuna, Sweden
| | - Fredrik Alm
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Pia Nerfeldt
- Department of Otorhinolaryngology, Karolinska University Hospital and Division of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Elisabeth Ericsson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Albornoz AE, Rana M, Hayes J, Englesakis M, Tsang M, Amin R, Gilfoyle E, Petre MA, Campisi P, Aoyama K. Perioperative clinical practice recommendations for pediatric tonsillectomy: a systematic review. Can J Anaesth 2024; 71:187-200. [PMID: 38182827 DOI: 10.1007/s12630-023-02668-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE Tonsillectomy is one of the most common surgical procedures performed in children. Since most clinical practice guidelines (CPGs) are designed to support surgical decisions, none are specifically designed for the perioperative management of children undergoing tonsillectomy. We aimed to identify and analyze the existing CPGs with recommendations for the perioperative management of children undergoing tonsillectomy by conducting a systematic review. SOURCE We searched Embase, MEDLINE, MEDLINE ePub Ahead of Print, and CINAHL for relevant articles published from inception to 3 August 2022. The inclusion criteria were: 1) CPG of perioperative recommendations for tonsillectomy under general anesthesia in children, 2) CPG that include at least one evidence-based recommendation, 3) peer-reviewed CPG published in English after 2000. We extracted data on baseline characteristics of each CPG and general recommendations for perioperative interventions or complications. PRINCIPAL FINDINGS Out of five eligible CPGs, AGREE II and REX confirmed that two CPGs were high quality while only one of the two was recommended for implementation without modifications. Most of the recommendations were for pain management. Acetaminophen was the only medication recommended in all five CPG. Except for the oldest CPG, the CPG all supported of the use of nonsteroidal anti-inflammatory drugs and steroids as a pain adjunct. CONCLUSIONS Acetaminophen, nonsteroidal anti-inflammatory drugs, and steroids are recommended in the perioperative management of pediatric tonsillectomy. Future CPG should further clarify the safe use of opioids based on severity of obstructive sleep apnea and in the context of opioid-sparing techniques, such as dexmedetomidine, high-dose dexamethasone, and gabapentinoids. STUDY REGISTRATION PROSPERO (CRD42021253374); first submitted 18 June 2021.
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Affiliation(s)
- Alfonso E Albornoz
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Jason Hayes
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Maisie Tsang
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Elaine Gilfoyle
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Paolo Campisi
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kazuyoshi Aoyama
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada.
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada.
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De Ravin E, Banik GL, Buzi A. Effect of ibuprofen on severity of surgically-managed pediatric post-tonsillectomy hemorrhage. Int J Pediatr Otorhinolaryngol 2023; 164:111422. [PMID: 36549016 DOI: 10.1016/j.ijporl.2022.111422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/08/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The association between ibuprofen use and severity of post-tonsillectomy hemorrhage (PTH) remains unclear. We aimed to compare PTH severity in patients who did or did not receive ibuprofen. METHODS A retrospective cohort study of pediatric patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 was performed. PTH severity was assessed using pre-tonsillectomy and post-hemorrhage hemoglobin and hematocrit values, estimated intraoperative blood loss, estimated hemorrhage flow rate, and need for transfusion. Differences in hemorrhage severity markers between the two cohorts were compared. RESULTS A total of 168 consecutive patients were included in this study. The mean age was 8.8 years, and 55.4% of patients were male. Sixty-five patients (38.7%) received ibuprofen postoperatively. There was no statistically significant difference in the mean change in hemoglobin (1.1 vs. 1.1, P = 0.85) or hematocrit (3.1 vs. 3.2, P = 0.97) between patients who received ibuprofen compared to those who did not. Similarly, there were no significant differences in need for transfusion (3.1% vs. 3.9%, P = 1.00) or occurrence of high-flow (arterial) blood loss (33.8% vs. 40.8%, P = 0.42) between the two groups. CONCLUSION Postoperative ibuprofen use does not appear to significantly increase PTH severity, as measured by change in hemoglobin and hematocrit values, need for transfusion, or presence of high-flow blood loss. This study introduces previously unexplored markers to assess PTH severity and supports further prospective studies to determine the effect of ibuprofen on PTH severity.
