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Lin C, Abboud S, Zoghbi V, Kasimova K, Thein J, Meister KD, Sidell DR, Balakrishnan K, Tsui BCH. Suprazygomatic Maxillary Nerve Blocks and Opioid Requirements in Pediatric Adenotonsillectomy: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2024; 150:564-571. [PMID: 38780948 PMCID: PMC11117150 DOI: 10.1001/jamaoto.2024.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/29/2024] [Indexed: 05/25/2024]
Abstract
Importance Pain management following pediatric adenotonsillectomies is opioid-inclusive, leading to potential complications. Objective To investigate the use of suprazygomatic maxillary nerve (SZMN) blocks to reduce pain and opioid use after pediatric intracapsular adenotonsillectomy and to measure recovery duration and incidence of complications. Design, Setting, and Participants This was a randomized, blinded, prospective single-center tertiary pediatric hospital that included 60 pediatric patients (2-14 years old) scheduled for intracapsular adenotonsillectomy from November 2021 to March 2023. Patients were excluded for having combined surgical procedures, developmental delay, coagulopathy, chronic pain history, known or predicted difficult airway, or unrepaired congenital heart disease. Participants were randomized to receive bilateral SZMN blocks (block group) or not (control group). Intervention SZMN block administered bilaterally under general anesthesia for intracapsular adenotonsillectomy. Primary Outcomes and Measures Opioid consumption, FLACC (Face, Legs, Activity, Cry, Consolability) scores, and rates of opioid-free postanesthesia care unit (PACU) stay. Secondary outcomes were recovery duration and incidence of adverse effects, ie, nausea, vomiting, block site bleeding, and emergency delirium. Results The study population included 53 pediatric patients (mean [SD] age, 6.5 [3.6] years; 29 [55%] females; 24 [45%] males); 26 were randomly assigned to the SZMN block group and 27 to the control group. The mean (SD) opioid morphine equivalent consumption during PACU stay was 0.15 (0.14) mg/kg for the 27 patients in the control group compared with 0.07 (0.11) mg/kg for the 26 patients in the block group (mean difference, 0.08; 95% CI, 0.01-0.15; Cohen d, 0.64). The block group had a higher incidence of opioid-free PACU stays (n = 7 patients; 58%) compared with the control group (n = 15 patients; 26%) (mean difference, 32%; 95% CI, 5%-53%). Patients in the block group experienced lower FLACC scores (0.7 vs 1.6; mean difference, 0.9; 95% CI, 0.2-1.6; Cohen d, 0.7). The overall occurrence of adverse events was similar in the 2 groups, with no reported nerve block-related complications. Conclusions and Relevance The results of the randomized clinical trial indicate that SZMN blocks are a useful adjunct tool for managing postoperative pain in pediatric intracapsular adenotonsillectomy. Use of these blocks during adenotonsillectomy provided clinically meaningful reductions of postoperative opioid consumption with a low risk of complications. Trial Registration ClinicalTrials.gov Identifier: NCT04797559.
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Affiliation(s)
- Carole Lin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Steven Abboud
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Veronica Zoghbi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Ksenia Kasimova
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Jonathan Thein
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Kara D. Meister
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Douglas R. Sidell
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Karthik Balakrishnan
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Ban C. H. Tsui
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Roskvist M, Alm F, Nerfeldt P, Ericsson E. Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery. PLoS One 2024; 19:e0298011. [PMID: 38451952 PMCID: PMC10919603 DOI: 10.1371/journal.pone.0298011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/16/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS). MATERIALS & METHODS A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries). RESULTS Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy. CONCLUSION The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.
