Comparison of ropivacaine, bupivacaine and lidocaine in the management of post-tonsillectomy pain

Analgesic Efficacy of Ropivacaine Infiltration on Early Post-Tonsillectomy Pain in Pediatrics

OBJECTIVE

To assess the analgesic efficacy of ropivacaine infiltration in the tonsillar fossa among pediatric patients undergoing tonsillectomy.

DATA SOURCES

PubMed, Scopus, Web of Science, and CENTRAL.

REVIEW METHODS

Eligible randomized controlled trials (RCTs) were assessed for bias using Cochrane's risk of bias tool (version 2). Our primary outcome was postoperative pain within 24 h, and secondary outcomes included operative time, intraoperative blood loss, time to first analgesia, bleeding, and nausea/vomiting. Data were pooled as mean difference, standardized mean difference, and risk ratio with a 95% confidence interval.

RESULTS

Our review included 11 RCTs, with a total of 712 patients. The quality of studies varied and included low risk (n = 8 RCTs), some concerns (n = 2 RCTs), and high risk (n = 1 RCT) of bias. The primary endpoint of postoperative pain across all time points was significantly reduced in the ropivacaine group compared with the placebo group. Trial sequential analysis (TSA) of the postoperative pain depicted conclusive evidence and unnecessity for further RCTs. The mean operative time was significantly reduced in the ropivacaine group compared with the placebo group. However, there was no significant difference between both groups regarding additional clinical (i.e., mean intraoperative blood loss and mean time to first analgesia) and safety (i.e., rates of bleeding and nausea/vomiting) outcomes.

CONCLUSION

This systematic review and meta-analysis demonstrated the safety and postoperative analgesic efficacy of ropivacaine versus placebo among pediatric patients undergoing tonsillectomy. There was no significant difference between both groups regarding intraoperative blood loss, time to first analgesia, and rate of postoperative bleeding.

LEVEL OF EVIDENCE

1 Laryngoscope, 134:3018-3029, 2024.

To Compare the Effects of Post-tonsillectomy Intra-operative Infiltration of Ropivacaine Versus Bupivacaine in Tonsillar Fossa

Tonsillectomy is one of the most common surgical procedures practiced in Otorhinolaryngology. A significant obstacle for the speedy and smooth recovery is early post- operative pain. Pain leads to negative outcomes such as poor intake, tachycardia, anxiety, delayed wound healing and insomnia. Aim to assess and compare the effect of post-incisional infiltration of 0.75% Ropivacaine v/s 0.5% Bupivacaine on post tonsillectomy pain, the on start of oral intake and stay in hospital and to investigate any complications that can arise due to infiltration of the said drugs. 60 Patients above the age of 5 years were posted for tonsillectomy or adenotonsillectomy under general anesthesia. Patients were blinded about the group in which they will be enrolled. Group A received Inj. ropivacaine (0.75%) 2 ml and Group B: received Inj. Bupivacaine (0.50%) 2 ml in each fossa. After surgery, no analgesics were given & patients were observed for the intensity of post-operative pain in the immediate post-operative period, at 2, 4, 6, 12, 24, 48 h and further if not discharged using VISUAL ANALOGUE SCORE (VAS) and VERBAL RATING SCALE(VRS). Post-operative pain assessment was done using VAS and VRS at 2nd, 4th, 6th, 12th, 24th and 48th hour which was found to be lower in Group 'A'. Patients in Group 'A' also started their oral intake sooner, had lesser hospitalization days than group 'B' patients. Longer time for Rescue analgesic and reduced total dose of analgesic required was seen in Group A compared to Group B. This comparative study on Post-incisional infiltration of 2 ml 0.75% Ropivacaine v/s 2 ml 0.5% Bupivacaine has shown that Ropivacaine is a more effective drug in reducing post-operative pain in comparison to Bupivacaine, proven statistically.

Absorption and pharmacokinetics of bupivacaine after bilateral topical administration in tonsillar fossae for posttonsillectomy pain relief

No previous studies have investigated the systemic absorption of bupivacaine when used topically for posttonsillectomy pain. The present study was undertaken to investigate the pharmacokinetics of bupivacaine after administration by a swab in the tonsillar fossae over 4 min after tonsillectomy. Eleven adult patients undergoing elective tonsillectomy were recruited. After removal of both tonsils, each of the two tonsillar fossae was covered with a swab moistened with 2 mL of bupivacaine 5 mg/mL, that is, a total of 20 mg bupivacaine. Blood samples were drawn after 0, 5, 10, 20, 30, 45, and 60 min. Bupivacaine was analyzed with an ultra-high-performance liquid chromatography-tandem mass spectrometry method. The highest single measured bupivacaine serum concentration was 23.2 ng/mL and took place 10 min after drug administration. Mean (±SD) Cmax was 11.4 ± 6.0 ng/mL and mean tmax was 11.3 ± 4.7 min. Mean t1/2 was 31.6 ± 9.3 min. As the toxic concentration threshold has been reported to be in the interval 1500-4500 ng/mL, the concentrations measured were well below 2% of the lowest cited toxic threshold. In conclusion, this study shows that applying 4 mL of bupivacaine 5 mg/mL by a swab in the tonsillar fossae posttonsillectomy yields very low plasma concentrations, suggesting its safe application without any risk of systemic toxic effects.

