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Stramiello JA, Ortega B, Brigger M, Nation JJ. Effect of Local Anesthetic Injections on Subjective Pain Scales in Pediatric Tonsillectomies: A Meta-analysis. Otolaryngol Head Neck Surg 2023; 168:619-627. [PMID: 35471955 DOI: 10.1177/01945998221094228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/25/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the effect of local anesthetic injection on subjective pain scores for pediatric tonsillectomies on postoperative days (PODs) 0 and 1. DATA SOURCES A comprehensive literature search was conducted with the PubMed, Embase, Web of Science, and Scopus databases. REVIEW METHODS A 2-researcher team following the PRISMA guidelines performed a systematic review and meta-analysis. Studies with original data and a saline injection control arm were selected. Corresponding authors were contacted for missing data. The collated data were analyzed with RevMan version 5.4 (Review Manager; Cochrane Collaboration). Random effects modeling and standard mean difference were utilized to control for heterogeneity. Surgical technique subgroup analysis was performed. RESULTS A total of 319 publications were identified, and 8 articles with 13 experimental arms (627 participants) were selected for meta-analysis. Local anesthetic injection was compared with placebo with saline injection. The standard mean difference for POD 0 pain was -0.81 (95% CI, -1.16 to -0.46; P < .00001) in favor of local anesthetic. The standard mean difference for POD 1 was -1.13 (95% CI, -1.48 to -0.78; P < .00001) in favor of local anesthetic. Subgroup analysis by surgical technique showed a less robust effect for cautery excision (-1.01 [95% CI, -1.37 to -0.66]) vs cold excisional technique (-1.19 [95% CI, -1.64 to -0.74]), with or without cautery-based hemostasis. CONCLUSIONS A local anesthetic injection during a pediatric tonsillectomy reduces postoperative pain on POD 0 and 1. Further analysis on total narcotic use and postoperative complications would benefit surgeon decision making.
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Affiliation(s)
- Joshua A Stramiello
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Briana Ortega
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Matthew Brigger
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, California, USA
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Javan Jonathon Nation
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, California, USA
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, USA
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Ortega B, Stramiello JA, Brigger M, Nation J. Anesthetic injections and analgesia use in pediatric post-tonsillectomy patients: A meta-analysis and systematic review. Int J Pediatr Otorhinolaryngol 2022; 152:110976. [PMID: 34799188 DOI: 10.1016/j.ijporl.2021.110976] [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: 07/19/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess the effect of local anesthetic injection on post-operative analgesia and complications for pediatric tonsillectomies on post-operative day (POD) 0 and 1. METHODS A 2-researcher team following the PRISMA guidelines performed a systematic review and meta-analysis. The databases Pubmed.gov, Embase, Web of Science, and Scopus were used. Studies written with original data utilizing a saline injection control arm were selected. Corresponding authors were contacted for missing data, which was used when possible. The collated data was analyzed with Review Manager (RevMan) Version 5.4., The Cochrane Collaboration, 2020. Surgical technique subgroup analysis was performed. RESULTS 319 publications were identified and 8 articles with 12 total experimental arms (529 participants) were selected. Local anesthetic injection was compared to saline injection. The standard mean difference for time until first analgesic was 0.68 min [0.26, 1.09](P = 0.001) in favor of local anesthetic. The odds ratio (OR) for patients receiving one or more narcotic doses on POD 0 was 0.22 [0.06, 0.84](P = 0.03) in favor of local anesthetic. CONCLUSIONS Use of an intraoperative anesthetic injection during pediatric tonsillectomy can help improve initial recovery as it delays the need for narcotic medication and may reduce postoperative narcotic usage on POD 0 and 1. In addition, a local anesthetic does not increase the risk of postoperative bleeding or dehydration.
