The effect of paracetamol, metamizole sodium and ibuprofen on postoperative hemorrhage following pediatric tonsillectomy

Effect and safety of perioperative ibuprofen administration in pediatric tonsillectomy: A systematic review and meta-analysis

OBJECTIVES

This study aimed to evaluate the safety and efficacy of perioperative ibuprofen administration by conducting a meta-analysis of pertinent literature.

METHODS

We conducted a comprehensive review of studies sourced from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases. The studies covered the period from database inception to June 2024. A perioperative ibuprofen administration group was compared to a control group administered either saline, acetaminophen, paracetamol, or opioids. The primary outcome was post-tonsillectomy bleeding that was categorized into overall bleeding and further classified as type 1 (observed at home or evaluated in the emergency department without additional intervention), type 2 (necessitating readmission for observation), and type 3 (requiring a return to the operating room for hemorrhage control). Morbidity incidence rates for postoperative nausea and vomiting were also assessed. The secondary outcomes assessed were postoperative pain management and the frequency of analgesic drug usage. Postoperative pain management was assessed from the incidence of emergency department visits or nurses' calls for pain independent of the presence or absence of dehydration.

RESULTS

Twenty-two studies with 27,149 patients were included and reviewed for this meta-analysis. Post-tonsillectomy bleeding (OR = 0.9954, 95 % CI [0.8800; 1.1260], I2 = 0.0 %) was not significantly higher in the ibuprofen administration group compared to the control group. In subgroup analysis of post-tonsillectomy bleeding severity, ibuprofen caused clinically insignificant type 1 post-tonsillectomy bleeding that did not require intervention (OR = 1.1310 [0.7398; 1.7289]). Clinically significant bleeding requiring hospital admission (type 2) or surgical control (type 3) was not observed. Administration of ibuprofen has demonstrated efficacy in reducing the need for analgesic drugs (OR = 0.4734, 95 % CI [0.2840; 0.7893]; I2 = 19.8 %) and is associated with a significant decrease in the incidence of postoperative nausea and vomiting (OR = 0.4886, 95 % CI [0.3156; 0.7562], I2 = 34.3 %).

CONCLUSION

This study demonstrated that administration of ibuprofen for pediatric tonsillectomy did not increase the incidence of clinically significant postoperative bleeding. Ibuprofen administration decreased the incidence and severity of postoperative pain, nausea, and vomiting.

Ibuprofen for acute postoperative pain in children

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Analgesic benefit of metamizole and ibuprofen vs. either medication alone: a randomized clinical trial

BACKGROUND

Postoperative pain relief remains a key problem after surgery. Multimodal pain therapy has proven beneficial in alleviating pain to a certain extent. However, when combining non-opioids, the focus has been on NSAIDs and paracetamol, but effects of combined use are only moderate. Metamizole could be a potent adjunct, due to its preclusion in several countries, data on its combined use are sparse, despite its common use in many countries. The aim of this study was to examine whether the combination of metamizole and ibuprofen is superior in relieving postoperative pain to either drug alone.

METHODS

For this randomized, placebo-controlled, cross-over study, 35 patients undergoing bilateral lower third molar extraction were randomized. Each patient received three applications of 1000mg metamizole + 400mg ibuprofen for surgery on one side and either 1000mg metamizole + placebo or 400mg ibuprofen + placebo on the other side. Pain ratings, rescue-medication (tramadol), and sleep were assessed for 18 hours.

RESULTS

The combined treatment of metamizole and ibuprofen showed lower mean pain scores over 12 hours than ibuprofen (2.4±1.3 vs 3.8±1.6; P=0.005)). Further, combined treatment showed lower mean pain scores over 6 hours than ibuprofen (2.0±1.2 vs. 3.1±1.6; P=0.022) or metamizole alone (2.0±1.2 vs. 3.3±1.7; P=0.015). Consumption of rescue medication was lowest in the combination-group (25% vs. 46%-metamizole; 50%-ibuprofen). The trial was stopped prematurely as the COVID-pandemic halted elective surgeries.

CONCLUSIONS

Combined use enables superior pain control compared to ibuprofen after molar extraction and tends to be superior to metamizole alone. The premature study-termination may overestimate this effect.