Comparison of postoperative analgesia in children following ropivacaine and lidocaine surgical field infiltration with epinephrine for cleft palate repair: A double-blinded, randomized controlled trial

STUDY OBJECTIVE

The study aimed to evaluate the efficacy of ropivacaine in providing postoperative analgesia for children undergoing cleft palate repair.

METHODS

A double-blinded, randomized controlled trial was conducted on sixty-four children scheduled for cleft palate repair. The patients received either local infiltration with 1% lidocaine or 0.2% ropivacaine before incision. The primary outcome was the postoperative average pain score, and secondary outcomes included pain scores at various time points, consumption of flurbiprofen and hydromorphone, effectiveness of nurse-controlled analgesia pump, and incidence of bradycardia, vomiting, and respiratory depression.

MAIN RESULTS

The results showed that the postoperative average pain score was significantly lower in the ropivacaine group compared to the lidocaine group (1.27±0.28 vs. 1.75±0.29, P<0.001). Pain scores at multiple postoperative time points were also lower in the ropivac:aine group. Additionally, consumption of flurbiprofen and hydromorphone was lower, and ineffective compressions of the nurse-controlled analgesia pump were reduced in the ropivacaine group. The incidence of vomiting, bradycardia, and respiratory depression did not show significant differences between the two groups.

CONCLUSION

Local infiltration with ropivacaine effectively provided postoperative analgesia for children undergoing cleft palate repair without major side effects. It was found to be superior to lidocaine in reducing the need for additional rescue analgesia.

Efficacy of Ropivacaine Administration on Post-tonsillectomy Pain in Adults: A Systematic Review and Meta-analysis of Randomized Placebo-controlled Trials

The objective of this investigation is to assess the efficacy of ropivacaine on intraoperative and postoperative endpoints like operative time, blood loss, pain, and bleeding among adult's patients undergoing for tonsillectomy. PubMed, CENTRAL, Scopus, and Web of Science databases were screened from inception until November 2022. The included RCTs were evaluated for risk of bias via risk of bias tool (second version). All endpoints were summarized as mean difference (MD) or standardized mean difference (SMD) for continues outcomes, and risk ration (RR) for dichotomous outcomes, under random-effect model. Four RCTs met our PICOS criteria, comprising a total of 257 patients. Regarding postoperative pain, there was a significant difference that favor ropivacaine group compared with placebo group within hours (n = 4 RCTs, SMD = -0.92, 95% CI [-1.57, -0.26], p = 0.006), and within days (n = 4 RCTs, SMD = -050, 95% CI [-0.82, -0.18], p = 0.002). However, there were no significant difference between ropivacaine and placebo groups I terms of operative time (n = 3 RCTs, SMD = -0.17, 95% CI [-0.45, 0.11], p = 0.22), intraoperative blood loss (n = 2 RCTs, SMD = -0.37, 95% CI [-1.41, 0.67], p = 0.49), and postoperative bleeding (n = 4 RCTs, RR = 2.27, 95% CI [0.90, 5.73], p = 0.08). In conclusion, administration of ropivacaine was associated with less postoperative pain among adult's patients who undergoing tonsillectomy. However, there were no benefit in term of reduction in operative time, intraoperative blood loss, and postoperative hemorrhage.

Lidocaine aerosol preoperative application for improving the comfort of pediatric patients undergoing tonsillectomy and adenoidectomy: A prospective randomized controlled trial

Background and Aims

The use of lidocaine aerosol for pediatric tonsil and adenoidectomy has been reported less frequently. We hope to improve the perioperative comfort of pediatric patients undergoing these procedures by applying lidocaine aerosol.