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Affiliation(s)
- Briana Ortega
- University of California San Diego Department of Surgery, Division of Otolaryngology, San Diego, CA, USA.
| | - Joshua A Stramiello
- University of California San Diego Department of Surgery, Division of Otolaryngology, San Diego, CA, USA
| | - Matthew Brigger
- University of California San Diego Department of Surgery, Division of Otolaryngology, San Diego, CA, USA; Rady Children's Hospital San Diego, Division of Pediatric Otolaryngology. San Diego, CA, USA
| | - Javan Nation
- University of California San Diego Department of Surgery, Division of Otolaryngology, San Diego, CA, USA; Rady Children's Hospital San Diego, Division of Pediatric Otolaryngology. San Diego, CA, USA
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Ji KSY, Greene NH, Eapen RJ, Commesso E, Raynor EM. Pre- Versus Post-Tonsillectomy Intraoperative Bupivacaine Injection in the Pediatric Population: An Age- and Surgical Indication-Stratified Analysis. EAR, NOSE & THROAT JOURNAL 2020; 101:518-525. [PMID: 33095665 DOI: 10.1177/0145561320968926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Postoperative respiratory depression is of concern in children undergoing adenotonsillectomy receiving postoperative opioids and may be mitigated with intraoperative bupivacaine. This study aims to compare the impact of bupivacaine on postoperative pain and sedation in various pediatric age and surgical indication subgroups. METHODS This is a case series with chart review of 181 patients <18 years old undergoing adenotonsillectomy at a tertiary care center (2013-2016). Postoperative outcomes were compared between those who received intraoperative bupivacaine before (pre-tonsillectomy) or after (post-tonsillectomy) tonsil removal and those who did not (none) using χ2 test and analysis of variance. Subanalysis was performed after stratifying into age and surgical indication subgroups. RESULTS Ninety-eight patients were included in the pre-tonsillectomy group, 47 in the post-tonsillectomy group, and 36 in the none group. The number of postanesthesia care unit opioid doses (P = .159) and pain scores at arrival (P = .362) or discharge (P = .255) were not significantly different between treatment groups overall. Among 0- to 5-year-olds, pre-tonsillectomy injection was associated with lowest mean (SD) discharge pain score of 0.55 (1.29) pre-tonsillectomy versus 0.71 (1.37) post-tonsillectomy versus 2 (1.63) none group (P = .004). Among 12- to 17-year-olds, no injection was associated with lowest mean (SD) discharge pain score of 2.33 (0.52) pre-tonsillectomy versus 5 (2.65) post-tonsillectomy versus 1.63 (1.60) none group (P = .020). Injection in patients with obstructive sleep apnea and/or sleep-disordered breathing did not improve postoperative outcomes. CONCLUSION Intraoperative bupivacaine may improve pain scores in younger pediatric populations, though it may not impact the amount of postoperative opioid use. Prospective analysis with a larger sample size is warranted to better outline opioid usage and pain control in this group.
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Affiliation(s)
- Keven S Y Ji
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nathan H Greene
- Division of Pediatrics, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Rose J Eapen
- South Bay Pediatric Otolaryngology, Manhattan Beach, CA, USA
| | - Emily Commesso
- Department of Head and Neck Surgery & Communication Sciences, Duke University Hospital, Durham, NC, USA
| | - Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke University Hospital, Durham, NC, USA
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Yap D, Ng M, Moorthy R. #10-Year Challenge: Local anaesthetic for post-tonsillectomy pain: Update meta-analysis. Clin Otolaryngol 2020; 45:517-528. [PMID: 32293106 DOI: 10.1111/coa.13547] [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: 10/05/2019] [Revised: 03/17/2020] [Accepted: 04/05/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Adequate management of post-tonsillectomy pain is an important consideration in postoperative management after tonsillectomy. A 2008 meta-analysis showed that the use of local anaesthetic either by infiltration or topical application reduced postoperative pain. OBJECTIVES To review the current evidence for the use of local anaesthetic as a means of reducing post-tonsillectomy pain and compare current evidence to the previous meta-analysis 10 years ago. METHOD Systematic literature searches of MEDLINE [*"ANESTHETICS, LOCAL"/ AND *TONSILLECTOMY/], EMBASE [*"LOCAL ANESTHETIC AGENT"/ AND *TONSILLECTOMY/] and PubMed [(Tonsillectomy).ti,ab AND (Local Anaesthetic).ti,ab OR (Local Anesthetic).ti,ab]. A meta-analysis of randomised control trials assessing the use of local anaesthetic agents for post-tonsillectomy pain. RESULTS Twenty-three studies were included in the meta-analysis. Overall, local anaesthetic, applied topically or infiltrated, significantly reduces pain scores compared with controls at 4-6 hours [-0.65 (95% CI: -0.77; -0.53)]; 24 hours [-0.50 (95% CI: -0.66, -0.35)]; and 5-7 days [-0.78 (95% CI: -0.90, -0.65)] (standardised mean differences). CONCLUSION Current studies suggest that use of peri-operative local anaesthetic during tonsillectomy does improve postoperative pain outcomes. The limitations of the analysis are as follows: all studies are small, and a multi-centred larger trial is recommended to guarantee statistical reliability. There was no description of significant adverse side effects from local anaesthetic use.