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Affiliation(s)
- Maria Roskvist
- Ear-, Nose- and Throat Clinic, County Hospital Mälarsjukhuset Eskilstuna, Sweden
| | - Fredrik Alm
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Pia Nerfeldt
- Department of Otorhinolaryngology, Karolinska University Hospital and Division of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Elisabeth Ericsson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Cohen N, Schissler K, Jeter J, Stathas A, Lozano J, Dave S, Lowe D. Change in Pediatric Adenotonsillectomy Postoperative Visit Patterns After Opioid Food and Drug Administration Warning. Pediatr Emerg Care 2024; 40:38-44. [PMID: 36972489 DOI: 10.1097/pec.0000000000002926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
STUDY OBJECTIVE This study aimed to determine the association between opioid prescriptions given after tonsillectomy with adenoidectomy (T + A) and pain-related return visit rates in pediatric patients. Determine association between Food and Drug Administration (FDA) black box warning against opioid use in this population and pain-related return visit rates. METHODS This was a single-institution retrospective cohort study of pediatric patients who underwent T + A between April 2012 and December 2015 and had return visits to the emergency department or urgent care center. Data were obtained from the hospital electronic warehouse using International Classification of Diseases-9/10 procedure codes. Odds ratios (ORs) with 95% confidence intervals (CIs) for return visits were calculated. Multivariate logistic regression analysis was used to measure association between opioid prescriptions and return visit rates as well as FDA warning and return visit rates adjusting for confounders. RESULTS There were 4778 patients who underwent T + A, median age, 5 years. Of these, 752 (15.7%) had return visits. Pain-related return visits were higher in patients who received opioid prescriptions (adjusted OR, 1.31; 95% CI, 1.09-1.57). After FDA warning, opioids were prescribed at a lower rate (47.9%) compared with previous (98.6%) (OR, 0.01; 95% CI, 0.008-0.02). Pain-related return visits were lower after FDA warning (OR, 0.73; 95% CI, 0.61-0.87). Steroid prescription rate increased after FDA warning (OR, 415; 95% CI, 197-874). CONCLUSIONS Opioid prescriptions were associated with higher pain-related return visits after T + A, whereas issuance of FDA black box warning against codeine use was associated with lower pain-related return visits. Our data suggest that the black box warning potentially had unintended benefits in pain management and health care usage.
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Affiliation(s)
- Naiomi Cohen
- From the Department of Pediatric Emergency Medicine, Nicklaus Children's Hospital, Miami, FL
| | - Kathryn Schissler
- Department of Pediatric Emergency Medicine, Connecticut Children's, University of Connecticut School of Medicine, Hartford, CT
| | | | - Adam Stathas
- Department of Medical Education, Nicklaus Children's Hospital, Miami, FL
| | - Juan Lozano
- Division of Medical and Population Health Sciences Education and Research, College of Medicine, Florida International University, Miami, FL
| | - Sandeep Dave
- Division of Pediatric Otolaryngology, Nicklaus Children's Hospital, Miami, FL
| | - David Lowe
- From the Department of Pediatric Emergency Medicine, Nicklaus Children's Hospital, Miami, FL
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Lima LACN, Otis A, Balram S, Giasson AB, Carnevale FA, Frigon C, Brown KA. Parents' perspective on recovery at home following adenotonsillectomy: a prospective single-centre qualitative analysis. Can J Anaesth 2023; 70:1202-1215. [PMID: 37160822 DOI: 10.1007/s12630-023-02479-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 05/11/2023] Open
Abstract
PURPOSE In North America, pediatric adenotonsillectomy (TA) is conducted as an ambulatory procedure, thus shifting the burden of postoperative care to parents. The purpose of this study was to describe this parental experience. METHODS We conducted a prospective single-centre qualitative study, recruiting the families of children (n = 317) undergoing elective TA in 2018. Parents were invited to submit written comments to two open-ended questions. We coded the comments from 144 parents in a grounded theory analysis and report representative exemplars. Themes and subthemes for the problems encountered, and strategies employed by parents, were developed. We then coded and classified factors that helped/hindered parents and developed models of the experience. RESULTS Some parents felt ill-prepared for the severity and duration of pain. Specific findings included a lack of strategies to manage pain at night, refusals, and night terrors. Parents identified the use of pain scales, pain diaries, and liaison with the research team as helpful supports at home. Inconsistent messaging was a barrier. The odynophagia associated with elixirs of acetaminophen and ibuprofen was a barrier to achieving analgesia. CONCLUSIONS The findings from this qualitative analysis provide insight into the challenges faced by parents when caring for their children at home following TA; these challenges included difficulties managing physical needs and pain. The analysis suggests that educational content should be standardized and include the use of pain scales and diaries, and both pharmacologic and nonpharmacologic strategies. Development of support at home, including a practicable liaison with health care providers, seems to be warranted. STUDY REGISTRATION ClinicalTrials.gov (NCT03378830); registered 20 December 2017.