Methods

A total of 122 pediatric patients receiving tonsil and adenoidectomy were randomly divided into a lidocaine aerosol group (Group L) and a saline group (Group C), with 61 patients in each group; 2.4% alkaline lidocaine aerosol and saline were sprayed in the pharynx before induction. Our primary outcome were the incidence and rate ratio (RR) of postoperative pharyngeal complications (oropharyngeal dryness, dysphagia, hoarseness, and sore throat) and the pharyngeal comfort score, the latter of which was assessed by the occurrence of the above complications (yes = 0 point, none = 1 point). The secondary outcomes included preoperative and intraoperative blood pressure and heart rate, the incidence of choking during the induction period, the intraoperative opioid dosage, and the pain level and depth of sedation at 2, 6, and 24 h postoperatively. Statistical software used in this study included PASS15.0, SPSS 26.0, and GraphPad Prism 9.3.1, and statistical methods used included the t-test, the χ² test, the Mann-Whitney U test, and the repeated measures analysis of variance.

Results

The incidence and RR of postoperative pharyngeal complications such as oropharyngeal dryness (RR: 0.667, 95% confidence interval [CI]: 0.458-0.970, p = 0.03), dysphagia (RR: 0.333, 95% CI: 0.114-0.976, p = 0.03), hoarseness (RR: 0.647, 95% CI: 0.433-0.967, p = 0.03), and sore throat (RR: 0.727, 95% CI: 0.547-0.967, p = 0.03) were significantly lower in Group L than in Group C at 2 h postoperatively, and the incidence and RR of postoperative sore throat was significantly lower in Group L than in Group C at 6 h postoperatively (RR: 0.717, 95% CI: 0.547-0.942, p = 0.01). The postoperative pharyngeal comfort scores were significantly higher in Group L than in Group C at all postoperative time points (p < 0.05). The Ramsay sedation score was significantly higher (p < 0.01) and FLACC (face, legs, activity, crying, and consolability) score was significantly lower (p < 0.01) in Group L than in Group C at 2 h postoperatively. In Group C, the blood pressure and heart rate significantly faster at all time points immediately after intubation and afterward, except at the end of surgery (p < 0.05).

Conclusions

In pediatric tonsil and adenoidectomy, the application of lidocaine aerosol before induction can reduce the incidence of postoperative pharyngeal complications, improve the child's postoperative pharyngeal comfort, and better realize perioperative "comfort medical treatment."

The analgesic Efficacy and Safety of Topically Applied Tramadol in Peritonsillar Space During Pediatric Adenotonsillectomy: A Meta-Analysis

OBJECTIVES

To evaluate the efficacy of topically applied tramadol in peritonsillar area for pain control and induction of perioperative morbidity in children undergoing adenotonsillectomy.

METHODS

Two authors independently searched the databases (MEDLINE, SCOPUS, and Cochrane databases) up to April 2022 for randomized controlled trials comparing the efficacy of an intraoperative peritonsillar administered tramadol with placebo or other agents only in pediatric patients. The outcomes were postoperative pain scores, time to take the first pain reducing drugs, and postoperative nausea/vomiting.

RESULTS

Our analysis was based on 17 trials. Peritonsillar administered tramadol significantly reduced postoperative pain at less than 20 minutes (SMD -1.5852, 95% CI [-2.3900; -0.7804]), 1 hour (SMD -1.5811, 95% CI [-2.3400; -0.8222]), 8 hours (SMD -1.0258, 95% CI [-1.8792; -0.1724]), 16 hours (SMD -0.8397, 95% CI [-1.4266; -0.2529]), and 1 day (SMD -1.0110, 95% CI [-1.5213; -0.5007]) and the time to take the first analgesic drug (SMD 1.6565, 95% CI [0.2838; 3.0293]) compared with the placebo. However, tramadol showed no significant difference on postoperative pain relief effects and the time to take the first analgesic drug compared to the other topical agents (bupivacaine, lidocaine, ketamine, and dexamethasone). Tramadol did not cause significant postoperative nausea and vomiting.

CONCLUSIONS

This study demonstrated that intraoperatively applied topical tramadol could control postoperative pain and reduce the analgesic uptake compared with a control. However, the efficacy of tramadol in pain control was similar to other agents in pediatric adenotonsillectomy.

The efficacy and safety of peri-tonsillar administrated agents on pain treatment after pediatric tonsillectomy: A network meta-analysis

OBJECTIVES

We assessed the pain control efficacies and associated morbidities of drugs administered locally (around the tonsils) in pediatric patients undergoing a tonsillectomy.

METHODS

Randomized controlled trials up to April 2022 were retrieved from six databases. The treatment networks featured six interventions (ropivacaine, bupivacaine, levobupivacaine, ketamine, tramadol, and dexamethasone) and a control (placebo). The outcomes were the postoperative pain scores, the time to use of the first analgesic drugs, and postoperative nausea/vomiting. Both pairwise and network meta-analyses were performed.