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Affiliation(s)
- Darren Yap
- ENT Department, Wexham Park Hospital, Slough, UK
| | - Miane Ng
- Royal Victoria Hospital, Belfast, UK
| | - Ram Moorthy
- ENT Department, Wexham Park Hospital, Slough, UK
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Ahmed SA, Omara AF. The Effect of Glossopharyngeal Nerve Block on Post-Tonsillectomy Pain of Children; Randomized Controlled Trial. Anesth Pain Med 2019; 9:e90854. [PMID: 31341828 PMCID: PMC6614918 DOI: 10.5812/aapm.90854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/02/2019] [Accepted: 04/06/2019] [Indexed: 11/30/2022] Open
Abstract
Background Sensory fibers of the glossopharyngeal nerve supply the tonsillar and peritonsillar areas. Thus, bilateral glossopharyngeal nerve block may alleviate post-tonsillectomy pain and improve postoperative analgesia. Objectives The purpose of this clinical trial was to evaluate the effect of glossopharyngeal nerve block on postoperative analgesia in children undergoing adeno-tonsillectomy Methods Ninety ASA I-II pediatric patients presented for adeno-tonsillectomy were included in this trial. They were equally divided and randomly assigned to one of two groups: A control group, in which children did not receive a nerve block, and a glossopharyngeal nerve block group, in which children received bilateral glossopharyngeal nerve block after surgery. The postoperative pain score (FLACC score) during rest and swallowing, the time for the first request for rescue analgesia, the total dose consumption of pethidine rescue analgesia, and the incidence of postoperative complications were all assessed. Moreover, response to gag reflex, degree of difficulty in swallowing, and parents’ satisfaction were recorded. Results Bilateral glossopharyngeal nerve block in children presented for adeno-tonsillectomy significantly prolonged the time for the first request of rescue analgesia, compared to the control group, reaching 5.833 ± 2.667 hours (P < 0.0001). It also decreased postoperative pethidine consumption to 0.878 ± 0.387 mg/kg (P = 0.0009). Moreover, it significantly decreased the postoperative FLACC score assessed two, four, six, and twelve hours after surgery, during rest and swallowing (P < 0.05). The response to gag reflex and difficulty in swallowing were also significantly decreased (P ≤ 0.0001 and 0.006, respectively). In addition, glossopharyngeal nerve block significantly increased parents’ satisfaction (P = 0.0002), with no significant increase in the incidence of postoperative complications (P > 0.05). Conclusions Bilateral glossopharyngeal nerve block in children undergoing adeno-tonsillectomy improved the duration and the quality of postoperative analgesia, decreased swallowing difficulties, and improved parents’ satisfaction.
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Affiliation(s)
- Sameh Abdelkhalik Ahmed
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
- Corresponding Author: Lecturer of Anesthesiology and Intensive Care, Faculty of Medicine, Saied St., Tanta University, Elgharbia Governate, Tanta, Egypt. Tel:+20-1002977048,
| | - Amany Faheem Omara
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
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Cassano M, Bayar Muluk N, Di Taranto F, Subramaniam S. A comparison of intraoperative haemostatic techniques during tonsillectomy: Suture vs electrocautery-A study to assess postoperative pain scores and duration to resumption of normal diet. Clin Otolaryngol 2018; 43:1219-1225. [PMID: 29733506 DOI: 10.1111/coa.13129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess postoperative pain and pattern of recovery to normal diet in children who underwent tonsillectomy. METHODS Cold steel tonsillectomy (or adenotonsillectomy) was performed in 61 children. Haemostasis was attained with sutures in Group 1 (n = 30, 8 tonsillectomy and 22 adenotonsillectomy), and electrocautery in Group 2 (n = 31, 6 tonsillectomy and 25 adenotonsillectomy). Information obtained included postoperative pain scores and the number of postoperative days taken to resume normal diet. The pain score was evaluated with the Wong-Baker FACES® Pain Rating Scale (WBFS). RESULTS Pain values in Group 1 (haemostasis with sutures) were significantly lower than those in Group 2 (haemostasis with cauterisation) from the 6th hour to the 7th postoperative day (P < .05). For both liquid and solid food, Group 1 returned to normal diet earlier, compared to Group 2 (P < .05). When comparing patients undergoing tonsillectomy vs adenotonsillectomy, resumption of normal diet was achieved later in the adenotonsillectomy patients (P < .05). In terms of postoperative bleeding, there were 2 significant events in Group 2 (electrocautery group), occurring on the 1st (severe) and 10th day (slight) in 2 children (6.5%). There were no postoperative bleeding events in Group 1. CONCLUSION Our results showed that suture haemostatis causes less pain and faster resumption of normal diet compared to electrocautery. In view of this, we recommend the use of sutures for achieving intraoperative haemostasis in paediatric patients.