Pain management in hemophilia: expert recommendations

INTRODUCTION

As a typical consequence of bleeding into muscles and joints, patients with severe hemophilia suffer from acute and chronic pain. In spite of its high prevalence, pain in this patient group is not always sufficiently considered or treated in an effective manner.

AIM

The recommendations presented in this paper address possible improvements in pain management in hemophilia patients and particularities that have to be taken into account in this patient group.

METHOD

The manifold aspects of pain management in hemophilia patients were discussed within the framework of an expert meeting. Based on the available literature and the experts' clinical experience, the participants developed a set of recommendations presented in this paper.

RESULTS

Pain management in patients with hemophilia is often insufficient, a fact that not only influences the patients' quality of life but also implies the risk of difficult to manage chronic pain. Both the prevalent polypharmacy (due to comorbidities) as well as the underlying disease itself present special challenges to pain therapy in this patient group. The present review and recommendations are intended to support medical professionals in recognising the risks of pain chronicity, applying basic principles of multimodal pain therapy, including the options of psychological intervention and modalities of physical medicine in therapy concepts, and reaching a comprehensive understanding of the range of analgesic options available.

Post-Tonsillectomy Ibuprofen: Is There a Dose-Dependent Bleeding Risk?

OBJECTIVES/HYPOTHESIS

Post-tonsillectomy hemorrhage (PTH) is a potentially life-threatening complication. A recent meta-analysis suggests that ibuprofen may increase the risk of PTH. The aims of this study were to 1) re-evaluate the effect of ibuprofen on PTH given additional recent evidence and 2) to evaluate a potential dose effect of ibuprofen.

STUDY DESIGN

Meta-analysis and meta-regression; single-institution retrospective review.

METHODS

We conducted a systematic review of the literature and a meta-analysis of 12 studies comparing postoperative ibuprofen analgesia to non-nonsteroidal anti-inflammatory drug (NSAID) controls. Next, we performed a meta-regression analysis to assess for an effect of dose, if any, on rates of PTH. Five studies specifying a dose of 5 mg/kg (828 patients, 1,411 controls) and 7 studies using 10 mg/kg (5,633 patients, 7,656 controls) were included. We then conducted a novel single-institution, retrospective review of data for 1,046 patients prescribed intermediate-dose 7.5 mg/kg ibuprofen.

RESULTS

Ibuprofen was not associated with an increased rate of PTH (log odds ratio [OR], 0.21; 95% confidence interval [CI] -0.15, 0.57). Meta-regression showed that ibuprofen dose (5 and 10 mg/kg) did not have a statistically significant effect on PTH (OR, 1.32; 95% CI 0.30, 5.84). Uncontrolled, aggregate rates of PTH across all studies were 2.29% (N = 828) for 5 mg/kg and 4.65% (N = 5,633) for 10 mg/kg dosing. The rate of secondary hemorrhage in patients prescribed 7.5 mg/kg ibuprofen was 3.10% (N = 1,046).

CONCLUSION

We found no statistically significant increased risk of PTH when ibuprofen is prescribed at the low or high range of commonly used clinical dosages, compared to a non-ibuprofen regimen. Further studies with less heterogeneity are needed to determine if there is a clinically relevant dose-dependent difference in PTH with ibuprofen.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Efficacy of an opioid-sparing analgesic protocol in pain control after less invasive cranial neurosurgery

An opioid-sparing protocol for postoperative pain management in less invasive cranial neurosurgery significantly lowered opioid usage while reducing pain scores.

Introduction:

Opioid overuse in postoperative patients is a worrisome trend, and potential alternatives exist which warrant investigation. Nonsteroidal anti-inflammatory drug use in treating postoperative cranial surgery pain has been hampered by concern for inadequate pain control and increased risk of hemorrhagic complications. A safe and effective alternative to opioid-based pain management is critical to improving postoperative care.

Objective:

The objective of this retrospective study was to determine whether an NSAID-based opioid-sparing pain management protocol (OSP) is effective in analgesic control of less invasive cranial surgery patients at 6-, 12-, and 24-hour postoperatively. Secondary aims included investigating differences in hemorrhagic complications.