RESULTS

All treatments controlled pain at 1 h and 1 day postoperatively. Although all agents tended to delay the time to the first analgesic drug, only bupivacaine, dexamethasone, ketamine, and tramadol significantly reduced the need for analgesics. No agent caused significant postoperative nausea or vomiting. The ranking hierarchy revealed that tramadol was superior in terms of pain control 1 h postoperatively, the time to the first analgesic drug, and the number of analgesic doses required; however, it ranked third in terms of operative time.

CONCLUSION

All drugs reduced postoperative pain. Tramadol was optimal in pain control, and dexamethasone also afforded good pain control with low incidences of nausea and vomiting.

A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy

Objectives

To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research.

Data Sources

PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley).

Methods

A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs.

Results

One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons.

Conclusion

Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.

Efficacy of bupivacaine infiltration for controlling post-tonsillectomy pain, duration of surgery and post-operative morbidities: A systematic review and meta-analysis

The objective of the present review and meta-analysis was to evaluate the efficacy of bupivacaine during tonsillectomy in terms of reducing the mean operative procedure duration, post-operative pain and the onset of post-operative morbidities. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed to perform a systematic literature search using the MEDLINE, Scopus, EMBASE and CENTRAL databases. The present meta-analysis sought to evaluate the efficacy of bupivacaine administered during tonsillectomy as compared to the administration of normal saline. The efficacy of the intervention was evaluated based on pain scores using the visual analogue scale, the duration of the operation and the occurrence of post-operative morbidities. Out of 1,427 records, 15 articles with 729 participants (mean age, 10.2±6.7 years) were included in the study. The present systematic review supported the use of bupivacaine during tonsillectomy at a level of evidence of 1b and confirmed beneficial effects of bupivacaine intervention by demonstrating small to large effect reductions in the visual analog scale score (Hedge's g, -1.48), the mean duration of the operative procedure (Hedge's g, -1.35) and the incidence of post-operative morbidity (Hedge's g, -0.23) in comparison to the placebo groups treated with normal saline. Based on these results, the administration of bupivacaine is recommended during tonsillectomies to reduce the perceived level of pain, the duration of the operation and the post-operative morbidity.

Ropivacaine: A Novel Local Anaesthetic Drug to Use in Otorhinolaryngology Practice

Ropivacaine is a long-acting amide local anaesthetic agent which has a significant vasoconstrictive property, long duration of action, least central nervous system and cardiac complications due to the pure (S)-enantiomer property by reversible inhibition of sodium ion influx in nerve fibres. By using additives the duration of analgesia may be prolonged. Ropivacaine has been used routinely in our otorhinolaryngology procedures since 2010 (10 years). The present article details the clinical applications of ropivacaine and its current place as a local anaesthetic in otorhinolaryngology practice.

Comparison of efficacy of lignocaine, ropivacaine, and bupivacaine in pain control during extraction of mandibular posterior teeth

BACKGROUND

The management of pain during extraction of mandibular third molars is an important requisite to achieve patient comfort and to obtain desired result in an effective manner. There are various anesthetics that can be used to achieve regional or local anesthetic effect in this regard.

AIM

The aim of this study was to compare the efficacy of 2% lignocaine with 1:80,000 adrenaline, 0.75% ropivacaine and bupivacaine in pain control during extraction of mandibular posterior teeth.

MATERIALS AND METHODS

This prospective, cross-sectional study included 300 study participants indicated for mandibular third molar surgical extractions. The study subjects were categorized into three broad groups - (a) Group I (n = 100): Third molar extractions performed using 2% Lignocaine with 1: 80,000 epinephrine; (b) Group II (n = 100): This group included subjects who underwent extractions of mandibular third molars using 0.75% ropivacaine and (c) Group III (n = 100): This group included patients who underwent extractions of mandibular third molars with bupivacaine. Inclusion criteria were: (a) partially impacted mandibular third molars which were symptomatic; (b) written informed consent. Exclusion criteria were - (a) any systemic diseases and/or undergoing any medication for same; (b) subjects not willing for extraction after clinical and radiographic examination and opinion and (c) subjects undergoing orthodontic therapy. Subject response for pain was recorded using - (a) visual analog scale (VAS) and (b) Verbal Rating scale (VRS). Postoperative pain was assessed using requirement of analgesics after extraction. SPSS version 21.0 was employed as statistical software. Statistical tool used was the Analysis of Variance test which was used for determining statistical significance which was set at a P value of lesser than 0.05 (significant).

RESULTS

On analysis of visual analog scale (VAS), it was observed that in Group I (2% Lignocaine with 1:80,000), no pain during the extraction procedure was demonstrated in 30 study participants while minimal or less pain was present in 70 patients, while in Group II (0.75% ropivacaine), 90 patients presented with no pain while ten patients had presented with minimal amount of pain during tooth extraction. While on the other hand, Group III patients whose mandibular third molars were extracted using local anesthesia by injecting bupivacaine, lack of any pain was observed in 69 patients while minimal pain was noted in 31 individuals. While making statistical comparison between three groups, a significant P = 0.03 was observed. Also, postoperative pain was noted in 60% of cases who underwent extraction using 2% lignocaine (Group I), 10% patients who had third molar extractions under Bupivacaine anesthesia presented with pain whereas none of the patients (0%), demonstrated the presence of pain following third molar extraction.