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Affiliation(s)
- Emma De Ravin
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Grace L Banik
- Division of Otolaryngology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Adva Buzi
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA; Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Gostian M, Stilkerich L, Pauly A, Waldfahrer F, Balk M, Rupp R, Allner M, Iro H, Gostian AO. Pain management after tonsillectomy-by demand or by-the-clock-is there a difference? EAR, NOSE & THROAT JOURNAL 2022:1455613221116223. [PMID: 35861363 DOI: 10.1177/01455613221116223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To improve pain management after tonsillectomy (TE) by comparing individual analgesic management by demand versus a fixed-scheduled analgesic treatment protocol in a prospective trial. PATIENTS AND METHODS Forty consecutive patients received individual pain treatment by demand (control group) followed by 40 patients who were treated by a fixed-scheduled four-staged escalating analgesic protocol (intervention group) after TE. Minimum and maximum pain as well as pain on ambulation (NRS 0-10) on the first postoperative day were defined as primary objectives. Secondary endpoints comprised the analgesic score, treatment-related side effects/pain-associated impairments, wish for more pain medication, and patient satisfaction. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire. RESULTS Patients of the control group reported comparable minimum (2.03 ± 1.42 vs 2.38 ± 1.79, P = 0.337, r = 0.110) and maximum pain (6.65 ± 2.10 vs 6.93 ± 1.86, P = 0.536, r = 0.07) and pain on ambulation (4.73 ± 2.26 vs 5.18 ± 2.19, P = 0.370, r = 0.10) compared to the intervention group. Patients in both groups were comparably well satisfied with the pain treatment (7.53 ± 2.40 vs 7.73 ± 2.30, P = 0.704, r = 0.04), experienced similar side effects and functional impairments (P > 0.050, Φ < 0.3), and did not ask for much more analgesic medication (P = 0.152, Φ = 0.160). CONCLUSION Pain control following TE was not distinctly affected by applying a fixed-scheduled analgesic treatment protocol compared to individual analgesic therapy. In conclusion, analgesic treatment after TE remains unsatisfying. Consequently, further efforts are needed to achieve a standardized and effective approach to the underlying pathophysiological causes of pain following TE.
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Affiliation(s)
- Magdalena Gostian
- Department of Anesthesiology and Intensive Care Medicine, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Lisa Stilkerich
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Anne Pauly
- Clinic Pharmacy, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany
| | - Frank Waldfahrer
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matthias Balk
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robin Rupp
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Moritz Allner
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Heinrich Iro
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Department of Otolaryngology, Head & Neck Surgery, Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Barrette LX, Harris J, De Ravin E, Balar E, Moreira AG, Rajasekaran K. Clinical practice guidelines for pain management after tonsillectomy: Systematic quality appraisal using the AGREE II instrument. Int J Pediatr Otorhinolaryngol 2022; 156:111091. [PMID: 35240561 DOI: 10.1016/j.ijporl.2022.111091] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/12/2022] [Accepted: 02/16/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE We identified and appraised clinical practice guidelines (CPGs) for the management of post-tonsillectomy pain using the Appraisal of Guidelines for Research and Evaluation (AGREE II) guideline research tool. MATERIALS AND METHODS We conducted a literature search to identify CPGs addressing pain management after tonsillectomy. CPGs meeting inclusion criteria were then appraised by four independent reviewers in six areas of quality, as defined by AGREE II. Scaled domain scores were calculated for each quality domain. Intraclass correlation coefficients (ICC) were calculated in each domain to assess interrater reliability across guideline appraisals. RESULTS Nine guidelines meeting inclusion criteria were identified from a systematic search of the literature. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline detailing tonsillectomy and postoperative management in pediatric patients received the highest average score, with a mean of 90.1% in the six areas of quality. Three guidelines scored higher than >60% in five domains or more, defining 'high' quality per AGREE II: AAO-HNS, Scottish Intercollegiate Guides Network (SIGN), and Ontario Ministry of Health CPGs. The highest-scoring domain was domain 4: Clarity of presentation (87.4%) across guidelines, while the lowest scoring domain was domain 5: Applicability (49.4%). Variability in scaled domain scores between all CPGs was relatively consistent across domains, with a mean standard deviation of 22.4%. The average ICC calculated across all six domains was 0.78, indicating 'strong agreement' between reviewers regarding guideline quality. CONCLUSION Of the nine available guidelines detailing pain management following tonsillectomy we identified, only three (33%) were deemed 'high'-quality after appraisal using the AGREE II instrument, suggesting a need for development of novel, methodologically rigorous CPGs.