Methods:

Five hundred sixty-six consecutive patients who underwent cranial surgery before and after implementation of the celecoxib-based OSP were eligible. Propensity score matching was used to match patients in each cohort.

Results:

The opioid-sparing cohort had lower pain scores at 6 hours (3.45 vs 4.19, P = 0.036), 12 hours (3.21 vs 4.00, P = 0.006), and 24 hours (2.90 vs 3.59, P = 0.010). Rates of postoperative hemorrhage were not significantly different (5% intervention vs 8% control, P = 0.527). The opioid-sparing pain management protocol provided comparable or better pain control in the first 24 hours after less invasive cranial surgery. Hemorrhage rates did not change with the use of an NSAID-based OSP.

Conclusion:

An effective alternative to the current standard opioid-based pain management is feasible for less invasive cranial surgery. Determinations of hemorrhage risk and more complex cranial surgery will require larger prospective randomized trials.

[Pain therapy for children and adolescents with hemophilia : Recommendations by an expert panel]

BACKGROUND

Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated.

OBJECTIVES

This paper discusses how to improve pain management for children and adolescents (0-18 years) with hemophilia and which specific features in this population should influence decisions in pain management.

MATERIALS AND METHODS

An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience.

RESULT

Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.

Postoperative Bleeding Associated with Ibuprofen Use after Tonsillectomy: A Meta-analysis

Objective

To better quantify the risk of ibuprofen-associated posttonsillectomy hemorrhage (PTH).

Data Sources

PUBMED/MEDLINE, Web of Science, and Cochrane Clinical Trials Database.

Review Method

Literature searches were performed for English-language publications containing the terms tonsillectomy, ibuprofen, and tonsillectomy from database inception to May 2017. Human clinical trials, prospective cohort studies, and retrospective cohort studies related to tonsillectomy, ibuprofen use, and posttonsillectomy hemorrhage among pediatric patients were selected. Electronic searches revealed 151 studies, of which 12 were deemed eligible for analysis. Studies were weighted according to level of evidence and risk of bias.

Results

Pooling of results across all studies showed a statistically significant increase in PTH among the patients taking ibuprofen (odds ratio, 1.38; 95% confidence interval, 1.11-1.72). The I 2 statistic of 20.8% demonstrates overall low study heterogeneity and good comparability of the results.

Conclusion

Our meta-analysis of available cohort studies and randomized controlled trials (RCTs) shows possible increased tendency to PTH with the use of ibuprofen. This has not been demonstrated in other studies and systematic reviews because their analyses were limited by use of multiple nonsteroidal anti-inflammatory drugs and inclusion of studies limited to the perioperative period and low sample size. However, the current analysis is limited due to inclusion of many retrospective cohort studies with unclear follow-up and no blinding. Further RCTs will be required to investigate this trend toward increased PTH.

Association of ibuprofen use with post-tonsillectomy bleeding in older children

OBJECTIVE

Evaluate post-tonsillectomy outcomes in children discharged with ibuprofen versus those without.

METHODS

This was a retrospective review of children who underwent tonsillectomy ± adenoidectomy from 2012 to 2016 at a tertiary care children's hospital. Main outcome measures included bleed rates, ER visits, and nurse phone calls.

RESULTS

Seven hundred and seventy-three patients were included; 504 had ibuprofen at discharge (ID) and 269 did not (NID). There were significant differences in mean age, 6.7 years in the ID group years versus 8.6 for the NID group (P < 0.001). Indication for surgery was sleep apnea in 70.5% of ID patients and 44.0% of NID patients (P < 0.001). Post-tonsillectomy bleeds occurred in 8.7% in the ID group and 5.9% of the NID group (P = 0.168). Other outcome measures revealed no significant differences between the two groups. There was no significant difference in the outcome measures between patients with sleep apnea or recurrent tonsillitis. Age was important; 12.1% of children 9-18 years versus 4.8% in children 3.1-6 years (P = 0.006) had post-tonsillectomy bleeding. For children 9-18 years old, 16.7% in the ID group bled versus 7.5% in the NID group (P = 0.039). Logistical regression revealed that age contributed to post-op bleeding, and ibuprofen contributed to number of ER visits.