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Affiliation(s)
- M Cassano
- Faculty of Medicine, ENT Department, University of Foggia, Foggia, Italy
| | - N Bayar Muluk
- Faculty of Medicine, ENT Department, Kırıkkale University, Kırıkkale, Turkey
| | - F Di Taranto
- Faculty of Medicine, ENT Department, University of Foggia, Foggia, Italy
| | - S Subramaniam
- ENT and Skull of Base Surgery Department, Clinical fellow at Ohio State University, Columbus, OH, USA
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Review of 1078 tonsillectomy: Retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.397118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Naja Z, Kanawati S, Al Khatib R, Ziade F, Naja ZZ, Naja AS, Rajab M. The effect of IV dexamethasone versus local anesthetic infiltration technique in postoperative nausea and vomiting after tonsillectomy in children: A randomized double-blind clinical trial. Int J Pediatr Otorhinolaryngol 2017; 92:21-26. [PMID: 28012528 DOI: 10.1016/j.ijporl.2016.10.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/10/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Local anesthetic infiltration and corticosteroids had shown effectiveness in reducing post tonsillectomy nausea, vomiting and pain. OBJECTIVES To compare the effect of intravenous dexamethasone versus pre-incision infiltration of local anesthesia in pediatric tonsillectomy on postoperative nausea and vomiting (PONV). The secondary objective was postoperative pain. METHODS A randomized double-blind clinical trial was conducted at a tertiary care teaching hospital. Children admitted to undergo tonsillectomy aged between 4 and 13 years from January 2015 to August 2015 were enrolled and divided into two groups. Both groups had general anesthesia. Group I received intravenous dexamethasone 0.5 mg/kg (maximum dose 16 mg) with placebo pre-incision infiltration. Group II received pre-incision infiltration a total of 2-4 ml local anesthesia mixture with saline and an equivalent volume of intravenous saline. RESULTS Group I consisted of 64 patients while group II had 65 patients. In the PACU, 15.6% of patients in group I experienced vomiting compared to 3.1% in group II (p-value = 0.032). After 24 h, the incidence of PONV was significantly higher in group I compared to group II (26.6% vs. 9.2% respectively, p-value = 0.019). At 48 h postoperatively, PONV was significantly higher in group I (p-value = 0.013). The incidence was similar in both groups after three, four and five postoperative days. Baseline pain and pain during swallowing were significantly different at 6, 12 and 24 h as well as days 1 through 5. Pain upon jaw opening was significantly different at 6, 12 and 24 h between the two groups. Pain while eating soft food was significantly different at 24 h and days 2 through 5. In the PACU, 20.3% of patients in group I received diclofenac compared to 3.1% in group II (p-value = 0.005). From day 1 till day 5, analgesic consumption was significantly higher in group I. CONCLUSION Local anesthetic infiltration in addition to NSAIDS and paracetamol could serve as a multimodal analgesia and decrease PONV. TRIAL REGISTRATION NCT02355678.
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Affiliation(s)
- Zoher Naja
- Anesthesia and Pain Management Department, Makassed General Hospital, Beirut, Lebanon.