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Affiliation(s)
| | - Jacob Harris
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emma De Ravin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eesha Balar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alvaro G Moreira
- Department of Pediatrics, University of Texas Health Science Center-San Antonio, TX, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Gude P, Geldermann N, Georgevici AI, Herzog‐Niescery J, Weber TP, Vogelsang H, Dazert S, van Ackeren K, Volkenstein S. Pain in children undergoing tonsillotomy with alternating ibuprofen and paracetamol - a prospective observational study. Acta Anaesthesiol Scand 2021; 65:1374-1380. [PMID: 34310700 DOI: 10.1111/aas.13959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/05/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Philipp Gude
- Department of Anesthesiology Ruhr‐University BochumSt. Josef‐ and St. Elisabeth‐Hospital Bochum Germany
| | - Niclas Geldermann
- Department of Anesthesiology Ruhr‐University BochumSt. Josef‐ and St. Elisabeth‐Hospital Bochum Germany
| | - Adrian I. Georgevici
- Department of Anesthesiology Ruhr‐University BochumSt. Josef‐ and St. Elisabeth‐Hospital Bochum Germany
| | - Jennifer Herzog‐Niescery
- Department of Anesthesiology Ruhr‐University BochumSt. Josef‐ and St. Elisabeth‐Hospital Bochum Germany
| | - Thomas Peter Weber
- Department of Anesthesiology Ruhr‐University BochumSt. Josef‐ and St. Elisabeth‐Hospital Bochum Germany
| | - Heike Vogelsang
- Department of Anesthesiology Ruhr‐University BochumSt. Josef‐ and St. Elisabeth‐Hospital Bochum Germany
| | - Stefan Dazert
- Department of Otorhinolaryngology, Head & Neck Surgery Ruhr‐University BochumSt. Elisabeth‐Hospital Bochum Germany
| | - Konstantin van Ackeren
- Department of Otorhinolaryngology, Head & Neck Surgery Ruhr‐University BochumSt. Elisabeth‐Hospital Bochum Germany
| | - Stefan Volkenstein
- Department of Otorhinolaryngology, Head & Neck Surgery Ruhr‐University BochumSt. Elisabeth‐Hospital Bochum Germany
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de Azevedo CB, Valera FCP, Carenzi LR, Küpper DS, Caetano JVB, Queiroz DLC, Anselmo-Lima WT, Tamashiro E. Does ibuprofen, prednisolone, or amoxicillin reduce post-tonsillectomy pain in children? A prospective randomized controlled trial. Int J Pediatr Otorhinolaryngol 2021; 148:110824. [PMID: 34229149 DOI: 10.1016/j.ijporl.2021.110824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/19/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate whether the use of anti-inflammatory or antibiotic in the postoperative period modifies pain in children undergoing tonsillectomy. METHODS 225 children who underwent cold knife tonsillectomy ± adenoidectomy were randomized into five groups, receiving #1 metamizole/acetaminophen, #2 amoxicillin, #3 ibuprofen, #4 prednisolone, or #5 amoxicillin plus prednisolone. All groups received oral analgesics (metamizole/acetaminophen) to use as needed. Pain was monitored during the 7 days following surgery using the Parents' Postoperative Pain Measurement (PPPM) and the Faces Pain Scale - Revised (FPS-R). Pain was also indirectly evaluated by the dose of analgesics administered on each day and by the time needed to return to a solid diet. RESULTS After losses (24%), 170 individuals were submitted for analysis. Multiple comparisons demonstrated that the evolution of pain between the different groups, as matched day-per-day, was not significantly different by either PPPM or FPS-R (p > 0.05). The instances of analgesic intake were also similar in all the groups (p > 0.05), as was the return to solid food ingestion (p = 0.41). All groups presented a similar standard of clinical improvement at intervals of 2 days (p < 0.01). Independent of postoperative pain management, patients developed significant pain up to the day 4 following surgery. CONCLUSION The addition of amoxicillin, ibuprofen, prednisolone, or amoxicillin and prednisolone does not modify postoperative pain in children undergoing cold-knife tonsillectomy. Special pain control should be performed on the first 4 days following tonsillectomy in children.