CONCLUSION

Ibuprofen is associated with significantly elevated post-tonsillectomy bleeding in older children, further research is needed and other analgesics should be considered.

Ancillary Medications and Outcomes in Post-Tonsillectomy Patients

To investigate the impact of medications on outcomes after tonsillectomy, a retrospective review using the Market Scan database was performed. A total of 306,536 privately insured children and adolescents (1 to 17 years old) who underwent tonsillectomy/adenoidectomy were identified from 2008 to 2012. Pharmaceutical claims identified patients who received outpatient prescriptions for ibuprofen, steroids, or topical anesthetics until discharge and for medications for the treatment of attention deficit hyperactivity disorder (ADHD) or montelukast up to 14 days postoperatively. Logistic regression compared prescription claims to outcomes, including postoperative bleeding, dehydration, emergency department visits, and readmissions. Ibuprofen was the only medication associated with increased odds of postoperative bleeding (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.07 to 1.95). Patients receiving steroids had lower odds of dehydration (OR: 0.74, 95% CI: 0.65 to 0.84) and emergency department visits (OR: 0.82, 95% CI: 0.76 to 0.88). Odds of dehydration were highest in patients taking ADHD medications (OR: 1.38, 95% CI: 1.15 to 1.66) and topical anesthetics (OR: 1.32, 95% CI: 1.10 to 1.59). Although causality cannot be assumed in observational studies, steroids and ibuprofen should be used judiciously.

Trends in the management of secondary post-tonsillectomy hemorrhage in children

OBJECTIVE

To define current practices in management of secondary post-tonsillectomy hemorrhage (PTH) in children by pediatric and general otolaryngologists.

INTRODUCTION

Bleeding after tonsillectomy is common. Our goal was to describe management methods across the U.S.

METHODS

Questions regarding perioperative management and treatment in response to three hypothetical cases featuring secondary post-tonsillectomy bleeding were posed via REDCap survey. Comparisons were made for pediatric otolaryngology fellowship training, regions of residency training and current practice, practice type, and number of years in practice.

RESULTS

A total of 400 surveys were distributed with 104 responses. Fellowship-trained respondents were more likely to have been in practice for less than ten years (41.5% versus 17.8%) and to practice in an academic setting (67.3% versus 13.6%). They were less likely to prescribe antibiotics after tonsillectomy and more likely to prescribe acetaminophen (98.3% versus 80.4%), ibuprofen (79.3% versus 56.5%), and narcotics (74.1% versus 50.0%) compared to general otolaryngologists. When faced with a post-tonsillectomy patient with visible clot but no active bleeding, pediatric otolaryngologists were less likely to remove the clot (31.6% versus 54.3%) and more likely to proceed to the OR (75.9% versus 56.5%) and admit the patient (87.9% versus 68.9%). Few regional differences were encountered; however, factors influencing the decision to pursue operative intervention varied by region.

CONCLUSION

Pediatric otolaryngologists are more likely to follow American Academy of Otolaryngology guidelines for tonsillectomy perioperative management. They also manage patients with secondary PTH differently than general otolaryngologists. Management trends are similar by region but salient factors considered in the decision-making process vary.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Assessment and management of pain in pediatric otolaryngology

INTRODUCTION

Pain is a disease by itself and it's a public health concern of major implication in children, not just because of the emotional component of the child and his family, but also due to the potential morbidity and mortality involving it. A proper assessment of pain it's a challenge in the pediatric population, due to their lack of understanding and verbalization of hurt. Additionally, a satisfactory treatment of pediatric pain can be arduous due to a lack of clinical knowledge, insufficient pediatric research, and the fear to opioid side effects and addiction.

OBJECTIVES

The aim of this review is to address the current definitions of pain, its physiological mechanisms and the consequences of its inadequate management, as well as, to guide the clinicians in the assessment and management of pain in the pediatric population at otolaryngology services.

METHODOLOGY

Narrative review by selective MeSH search terms: Children, Pediatrics, Otolaryngology, Pain measurement, Pain Management, Analgesics and Analgesia, from databases: MEDLINE/PubMed, Cochrane, ISI, Current Contents, Scielo and LILACS, between January 2000 and May 2016.