CONCLUSION

0.75% Ropivacaine is the most effective local anesthetic agent that can be used for extracting mandibular third molars due to its effective pain control both during and following the procedure when compared to 2% lignocaine and bupivacaine.

Topical ropivacaine for analgesia of aplasia cutis congenita in newborns with hereditary epidermolysis bullosa

Aplasia cutis congenita (ACC) in patients with hereditary epidermolysis bullosa (EB) is often associated with major pain. We report our experience with using topical ropivacaine during dressing in newborns with ACC. Eight full-term newborns with EB and ACC were hospitalized in a neonatal intensive care unit for severe pain during dressing despite the use of paracetamol, opioids (n = 8) or ketamine (n = 7). Topical xylocaine was poorly tolerated and not effective. Ropivacaine 2 mg/ml was used directly in contact with the ACC, with a maximum 1 mg/kg/day, which enabled care without the child crying. No immediate or late systemic toxicity was observed. Topical ropivacaine 0.2% appears to be an interesting topical analgesic, with good clinical tolerance and rapid action, in newborns with ACC and EB. These data need to be confirmed in a prospective study including pharmacokinetics evaluations.

Addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia improves analgesic efficacy after tonsillectomy and adenoidectomy: A randomized controlled trial

OBJECTIVES

The aim of this study was to determine whether the addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia was more effective than ropivacaine alone in attenuating pain after tonsillectomy and adenoidectomy.

METHODS

This was a double-blind randomized clinical trial. One hundred and twenty children scheduled for tonsillectomy and adenoidectomy using a combination of general anaesthesia and local infiltration anaesthesia were randomized into the dexmedetomidine plus ropivacaine group (DR) and ropivacaine group (R). The children were locally infiltrated with 1 μg kg^-1 dexmedetomidine and 0.25% ropivacaine in the DR group or 0.25% ropivacaine alone in the R group. In both groups, local infiltration anaesthesia was performed using 5 ml of solution. The pain scores were recorded at the 1st, 4th, 8th, 12th, 16th, 20th, and 24th hours after surgery using the Face Legs Activity Cry Consolability (FLACC) scale. When the pain score exceeded 4, paracetamol syrup (15 mg kg^-1) was administered as a rescue analgesic. Time to the first administration of analgesic was recorded.

RESULTS

8th, 16th, 20th, and 24th hours after surgery, the children in the DR group had lower pain scores than those in the R group (P<0.05). The time to the first administration of analgesic was significantly longer in the DR group (mean: 10.4 h, range: 9.4-11.4 h) than in the R group (mean: 8.1 h, range: 7.3-8.8 h) (P < 0.001).

CONCLUSION

The addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia effectively improved the efficacy of analgesia and extended the duration of analgesia after tonsillectomy and adenoidectomy.

Ultrasound-guided serratus anterior plane block combined with parasternal block in subcutaneous implantable cardioverter defibrillator implantation: Results of a pilot study

BACKGROUND

The standard approach to subcutaneous defibrillator (S-ICD) implantation often requires general anesthesia or anesthesiologist-delivered deep sedation. Ultrasound-guided serratus anterior plane block (SAPB) combined with parasternal block (PSB) has been proposed in order to provide anesthesia/analgesia and to reduce the need for sedation during S-ICD implantation. In this pilot study, we compared the double-block approach (SAPB + PSB) with the single-block approach (SAPB only) and with the standard approach involving local anesthesia and sedation.

METHODS

We prospectively enrolled 22 patients undergoing S-ICD implantation: in 10, the single-block approach was adopted; in 12, the double-block approach. As a control group, we retrospectively enrolled 14 consecutive patients who had undergone S-ICD implantation under standard local anesthesia and sedation in the previous 6 months. Intra- and postprocedural data, including patient-reported pain intensity, were collected and compared in the three study groups.

RESULTS

The double-block approach was associated with a shorter procedure duration than the single-block and standard approaches (63.3 ± 7.9 vs 70.1 ± 6.8 vs 76.9 ± 7.8 min; P < .05) and with a lower dose of local an aesthetic for infiltration (18.9 ± 1.7 vs 27.5 ± 4.6 vs 44.6 ± 4.0 cc; P < .001). Both the double- and single-block approaches were associated with lower pain intensity at the device pocket and the lateral tunneling site (P < .05). The double-block approach proved superior to the other two approaches in controlling intraoperative pain at the parasternal tunneling site (P < .05).