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Affiliation(s)
| | - Fabiana C P Valera
- Ribeirao Preto Medical School, University of São Paulo (FMRP-USP), Brazil.
| | | | - Daniel S Küpper
- Ribeirao Preto Medical School, University of São Paulo (FMRP-USP), Brazil.
| | | | | | | | - Edwin Tamashiro
- Ribeirao Preto Medical School, University of São Paulo (FMRP-USP), Brazil.
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Gostian AO, Loeser J, Tholen C, Wolber P, Otte M, Schwarz D, Heindl LM, Balk M, Gostian M. Postoperative pain after tonsillectomy - the value of standardized analgesic treatment protocols. Auris Nasus Larynx 2020; 47:1009-1017. [PMID: 32536501 DOI: 10.1016/j.anl.2020.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/24/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To alleviate pain after tonsillectomy (TE) with escalating gradual treatment protocols in a prospective trial. MATERIALS & METHODS Following TE, 83 consecutive adult patients were treated with two different four-staged escalating analgesic protocols. Metamizole served as basic medication in protocol 1 (PT1; n = 44), whereas with protocol 2 (PT2; n = 39) ibuprofen was applied as baseline analgesic. Both protocols were escalated according to the patient´s needs to metamizole and ibuprofen vice versa and additional weak to strong opioids. The primary efficacy endpoint was defined as the minimum and maximum pain as well as pain on ambulation (NRS, 0-10). Secondary endpoints comprised analgesic score, patient satisfaction and treatment-related side-effects. RESULTS Both patient groups exhibited similar demographic characteristics (PT1: Ø 28.8 years; 64% ♀ and PT2: Ø 26.6 years; 56% ♀). Maximum pain (6.7 ± 1.9 vs. 7.6 ± 1.6, t(81) = -2.254, p = 0.027) and pain on ambulation (5.0 ± 1.8 vs. 5.8 ± 1.8, t(81) = -2.114, p = 0.038) were significantly higher with PT2. 68.2% of patients with PT1 needed an escalation of analgesic treatment compared to 100% with PT2 (p < 0.001). The opioid consumption was also significantly higher with PT2 (43.2% vs. 71.8%, p < 0.001). There were no significant differences regarding functional impairments, side-effects and patient satisfaction (7.0 ± 2.0 vs. 7.4 ± 2.4, t(79) = -0.897, p = 0.373). CONCLUSION Both treatment protocols yielded in a high degree of patient satisfaction but dissatisfactory pain relief following TE. Metamizole can be recommended as a basic medication allowing for improved pain relief. Reported pain intensities were independent of the amount of opioid intake. Further research is mandatory to standardize and improve analgesic treatment after TE.
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Affiliation(s)
- Antoniu-Oreste Gostian
- Department of ENT, Head and Neck Surgery, University of Erlangen-Nuremberg, Waldstrasse 1, 91054 Erlangen, Erlangen, Germany.