RESULTS

129 articles were reviewed according to the requirements of the objectives. Pain measurement is a challenge in children as there are no physical signs that constitute an absolute or specific indicator of pain, and its diagnosis must rely on physiological, behavioral and self-report methods. Regarding treatment, a suitable alternative are the non-pharmacological cognitive/behavioral therapies helped by pharmacological therapies tailored to the severity of pain and the child's age. We provide evidence-based recommendations on pain treatment, including non-opioid analgesics, opioid analgesics and adjuvant medicines to improve the management of pain in children in otolaryngology services.

CONCLUSIONS

We present a global review about assessment and management of pain in pediatric otolaryngology, which leads to future specific reviews on each topic. Research gaps on pain assessment and pharmacological interventions in neonates, infants and children are very wide and it should be promoted ethical and safe research on pain control in this population.

The Use of Ibuprofen in Posttonsillectomy Analgesia and Its Effect on Posttonsillectomy Hemorrhage Rate

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.

A Randomized Controlled Trial of Oral Versus Intravenous Administration of a Nonnarcotic Analgesia Protocol Following Pediatric Craniosynostosis Corrections on Nausea and Vomiting Rates

BACKGROUND

The authors' center uses a nonnarcotic postoperative regimen following craniosynostosis corrections. Despite opioid avoidance, the authors noted that some children still experienced nausea and vomiting following the oral administration of either acetaminophen or ibuprofen. This study sought to evaluate whether intravenous administration of these medications might reduce nausea and vomiting rates.

METHODS

A total of 50 children undergoing craniosynostosis corrections were prospectively randomized to a control group given only oral ibuprofen (10 mg/kg) and acetaminophen (15 mg/kg), or a treatment group given only intravenous ketorolac (0.5 mg/kg) and acetaminophen (15 mg/kg). All patients were assessed for postoperative nausea and vomiting by a blinded research nurse.

RESULTS

Twenty-eight patients randomized to the oral control group, and 22 to the intravenous treatment group. No statistically significant differences were identified between groups, including: age, weight, sex, before history of severe postoperative nausea and vomiting, or procedure. With similar anesthesia times there was significantly more vomiting episodes in the oral group (71% versus 41%). Using a multivariate logistic regression, controlling for age, weight and procedure, the odds ratio for vomiting in the oral control versus intravenous experimental groups was 3.61 (95% CI 1.11-1.76; P = 0.033), and for postoperative nausea was 14.0 (95% CI 1.40-71.69, P = 0.010).

CONCLUSIONS

The authors found a significant reduction in nausea and vomiting among children randomized to receive intravenous medications. In addition, the intravenous delivery of medications has the theoretical advantage of insuring an effective full dose delivery. Based on these findings, our standard process is to preferentially manage all children following craniosynostosis corrections with intravenous nonnarcotics.

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients

OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.

Outcomes of an Alternating Ibuprofen and Acetaminophen Regimen for Pain Relief After Tonsillectomy in Children

Objectives:

To determine the outcomes of alternating doses of ibuprofen and acetaminophen in the treatment of post-tonsillectomy pain in children and to identify characteristics of children who had inadequate pain control.

Methods:

The medical records of children who received alternating doses of ibuprofen and acetaminophen for post-tonsillectomy pain between August 2012 and November 2013 at a tertiary care children’s hospital were reviewed. Incidences of postoperative bleeding and unresolved pain were determined.

Results:

A total of 583 patients (304 males, 279 females, age range =1-18 years) had received alternating doses of ibuprofen and acetaminophen after tonsillectomy and adenoidectomy. Of the 583 patients, 56 (9.6%) reported inadequate pain control. Age, sex, obesity, presence of comorbid conditions, indications for surgery, and concurrent surgical procedures were not different between children who had adequate analgesia and children who had unresolved pain. Twenty-four patients (4.1%) had postoperative bleeding. Nine patients (1.5%) required surgical intervention for bleeding.