CONCLUSIONS

In our study, SAPB combined with PSB was superior to SAPB alone and to the standard approach in controlling intraoperative pain during S-ICD implantation. In addition, this approach resulted in shorter procedure durations.

Effect of lidocaine on pain caused by nasal pack removal after closed reduction of nasal bone fractures

Background

Pain caused by nasal pack removal after closed reduction of nasal bone fractures is a common problem. This study investigated the effect of infiltrating lidocaine into nasal packs on the pain caused by pack removal after closed reduction of nasal bone fractures.

Methods

Seventy-five patients who underwent closed reduction of nasal bone fractures between March 2016 and March 2018 were enrolled in this prospective, randomized, single-blind study. Merocel (hydroxylated polyvinyl acetate) packs were applied bilaterally and retained for 5 days. Twenty minutes before removal, both packs were rehydrated with 6 mL of 2% lidocaine in 26 patients and with 6 mL of saline in 24 patients; the packs were not rehydrated in 25 patients. Visual analog scale (VAS) scores for pain on removal were recorded.

Results

The mean VAS score was 5.3±2.0 in all patients, 3.8±1.5 in the lidocaine group, 5.8±1.4 in the saline group, and 6.3±2.1 in the non-rehydrated group. There was a significant difference in the pain score between the lidocaine and saline groups (P<0.001) but not between the saline and non-rehydrated groups (P=0.186).

Conclusions

Infiltration of lidocaine into Merocel packs reduced the pain caused by pack removal after closed reduction of nasal bone fractures.

Role of Preincisional Peritonsillar Infiltration of Bupivacaine in Postoperative Pain Relief in Tonsillectomy Patients

Tonsillectomy is one of the most common surgical procedures carried out in ENT since ancient time, is associated with several morbidities in which the pain and bleeding being the commonest and can cause considerable delay in starting oral intake and discharge from the hospital. Different methods have been used to reduce posttonsillectomy pain including use of opioids, sucralfate and local anaesthetics. Local anaesthetics in the form of pre-incisional or post-incisional peritonsillar infiltration and also topical post-incisional spray or packing are some of the most effective methods for post-tonsillectomy pain management. In our hospital, a study was carried out for preincisional peritonsillar infiltration of 0.5% bupivacaine in tonsillectomy patients for post operative pain relief. Written informed valid consent was taken, all routine investigations were done. Pre anaesthetic check up was done and bupivacaine test dose was given, none of the patients showed allergic reactions. Our study showed that this is effective method of controlling post operative pain. Patients receiving bupivacaine showed lower pain scores 6 h post operatively. The mean pain scores for Bupivacaine group were 2.85, 5.52 and 7.04 versus 5.04, 7.04 and 7.61 in saline group at 2, 4, and 6 h post operatively (t value significant). Pre incisional peritonsillar infiltration of 0.5% bupivacaine significantly reduces postoperative pain till 6 h, thereby reducing the need of analgesics intraoperatively and post operatively. Oral intake was also earlier without any adverse effects in our study.

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Introduction  Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective  To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods  In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results  Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo ( p  < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion  We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

A Randomized Single-Blinded Trial of Posttonsillectomy Liposomal Bupivacaine among Adult Patients

Objective

To determine whether liposomal bupivacaine (Exparel) is safe and effective in the management of posttonsillectomy pain among adult patients.

Study Design

A prospective single-blind randomized controlled trial.

Setting

An academic quaternary care center (Mayo Clinic, Rochester, Minnesota).

Subjects and Methods

From May 2015 to December 2016, 39 patients were randomized to receive oral pain medication and 8 mL of injected liposomal bupivacaine or oral pain medication alone for treatment of their posttonsillectomy pain. Visual analog scale pain intensity scores, oral pain medication usage, liquid oral intake, and complications were recorded for 2 weeks after the procedure.

Results

Thirty-nine patients were randomized, with 17 patients in the liposomal bupivacaine group and 22 in the control group. Fifteen patients in the liposomal bupivacaine group and 18 patients in the control group completed the study. Pain intensity score on postoperative day 1 ( P = .043) proved to be the only statistically significant result, with no difference noted in pain scores on postoperative days 2 to 14. There was no difference in pain medication usage, liquid oral intake, postoperative hemorrhage, or adverse events between groups.

Conclusions

The injection of liposomal bupivacaine in the posttonsillectomy wound bed demonstrates improved pain intensity scores for the first 24 hours after surgery with no adverse complications noted in comparison with patients who did not receive the injection. Given the limited pain reduction and increased cost, use of liposomal bupivacaine in adult tonsillectomy patients appears to have minimal indication for use.