| | - Saleh Kanawati
- Anesthesia and Pain Management Department, Makassed General Hospital, Beirut, Lebanon
| | - Rania Al Khatib
- Anesthesia and Pain Management Department, Makassed General Hospital, Beirut, Lebanon
| | - Fouad Ziade
- Faculty of Public Health, Lebanese University, Beirut, Lebanon
| | - Zeina Z Naja
- Pediatric Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad Salah Naja
- Medicine Department, Lebanese American University, Beirut, Lebanon
| | - Mariam Rajab
- Pediatrics Department, Makassed General Hospital, Beirut, Lebanon
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Post-tonsillectomy dietary advice: systematic review. The Journal of Laryngology & Otology 2016; 130:889-892. [DOI: 10.1017/s0022215116008914] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:To determine if there is evidence that post-tonsillectomy dietary advice affects post-operative morbidity.Method:A systematic review was conducted of Embase, Medline, the Cumulative Index to Nursing and Allied Health Literature and PsycInfo, to November 2014.Results:Seventeen articles were included; their heterogeneous nature prevented meta-analysis. Of these, all three small, randomised studies showed no statistical difference in morbidity between restricted and non-restricted diets.Conclusion:Most post-tonsillectomy dietary advice is based on historical anecdotes and not rigorous scientific testing. The existing small-scale, randomised studies show no statistical difference in morbidity between non-restricted and restricted diets.
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Tekelioglu UY, Apuhan T, Akkaya A, Demirhan A, Yildiz I, Simsek T, Gok U, Kocoglu H. Comparison of topical tramadol and ketamine in pain treatment after tonsillectomy. Paediatr Anaesth 2013; 23:496-501. [PMID: 23521170 DOI: 10.1111/pan.12148] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 01/05/2013] [Accepted: 02/04/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES/AIM The primary objective of this study is to evaluate the effects of topically applied ketamine or tramadol on early postoperative pain scores in children undergoing tonsillectomy. The secondary aim of the study is to assess nausea, vomiting, difficulty in swallowing, and sore throat characteristics of the patients. BACKGROUND Tonsillectomy surgery is frequently associated with postoperative pain, which usually requires substantial consumption of analgesics including opioids. Safe and effective post-tonsillectomy pain control is still a clinical dilemma, in spite of the use of various surgical and anesthetic techniques. METHODS A total of 60 children, aged between 4 and 10 years, scheduled for tonsillectomy, were randomly assigned to one of three groups. Study drugs were administered to both tonsillar fossae for 5 min. In 5 ml artificial saliva, Group K (n = 20) received 0.4 ml (20 mg) ketamine and Group T (n = 20) received 0.8 ml tramadol HCl solution. Group C (n = 20) received only 5 ml saline as a control. Ramsay Sedation Scale and FACES PRS Score, nausea, vomiting, difficulty in swallowing, and sore throat were evaluated. RESULTS There was no difference among the groups in terms of baseline characteristics, including age, sex, and ASA profile (P > 0.05 for all). Systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, respiratory rate, and saturation of peripheral oxygen (SpO2 ) values were not significantly different among the groups in all time points (P > 0.05 for all). There was a statistically significant difference among the groups according to Ramsay Sedation Scales in 40th minute (P < 0.001). There were statistically significant differences among the groups in terms of Wong-Baker FACES Pain Rating Scale Score in all time points (P < 0.004 for all). There was a statistically significant difference among the groups in terms of rescue analgesia necessity in 5th and 10th minute (P < 0.001 and P = 0.003). There was a statistically significant difference among the groups in terms of sore throat in 5th and 10th minute (P < 0.001 for both). Neither rescue analgesia necessity nor sore throat characteristics was different between the Group T and Group K in all time points. CONCLUSION Topical tramadol and ketamine seem to be safe, effective, and easy analgesic approach for decreasing tonsillectomy pain.
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Affiliation(s)
- Umit Y Tekelioglu
- Department of Anesthesiology and Reanimation, Abant Izzet Baysal University Medical School, Bolu, Turkey.