Conclusions:

Alternating doses of ibuprofen and acetaminophen provided an effective treatment for post-tonsillectomy pain in the majority of children and did not increase rate of bleeding. Means of improving response rate to alternating doses of ibuprofen and acetaminophen merit further investigation.

[Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]

BACKGROUND

Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally.

NON-OPIOIDS

The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration.

OPIOIDS

In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel.

KETAMINE

Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.

Acetaminophen plus ibuprofen versus opioids for treatment of post-tonsillectomy pain in children

OBJECTIVE

To determine the efficacy and safety of acetaminophen plus ibuprofen in treatment of post-tonsillectomy pain compared to acetaminophen plus opioids in children.

STUDY DESIGN

Retrospective medical record review.

SETTING

Tertiary-care children's hospital between September 2012 and March 2013.

SUBJECTS AND METHODS

All children undergoing total tonsillectomy (n=1065). Analysis included descriptive analysis, chi-square testing, and logistic regression controlling for age, diagnosis, trainee involvement, concurrent surgical procedures, and Coblator use for differences of outcomes: (1) post-operative bleeding, (2) emergency department (ED) visits for pain, dehydration, or bleeding, and (3) nurse phone calls from families.

RESULTS

All patients received acetaminophen. Seventy-four percent received ibuprofen (n=783) and 26.5% did not receive ibuprofen (n=282). In the ibuprofen group, 32.2% received opioids (n=252). Over eight percent of children had post-operative hemorrhage of any amount reported (n=89). Forty-eight percent of these required operative intervention (n=43). Ibuprofen prescription did not impact post-operative bleeding; operative intervention for bleeding, ED visits, or nurse phone calls either on chi-squared or logistic regression testing. Increasing age was found to increase bleeding risk as well as the likelihood of visiting the ED or calling the clinic nurses. All patients with multiple bleeding episodes were in the ibuprofen group.

CONCLUSION

Prescription of ibuprofen did not increase the risk of bleeding and did not increase the likelihood of a post-operative ED visit or nurse phone call. Ibuprofen prescription may possibly increase the risk of multiple bleeding episodes, but further prospective studies are needed. Increased age increases the risk of bleeding, ED visits, and nurse phone calls.

Analgesic effect of magnesium in post-tonsillectomy patients: a prospective randomised clinical trial

The aim of this study was to assess the analgesic, bleeding and nausea/vomiting effects of magnesium with and without metamizol on post-tonsillectomy patients. This prospective and randomised clinical trial included 54 patients aged 18-63 years who were scheduled for elective tonsillectomy. The patients were randomly divided into two groups and administered either magnesium with metamizol or only metamizol. They had been classified as physical status class I and II using the American Society of Anesthesiologists guidelines. All patients underwent the same surgical procedure performed by a single surgeon. The groups did not differ according to age, sex, or duration of anaesthesia or surgery. Postoperative pain, bleeding and nausea/vomiting were evaluated using the VAS and bleeding and nausea/vomiting scores on the first, fifth and tenth days. On the first, fifth and tenth postoperative days, the VAS scores of the magnesium with metamizol group were significantly lower than those of the metamizol-only group (p1 = 0.001; p5 = 0.015; p10 = 0.015). There were no significant differences in postoperative bleeding and nausea/vomiting scores between the two groups (p = 0.425 and p = 0.258, respectively). This study showed that magnesium enhanced the analgesic effect on post-tonsillectomy pain. Use of magnesium with an analgesic drug may be beneficial for management of post-tonsillectomy pain.

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

BACKGROUND

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

OBJECTIVE OF REVIEW

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

SEARCH STRATEGY

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

EVALUATION METHOD

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

RESULTS

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

CONCLUSIONS

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

Tonsillectomy and adenoidectomy

Adenotonsillectomy (AT) is one of the most common pediatric surgical procedures performed in the United States; more than 530,000 are performed annually in children younger than 15 years of age. AT was traditionally performed for recurrent tonsillitis and its sequelae but in recent times, sleep-disordered breathing/obstructive sleep apnea in children has emerged as the primary indication for surgical removal of adenoids and tonsils. The new guidelines used by clinicians to identify children who are appropriate candidates for AT address indications based primarily on obstructive and infectious causes.

Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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