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

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.

The Effect of Systemic Magnesium on Postsurgical Pain in Children Undergoing Tonsillectomies: A Double-Blinded, Randomized, Placebo-Controlled Trial

BACKGROUND

Tonsillectomy is a frequently performed surgical procedure in children; however, few multimodal analgesic strategies have been shown to improve postsurgical pain in this patient population. Systemic magnesium infusions have been shown to reliably improve postoperative pain in adults, but their effects in pediatric surgical patients remain to be determined. In the current investigation, our main objective was to evaluate the use of systemic magnesium to improve postoperative pain in pediatric patients undergoing tonsillectomy. We hypothesized that children who received systemic magnesium infusions would have less post-tonsillectomy pain than the children who received saline infusions.

METHODS

The study was a prospective, randomized, double-blinded, clinical trial. Subjects were randomly assigned using a computer-generated table of random numbers to 1 of the 2 intervention groups: systemic magnesium infusion (initial loading dose 30 mg/kg given over 15 minutes followed by a continuous magnesium infusion 10 mg/kg/h) and the same volume of saline. The primary outcome was pain scores in the postanesthesia care unit (PACU) measured by FLACC (Face, Legs, Activity, Cry, Consolability) pain scores. Pain reduction was measured by the decrement in the area under the pain scale versus 90-minute postoperative time curve using the trapezoidal method. Secondary outcomes included opioid consumption in the PACU, emergence delirium scores (measured by the pediatric anesthesia emergence delirium scale), and parent satisfaction.

RESULTS

Sixty subjects were randomly assigned and 60 completed the study. The area under pain scores (up to 90 minutes) was not different between the study groups, median (interquartile range [IQR]) of 30 (0-120) score × min and 45 (0-135) score × min for the magnesium and control groups, respectively (P = 0.74). Similarly, there was no clinically significant difference in the morphine consumption in the PACU between the magnesium group, median (IQR) of 2.0 (0-4.44) mg IV morphine, compared with the control, median (IQR) of 2.5 (0-4.99) mg IV morphine (P = 0.25). The serum level of magnesium was significantly lower in the control group than in the treatment group at the end of the surgery (P < 0.001).

CONCLUSIONS

Despite a large number of studies demonstrating the efficacy of systemic magnesium for preventing postsurgical pain in adults, we could not find evidence for a significant clinical benefit of systemic magnesium infusion in children undergoing tonsillectomies. Our findings reiterate the importance of validating multimodal analgesic strategies in children that have been demonstrated to be effective in the adult population.

Post-tonsillectomy pain control: consensus or controversy?

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.

Comparison of topical anesthetic effects of lidocaine, prilocaine, ropivacaine, and bupivacaine in transnasal fiberoptic nasopharyngolaryngoscopy

BACKGROUND

This study was designed to investigate the topical anesthetic efficacy of four different solutions including lidocaine spray, bupivacaine, ropivacaine, and prilocaine used in patients undergoing transnasal fiberoptic nasopharyngolaryngoscopic examination (TFL).

METHODS

The study included 200 patients who underwent anterior rhinoscopy and TFL examination as a part of routine otolaryngological evaluation in our outpatient clinics. Of these, 111 were female and 89 were male patients. The mean age of the patients was 32 ± 8 years (aged between 19 and 55 years). The patients were randomly divided into five groups. Five groups received one of the local anesthetics studied in our trial (10% lidocaine, 0.5% ropivacaine, 0.25% bupivacaine, 2% prilocaine, and saline solution) in each right side of the nose for 10 minutes before TFL. Each separate examination was performed on the right side of the nasal cavity. After the examination, the patients were asked to note the intensity of the pain that they have experienced during the TFL, by using a 100-mm visual analog scale (VAS).

RESULTS

The mean VAS scores were 2.08 (SD, 0.62) in the lidocaine group, 2.21 (SD, 0.66) in the prilocaine group, 3.92 (SD, 0.58) in the ropivacaine group, 4.15 (SD, 0.64) in the bupivacaine group, and 6.35 (SD, 0.65) in the saline solution group. The lidocaine and prilocaine groups had significantly better VAS scores versus ropivacaine, bupivacaine, and saline solution groups (p < 0.05).

CONCLUSION

To provide ideal examination comfort and optimum patient tolerability during TFL evaluation of upper respiratory airway topical lidocaine and prilocaine applications were found to be more efficacious and effective medication for anesthesia of the intranasal mucosa compared with bupivacaine and ropivacaine solutions.

Tonsillitis and sore throat in children

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

Preemptive Submucosal Infiltration with Ropivacaine for Uvulopalatopharyngoplasty

Objective

To evaluate the preemptive analgesic effect of submucosal infiltration of ropivacaine for uvulopalatopharyngoplasty.