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Choi HR, Cho JK, Lee S, Yoo BH, Yon JH, Kim KM. The effect of remifentanil versus N(2)O on postoperative pain and emergence agitation after pediatric tonsillectomy/adenoidectomy. Korean J Anesthesiol 2011; 61:148-53. [PMID: 21927686 PMCID: PMC3167135 DOI: 10.4097/kjae.2011.61.2.148] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/04/2011] [Accepted: 01/17/2011] [Indexed: 11/28/2022] Open
Abstract
Background Remifentanil can be an alternative to N2O in general anesthesia. Intraoperative remifentanil may lead to acute opioid tolerance. This study aims to assess the effect of remifentanil substituted for 70% N2O on postoperative pain in children undergoing tonsillectomy/adenoidectomy. In addition, we evaluated the effect of remifentanil infusion on incidence of emergence agitation in these patients. Methods Eighty children, aged 2-12 years, undergoing tonsillectomy/adenoidectomy were randomly allocated to the N2O group (Group N; n = 40, sevoflurane and 70% N2O) or remifentanil group (Group R; n = 40, sevoflurane with remifentanil infusion at the rate of 0.17 µg/kg/min). In the recovery room, severity of pain and agitation were assessed by an investigator blinded to the assigned group. Time to eye opening and incidence of severe pain and agitation were compared between groups. Logistic regression was used to identify factors related to occurrence of severe pain and agitation. Results Number of patients with severe postoperative pain was 6 and 16 in groups N and R, respectively (P = 0.012). Incidence of emergence agitation was not significantly different between groups. Remifentanil infusion was a significant factor related to the occurrence of severe postoperative pain (P = 0.015), and age was inversely related to occurrence of emergence agitation (P = 0.001). Conclusions In children undergoing tonsillectomy/adenoidectomy, intraoperative remifentanil infusion may increase incidence of severe postoperative pain compared to N2O, but it may not affect incidence of emergence agitation.
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Affiliation(s)
- Hey-Ran Choi
- Department of Anesthesiology and Pain Medicine, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea
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Intraoperative Bupivacaine for Reduction of Post-Tonsillectomy Pain: A Randomized, Placebo-Controlled, Double-Blind Study of 26 Patients. EAR, NOSE & THROAT JOURNAL 2009. [DOI: 10.1177/014556130908800908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We conducted a randomized, controlled, double-blind, prospective study to evaluate the effect of intraoperative bupivacaine injection on postoperative pain control following Bovie cautery-assisted tonsillectomy in 26 adults. Sixteen patients were injected with 10 ml of 0.5% bupivacaine with 1:200,000 epinephrine, and 10 were injected with 10 ml of normal saline solution. For 10 days after surgery, patients completed a questionnaire to rate their overall pain and to record their narcotic consumption and oral intake. At study's end, there was no statistically significant difference in pain scores, narcotic use, and oral intake between the bupivacaine group and the controls (p = 0.13, 0.37, and 0.35, respectively). We conclude that the effects of perioperative bupivacaine on postoperative pain control in tonsillectomy patients are similar to those of placebo.
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Infiltrations cicatricielles en injections uniques. Neurochirurgie, chirurgie ORL, thoracique, abdominale et périnéale. ACTA ACUST UNITED AC 2009; 28:e163-73. [DOI: 10.1016/j.annfar.2009.01.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Grainger J, Saravanappa N. Local anaesthetic for post-tonsillectomy pain: a systematic review and meta-analysis. Clin Otolaryngol 2008; 33:411-9. [DOI: 10.1111/j.1749-4486.2008.01815.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, Tyrrell J, Walker S, Williams G. Postoperative pain. Paediatr Anaesth 2008; 18 Suppl 1:36-63. [PMID: 18471177 DOI: 10.1111/j.1460-9592.2008.02431.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND AND OBJECTIVES Tonsillectomy is frequently associated with postoperative pain of considerable duration, which is usually accompanied by the substantial consumption of both opioid and non-opioid analgesics. Despite the use of different surgical and anaesthetic techniques in the search for safe and effective post-tonsillectomy pain relief, this problem remains a clinical dilemma. The aim of the current study was to evaluate the potential effects of topically administered ketamine and morphine by an oral rinse into the tonsillar fossae. METHODS In all, 60 children, 15 for each group, aged between 3 and 12 yr scheduled for tonsillectomy were randomly assigned to one of four groups. Study drugs were administered to both tonsillar fossae for 5 min. Group K received 0.4 mL (20 mg) ketamine in 10 mL artificial saliva, Group KM received 0.4 mL (20 mg) ketamine + 5 mL (20 mg) 4 per thousand morphine aqueous solution in 5 mL artificial saliva, Group M received 5 mL (20 mg) 4 per thousand morphine aqueous solution in 5 mL artificial saliva, Group C received only 10 mL artificial saliva. Postoperative pain, nausea, vomiting, sedation and bleeding were evaluated. RESULTS Pain scores were higher in the control group at arrival in the recovery ward (P < 0.05). Morphine and ketamine groups had longer effective analgesia time than the morphine + ketamine and control groups. The 24-h analgesic consumption was significantly higher in the control group. CONCLUSION Topical ketamine and morphine seems to be a safe and easy analgesic approach for decreasing adenotonsillectomy pain.