| | - Johannes Loeser
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Christian Tholen
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Philipp Wolber
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Martin Otte
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - David Schwarz
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | | | - Matthias Balk
- Department of ENT, Head and Neck Surgery, University of Erlangen-Nuremberg, Waldstrasse 1, 91054 Erlangen, Erlangen, Germany
| | - Magdalena Gostian
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
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Gude P, Gustedt F, Bellgardt M, Vogelsang H, Herzog-Niescery J, Dazert S, Weber TP, Volkenstein S. High dose ibuprofen as a monotherapy on an around-the-clock basis fails to control pain in children undergoing tonsil surgery: a prospective observational cohort study. Eur Arch Otorhinolaryngol 2020; 277:2115-2124. [DOI: 10.1007/s00405-020-05929-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
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A descriptive analysis of pediatric post-tonsillectomy pain and recovery outcomes over a 10-day recovery period from 2 randomized, controlled trials. Pain Rep 2020; 5:e819. [PMID: 32440612 PMCID: PMC7209815 DOI: 10.1097/pr9.0000000000000819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/18/2019] [Accepted: 02/04/2020] [Indexed: 12/21/2022] Open
Abstract
Pediatric tonsillectomy involves an often painful and lengthy recovery period, yet the extended recovery process is largely unknown. This article describes postoperative recovery outcomes for 121 children aged 4 to 15 (mean 6.6 years, SD = 2.3) years enrolled in 1 of 2 clinical trials of analgesia safety and efficacy after tonsillectomy. Postoperative analgesia included scheduled opioid analgesic plus acetaminophen/ibuprofen medication use (first 5 days) and “as-needed” use (last 5 days). Clinical recovery as measured daily by the Parents' Postoperative Pain Measure (PPPM; an observational/behavioral pain measure), children's self-reported pain scores, side-effect assessments, need for unanticipated medical care, and satisfaction with recovery over 10 days was assessed. Higher Parents' Postoperative Pain Measure scores were correlated with poorer sleep, receipt of breakthrough analgesics, distressing side effects, higher self-reported pain scores, and need for unanticipated medical care. Higher self-reported pain scores were associated with more distressing adverse events, including nausea, vomiting, insomnia, lower parent satisfaction, and unplanned medical visits and hospitalizations. Pain and symptoms improved over time, although 24% of the children were still experiencing clinically significant pain on day 10. Scheduled, multimodal analgesia and discharge education that sets realistic expectations is important. This study adds to the emerging body of literature that some children experience significant postoperative pain for an extended period after tonsillectomy.
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Nguyen XL, Briffod J, Couloigner V, Darqué F, Kerbrat JB, Vecchierini MF. [Adolescent obstructive sleep apnoea syndrome: Characteristics and treatment]. Rev Mal Respir 2019; 36:697-706. [PMID: 31255317 DOI: 10.1016/j.rmr.2018.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/29/2018] [Indexed: 12/28/2022]
Abstract
Although the prevalence of the obstructive sleep apnoea syndrome (OSAS) is high in adolescents, studies pertaining to adolescent OSAS are less numerous than childhood studies. Cases of adolescent OSAS may consist of residual OSAS after adenotonsillectomy, but most often are de novo cases. Major pathophysiological factors are weight excess or even high-grade obesity, and the association of upper airway narrowing and tonsillar hypertrophy (pharyngeal, palatal or even lingual). ENT and systematic orthodontic assessments are the main points. In case of predisposing factors such as dental, occlusal or dento-facial abnormalities, a specific orthodontic treatment can be discussed. First line treatment is surgical adenotonsillectomy; surgical reduction of the lingual tonsils is seldom required. CPAP treatment may be indicated in the case of severe comorbidities (craniofacial malformations, neuromuscular diseases…) or in obese adolescents with severe residual OSAS. Treatment of adolescent OSAS has to be comprehensive and multidisciplinary, taking into account the specific treatments of obesity and abnormal sleep/wake rhythms.
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Affiliation(s)
- X-L Nguyen
- Unité somnologie et fonction respiratoire, hôpital St-Antoine, 75012 Paris, France
| | - J Briffod
- Centre médical spécialisé de l'enfant et de l'adolescent, 17, rue Froment, 75011 Paris, France
| | - V Couloigner
- Service d'ORL pédiatrique, hôpital Necker-Enfants Malades, université Paris Descartes, AP-HP, 75015 Paris, France
| | - F Darqué
- Unité d'orthopédie dento-faciale, hôpital Pellegrin, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - J-B Kerbrat
- Pathologies du sommeil, groupe hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France
| | - M-F Vecchierini
- Centre du sommeil et de la vigilance, Hôtel-Dieu, 1, place du Parvis Notre-Dame, 75181 Paris cedex 04, France.