Study Design

Randomized controlled trial.

Setting

Comprehensive clinical center and academic hospital.

Subjects and Methods

Fifty consecutive male patients scheduled for uvulopalatopharyngoplasty were divided randomly into group A and group B. In group A, 4 mL of 0.33% ropivacaine and normal saline with epinephrine was preincisionally injected under the mucosa on both sides of the tonsillar fossa, soft palate, and the lower part of palatoglossal arch, whereas the upper and middle parts of the palatoglossal arch and the upper part of the palatopharyngeal arch were infiltrated with 2 mL of the same mixture. In group B, an identical volume of normal saline with epinephrine was administered. In both groups, postoperative pain was initially controlled by intravenous morphine titration until patient-controlled analgesia with morphine could be used. Cumulative patient-controlled analgesic morphine consumption; visual analog scale scores at 4, 8, 12, 24, and 48 hours postoperatively at rest and during swallowing; and opioid-related adverse effects were recorded.

Results

The visual analog score was lower at rest during the 48-hour postoperative period and during swallowing within the first 12 hours for group A versus group B ( P < .05). Patients in group A required 44.1%, 38.2%, and 41.1% less morphine during the first 24 hours, 24 hours to 48 hours, and 48 hours postoperatively, respectively, and fewer patients experienced nausea, vomiting, and pruritus ( P < .05).

Conclusion

Preemptive submucosal infiltration with 0.33% ropivacaine effectively controlled pain after uvulopalato-pharyngoplasty.

Ropivacaine plus dexamethasone infiltration reduces postoperative pain after tonsillectomy and adenoidectomy

OBJECTIVE

To compare the effect of ropivacaine plus dexamethasone and ropivacaine alone as infiltration anesthesia on postoperative pain, nausea and vomiting, and oral intake in children after tonsillectomy and adenoidectomy.

METHODS

Two hundred pediatric patients scheduled for tonsillectomy and adenoidectomy were prospectively enrolled and randomly placed in a ropivacaine with dexamethasone group (RD) or a ropivacaine alone group (R). Treatment for both groups was administered by local infiltration, and pain scores were recorded at various intervals. Primary outcomes were pain scores recorded 4-24h postoperation. Secondary outcomes included time to the first administration of analgesic and total consumption of analgesics for all children, time to first water request, first oral intake, incidence of nausea or vomiting, and time to discharge.

RESULTS

From postoperative hours 4-24, children in the RD group had lower pain scores than children in the R group (P < 0.05). Total fentanyl consumption was significantly decreased in the RD group compared to the R group (50.9 ± 9.3 vs. 103.9 ± 11.5 μg, P < 0.001). The time to first water request and first oral intake were significantly shorter in the RD group [(40 min (27-64) vs. 64 min (43-89); P < 0.001) and (54 min (40-91) vs. 85 min (67-127); P < 0.001), respectively]. Oral intake was significantly improved, and the incidence of nausea and vomiting were reduced in the RD group (P < 0.05). The time to discharge was shorter in the RD group when compared with the R group (9.06 ± 0.89 d vs. 7.05 ± 0.71 d; P < 0.001).

CONCLUSIONS

Ropivacaine plus dexamethasone infiltration effectively lowers pain, improves oral intake, lowers postoperative nausea and vomiting, and decreases the time to discharge.

Preemptive peritonsillar infiltration with lidocaine for relief of bipolar adult post-tonsillectomy pain: a randomized, double-blinded clinical study

There are discordant results in the studies of the peritonsillar infiltration in adults undergoing the tonsillectomy. The study is to compare the effect of the preemptive peritonsillar infiltration with lidocaine in bipolar tonsillectomy in adult. 172 adult patients were randomly located into five groups before tonsillectomy: group 0: without the peritonsillar infiltration, group 1: for 3 ml normal saline with 1:200,000 epinephrine per tonsil, group 2: for 3 ml 1 %lidocaine with 1:200,000 epinephrine per tonsil, group 3: for 8 ml normal saline with 1:200,000 epinephrine per tonsil, group 4: for 8 ml lidocaine with 1:200,000 epinephrine per tonsil. The post-operative pain in the following 7 days was assessed by visual analog scale. Operation time and post-operative bleeding were also recorded. No significant differences were found between operative times, post-tonsillectomy hemorrhage between the five groups. The differences between pain scores of the group 0, group 1 and group 2 were not statistically significant (P > 0.05). The differences between pain scores of group 3, group 4 against group 0, group 1, group 2 were statistically significant (P < 0.05). We found the volume of peritonsillar infiltration might contribute to the relief of pain of the bipolar post-tonsillectomy.