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Erhan OL, Göksu H, Alpay C, Beştaş A. Ketamine in post-tonsillectomy pain. Int J Pediatr Otorhinolaryngol 2007; 71:735-9. [PMID: 17296236 DOI: 10.1016/j.ijporl.2007.01.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2006] [Revised: 01/05/2007] [Accepted: 01/06/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There has yet been no ideal method for postoperative analgesia in children. Ketamine demonstrates a potent analgesic effect by central blockage of perception of pain with sub-anesthetic doses. Preoperative intramuscular administration of ketamine for sedation decreases the pain during swallowing after tonsillectomy, while it provides long-term analgesia when applied around the incision. The aim of this study is to compare the effectiveness of ketamine administered to the tonsillar region following tonsillectomy for postoperative pain management. METHODS After obtaining consent from the local ethics committee and the parents, 60 patients from the ASA groups I and II, between 3 and 7 years of age, planned for adenotonsillectomy as outpatients, were included in the study. Subjects were randomly assigned to two equal groups and 2ml 0.9% saline for group S, and 0.5mgkg(-1) ketamine and saline 2ml in volume for group K were administered into the tonsillar region. All subjects were monitored in a standard manner and SpO(2), systolic arterial pressure (SAP), and cardiac pulse rates were recorded in 5min intervals. The CHEOPS and Wilson sedation scale were used to evaluate pain levels and sedative condition, respectively. Nausea and vomiting scores of the subjects were also noted. The time of the first analgesic administration and the total amount of analgesics in an 8-hour period were recorded. Student-T and Chi-Square tests were used for the statistical evaluation of the data and a p value of <0.05 was accepted as significant. RESULTS There were no significant differences between groups according to age, sex, weight, intermittent SAP and cardiac pulse rates. However, the CHEOPS value, the first analgesic need and the total amount of analgesic need were in favor of ketamine (p<0.05). CONCLUSIONS In previous studies, no significant differences were demonstrated in pre-emptive analgesia with ketamine, magnesium, morphine, and clonidine. The dose of ketamin and the volume used in this study caused no sedation or nausea and provided a high level of analgesia. Ketamine infiltration into the tonsillar region after tonsillectomy was found to be easy and effective.
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Affiliation(s)
- Omer Lütfi Erhan
- Firat University Medical Faculty, Department of Anesthesiology and Reanimation, 23119 Elazig, Turkey
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Ashbach MN, Ostrower ST, Parikh SR. Tonsillectomy Techniques and Pain: A Review of Randomized Controlled Trials and Call for Standardization. ACTA ACUST UNITED AC 2007; 69:364-70. [DOI: 10.1159/000108369] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Coulthard P, Rolfe S, Mackie I, Gazal G, Morton M, Jackson-Leech D. Intraoperative local anaesthesia for paediatric postoperative oral surgery pain – a randomized controlled trial. Int J Oral Maxillofac Surg 2006; 35:1114-9. [DOI: 10.1016/j.ijom.2006.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 06/08/2006] [Accepted: 07/05/2006] [Indexed: 10/24/2022]
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Abstract
PURPOSE OF REVIEW Even though pediatric tonsillectomy is a well accepted treatment for upper airway obstruction or recurrent tonsillar infection, the painful recovery of this operation is unwelcome. As more studies are published on the beneficial effects of tonsillectomy, the number of tonsillectomies performed is likely to increase. It would behoove any surgeon performing this operation to be aware of the available options for post/perioperative pain control. RECENT FINDINGS New techniques used to perform tonsillectomy, innovative adjuvant medical therapy and other tools are reviewed. SUMMARY The search for 'the painless tonsillectomy' continues. Finding a technique that works best for each surgeon is paramount to successful tonsillectomy. Patient comfort, surgical time, complications such as bleeding and regrowth of tonsillar tissue, or recurrence of symptoms that lead to the initial operation should all be considered in the surgeon's choice of a particular tonsillectomy technique. Medical therapies such as corticosteroids in the perioperative period are well accepted as a pain adjuvant. Newer adjuvants include the use of pretonsillectomy injection of mixtures that include local anesthetics with opioids and clonidine. The use of nonsteroidal antiinflammatory drugs appears to be helpful for pain, but controversial regarding bleeding. Another successful strategy used to decrease pain perception is distraction.
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