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Hedenmalm K, Blake K, Donegan K, Macia MA, Gil M, Williams J, Montero D, Candore G, Morales D, Kurz X, Arlett P. A European multicentre drug utilisation study of the impact of regulatory measures on prescribing of codeine for pain in children. Pharmacoepidemiol Drug Saf 2019; 28:1086-1096. [PMID: 31219227 PMCID: PMC6771637 DOI: 10.1002/pds.4836] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/01/2019] [Accepted: 04/23/2019] [Indexed: 12/19/2022]
Abstract
Purpose In June 2013, following recommendations from the World Health Organization (WHO) and Food and Drug Administration (FDA), the European Medicines Agency agreed updates to the codeine product information regarding use for pain in children younger than 12 years and children undergoing tonsillectomy or adenoidectomy (TA) for obstructive sleep apnoea. This study was conducted to (a) assess effectiveness of these measures on codeine prescribing in the “real‐world” setting and (b) test feasibility of a study using a common protocol by regulators with access to databases. Methods The study was performed using BIFAP (Spain), CPRD (UK), and IMS® Disease Analyzer (France and Germany) databases. Prescribers included general practitioners (GPs) (France and UK), GPs and paediatricians together (Spain), and GPs, paediatricians, and ear, nose, and throat (ENT) specialists separately (Germany). Between January 2010 and June 2015, prevalence of codeine prescribing was obtained every 6 months, and a time series analysis (joinpoint) was performed. Codeine prescribing within ±30 days of TA was also identified. Furthermore, doses, durations, and prior prescribing of other analgesics were investigated. Results Over the 5‐year period, codeine prescribing decreased in children younger than 12 years (by 84% in France and Spain, 44% in GP practices in Germany, and 33% in the United Kingdom). The temporal pattern was compatible with the regulatory intervention in France and the United Kingdom, whereas a decrease throughout the study period was seen in Germany and Spain. Decreased prescribing associated with TA was suggested in ENT practices in Germany. Conclusions Codeine prescribing for children decreased in line with introduced regulatory measures. Multidatabase studies assessing impact of measures by EU regulators are feasible.
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Affiliation(s)
- Karin Hedenmalm
- Business, Data and Analytics Department, European Medicines Agency, London, UK
| | - Kevin Blake
- Specialised Scientific Disciplines Department, European Medicines Agency, London, UK
| | - Katherine Donegan
- Vigilance and Risk Management of Medicines, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Miguel-Angel Macia
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain
| | - Miguel Gil
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain
| | - Julie Williams
- Pharmacovigilance and Risk Management Planning, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Dolores Montero
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain.,Spanish Medicines & Medical Devices Agency (Agencia Española de Medicamentos y Productos Sanitarios), Madrid, Spain
| | - Gianmario Candore
- Business, Data and Analytics Department, European Medicines Agency, London, UK
| | - Daniel Morales
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, London, UK
| | - Xavier Kurz
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, London, UK
| | - Peter Arlett
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, London, UK
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Hanani T, Gadban H, Jahshan F, Ronen O. Tantum verde mouthwash for tonsillectomy: A prospective, double-blind, randomized control trial. Int J Pediatr Otorhinolaryngol 2019; 121:173-178. [PMID: 30917302 DOI: 10.1016/j.ijporl.2019.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Post-tonsillectomy pain control is still considered a challenge. Topical agents would seem to be an ideal, safe option. Our objective was to compare the efficacy of mouthwash preparation with anti-inflammatory, anesthetic, and analgesic properties (Tantum Verde®, 0.15% benzydamine hydrochloride) with that of placebo in improving post-tonsillectomy morbidity. METHODS A prospective, double blind, randomized clinical trial was performed. Patients older than 12-years-of-age who underwent tonsillectomy were recruited. Participants were randomized into 2 groups to receive either 0.15% benzydamine hydrochloride (TV) mouthwash solution (study arm) or a placebo solution. They were instructed to gargle the intervention they received 3 times a day for 7 days following surgery. Primary outcomes were intensity and duration of post-operative pain (using VAS visual analogue score) during a 2-week follow-up period. Secondary outcomes were pain medication demand, readmission, incidence of post-operative bleeding, hospital stay duration, and time to resume normal solid diet. RESULTS Thirty-nine patients completed the study, of whom 23 received TV and 16 received placebo. The mean age was 23.1 years. There was no significant difference between the groups in the primary or secondary outcomes. CONCLUSIONS The data suggest that topical treatment with TV mouthwash solution was not found to be superior to placebo in the management of post-tonsillectomy pain, bleeding, and return to a regular solid diet. Further research studies should be designed to investigate the ideal treatment for reducing post-tonsillectomy morbidity. CLINICAL TRIAL REGISTRATION NIH identifier: NCT02190762; IRB NHR002814.
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Affiliation(s)
- Tal Hanani
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Hussein Gadban
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Forsan Jahshan
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Ohad Ronen
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel.
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15
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Pain after tonsillectomy: effectiveness of current guidelines? Eur Arch Otorhinolaryngol 2017; 275:281-286. [DOI: 10.1007/s00405-017-4788-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
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Pfaff JA, Hsu K, Chennupati SK. The Use of Ibuprofen in Posttonsillectomy Analgesia and Its Effect on Posttonsillectomy Hemorrhage Rate. Otolaryngol Head Neck Surg 2016; 155:508-13. [DOI: 10.1177/0194599816646363] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 04/05/2016] [Indexed: 11/16/2022]
Abstract
Objective To determine the effect of ibuprofen on posttonsillectomy bleeding when compared with codeine in posttonsillectomy analgesia. Study Design Case series with chart review. Setting Tertiary care children’s hospital, Philadelphia, Pennsylvania. Subjects and Methods On July 1, 2012, our institution transitioned from acetaminophen with codeine to ibuprofen for posttonsillectomy analgesia. Pediatric patients (0-18 years old) who underwent surgery from July 1, 2010, to June 30, 2012, were placed in the codeine cohort, and those who underwent surgery from July 1, 2012, to June 30, 2014, were placed in the ibuprofen cohort. Results A total of 6014 patients underwent tonsillectomy between July 1, 2010, and June 30, 2014, and 211 patients presented for posttonsillectomy hemorrhage during the same period. The incidence of readmission for posttonsillectomy hemorrhage was 3.4% and 3.6% ( P = .63; odds ratio [OR] = 1.07; 95% confidence interval [95% CI]: 0.811-1.410) for the codeine and ibuprofen groups, respectively, and the incidence of second operation for control of posttonsillectomy bleeding for the codeine and ibuprofen groups was 1.9% and 2.2% ( P = .54; OR = 1.117; 95% CI: 0.781-1.600), respectively. Patients aged 11 to 18 years demonstrated a higher incidence of posttonsillectomy bleeding events overall. When age is controlled, multivariate logistic regression demonstrated no statistically significant increase in posttonsillectomy bleeding events among pediatric patients treated with ibuprofen versus patients treated with codeine (readmission: P = .617; OR = 0.932; 95% CI: 0.707-1.228; reoperation: P = .513; OR = 0.887; 95% CI: 0.618-1.272). Conclusion Age is an independent risk factor for posttonsillectomy bleeding. When age is controlled, there is no statistically significant increase in the incidence of posttonsillectomy bleeding events among patients treated with ibuprofen when compared to patients treated with codeine.
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Affiliation(s)
- Julia A. Pfaff
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
- St Christopher’s Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Kevin Hsu
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
- St Christopher’s Hospital for Children, Philadelphia, Pennsylvania, USA
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Guntinas-Lichius O, Geißler K, Komann M, Schlattmann P, Meissner W. Inter-Hospital Variability of Postoperative Pain after Tonsillectomy: Prospective Registry-Based Multicentre Cohort Study. PLoS One 2016; 11:e0154155. [PMID: 27120174 PMCID: PMC4847852 DOI: 10.1371/journal.pone.0154155] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/09/2016] [Indexed: 11/18/2022] Open
Abstract
Objectives Although tonsillectomy is one of the most frequent and painful surgeries, the association between baseline and process parameters and postoperative pain are not fully understood. Methods A multicentre prospective cohort study using a web-based registry enrolled 1,527 women and 1,008 men aged 4 to 85 years from 52 German hospitals between 2006 and 2015. Maximal pain (MP) score the first day after surgery on a numeric rating scale (NRS) from 0 (no pain) to 10 (MP) was the main outcome parameter. Results The mean maximal pain score was 5.8±2.2 (median 6). Multivariable analysis revealed that female gender (Odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12 to 1.56; p = 0.001), age <20 years (OR = 1.56; CI = 1.27 to 1.91; p<0.0001), no pain counselling (OR = 1.78; CI = 1.370 to 2.316; p<0.001), chronic pain (OR = 1.34; CI = 1.107 to 1.64; p = 0.004), and receiving opioids in recovery room (OR = 1.89; CI = 1.55 to 2.325; p<0.001) or on ward (OR = 1.79; CI = 1.42 to 2.27; p<0.001) were independently associated with higher experienced maximal postoperative pain (greater the median of 6). The effect of age on pain was not linear. Maximal pain increased in underage patients to a peak at the age of 18 to 20 years. From the age of ≥20 years on, maximal pain after tonsillectomy continuously decreased. Even after adjustment to all statistically important baseline and process parameters, there was substantial variability of maximal pain between hospitals with a heterogeneity variance of 0.31. Conclusion Many patients seem to receive insufficient or ineffective analgesia after tonsillectomy. Further research should address if populations at risk of higher postoperative pain such as females, younger patients or those with preexisting pain might profit from a special pain management protocol. Beyond classical demographical and process parameters the large variability between different hospitals is striking and indicates the existence of other unknown factors influencing postoperative pain after tonsillectomy.
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Affiliation(s)
| | - Katharina Geißler
- Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany
| | - Marcus Komann
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Peter Schlattmann
- Department of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, Jena, Germany
| | - Winfried Meissner
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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Abstract
Pediatric post-tonsillectomy analgesia continues to be highly debated and an area of active research. Tonsillectomy pain can lead to significant patient morbidity, and incur potentially avoidable healthcare costs. Moreover, the various analgesic classes, each present their own risk profiles and unique side effects when used in children post-tonsillectomy. This review delineates the clinical and pathophysiological basis for post-tonsillectomy pain, types of analgesics and their risk profiles, as well as special considerations in this clinical population and a review of alternative analgesic treatment options. This article presents a summary of recent literature and discusses evidence-based management options to aid medical and allied health professionals who may encounter these patients.
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Affiliation(s)
- Natasha Cohen
- Otolaryngology, Head & Neck Surgery Division, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Doron D Sommer
- Otolaryngology, Head & Neck Surgery Division, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
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Abstract
PURPOSE OF REVIEW The aim of this review was to discuss recent developments in paediatric anaesthesia, which are particularly relevant to the practitioner involved in paediatric outpatient anaesthesia. RECENT FINDINGS The use of a pharmacological premedication is still a matter of debate. Several publications are focussing on nasal dexmedetomidine; however, its exact place has not yet been defined. Both inhalational and intravenous anaesthesia techniques still have their advocates; for diagnostic imaging, however, propofol is emerging as the agent of choice. The disappearance of codeine has left a breach for an oral opioid and has probably worsened postoperative analgesia following tonsillectomy. In recent years, a large body of evidence for the prevention of postoperative agitation has appeared. Alpha-2-agonists as well as the transition to propofol play an important role. There is now some consensus that for reasons of practicability prophylactic antiemetics should be administered to all and not only to selected high-risk patients. SUMMARY Perfect organization of the whole process is a prerequisite for successful paediatric outpatient anaesthesia. In addition, the skilled practitioner is able to provide a smooth anaesthetic, minimizing complications, and, finally, he has a clear concept for avoiding postoperative pain, agitation and vomiting.
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