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Affiliation(s)
- Laura A C N Lima
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Annik Otis
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Sharmila Balram
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Annick Bérard Giasson
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | | | - Chantal Frigon
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Karen A Brown
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada.
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Johnson RF, Beams DR, Zaniletti I, Chorney SR, Kou YF, Lenes-Voit F, Ulualp S, Liu C, Mitchell RB. Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children. JAMA Otolaryngol Head Neck Surg 2023; 149:431-438. [PMID: 36995688 PMCID: PMC10064285 DOI: 10.1001/jamaoto.2023.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/06/2023] [Indexed: 03/31/2023]
Abstract
Importance The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored. Objective To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event. Design, Settings, and Participants This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023. Main Outcomes and Measures Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy. Results Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%. Conclusions and Relevance This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.
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Affiliation(s)
- Romaine F. Johnson
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Dylan R. Beams
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
| | | | - Stephen R. Chorney
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Yann-Fuu Kou
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Felicity Lenes-Voit
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Seckin Ulualp
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Christopher Liu
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Ron B. Mitchell
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
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Commesso EA, Osazuwa-Peters N, Frank-Ito DO, Einhorn L, Ji KSY, Greene NH, Eapen RJ, Raynor EM. Opioid and non-opioid analgesic prescribing practices for pediatric adenotonsillectomy in a tertiary care center. Int J Pediatr Otorhinolaryngol 2022; 163:111337. [PMID: 36302324 DOI: 10.1016/j.ijporl.2022.111337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/18/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
IMPORTANCE The U.S. is in an opioid epidemic with greater than 40,000 deaths annually. Pediatric adenotonsillectomy is one of the most common and painful otolaryngology surgeries performed, often associated with opioid prescriptions. OBJECTIVE To understand postoperative prescribing practices of adenotonsillectomy in a tertiary care institution and associated postoperative emergency department (ED) visits. DESIGN Descriptive analysis of retrospective cohort data. SETTING Tertiary academic healthcare institution. PARTICIPANTS Pediatric patients <18yo undergoing adenotonsillectomy between 2013 and 2016. INTERVENTIONS/EXPOSURES Postoperative analgesic regimens assessed including opioid and non-opioid analgesic prescriptions upon discharge from tonsillectomy surgery. MAIN OUTCOMES AND MEASURES Main outcomes included ED presentation within 30-days of surgery and reoperation. Secondary outcomes included reason for ED presentation and relation to prescribed analgesics. Data was analyzed between November 2021-February 2022. RESULTS 200 patients were included in the study with 69% prescribed opioids, and 51% prescribed non-opioid analgesics. Number of opioid doses ranged widely with a median of 37 (Q1, Q3: 0, 62). There were no demographic differences in patients prescribed opioids from those who were not. Of those patients who presented to the ED, 81% were not specifically prescribed acetaminophen (p < 0.001). Regression analysis models were not predictive of postoperative analgesic regimen or 30-day ED presentation (p > 0.05) CONCLUSIONS: Wide ranges of post tonsillectomy prescribing practices currently exist in our institution. Prescribing acetaminophen may help to reduce 30-day ED presentation rate. Larger prospective studies are needed to optimize pain control regimens and reduce variability of opioid prescribing practices. Standardization of postoperative pain medication doses may also reduce postoperative ED presentations.
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Affiliation(s)
- Emily A Commesso
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA
| | - Nosayaha Osazuwa-Peters
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA
| | - Dennis O Frank-Ito
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA
| | - Lisa Einhorn
- Duke University School of Medicine, Department of Anesthesiology, Division of Pediatrics, Durham, NC, 27710, USA
| | - Keven S Y Ji
- Oregon Health & Science University, Department of Otolaryngology-Head & Neck Surgery, Portland, OR, 97239, USA
| | - Nathaniel H Greene
- Legacy Emanuel Medical Center and Randall Children's Hospital, Portland, OR, 972272, USA
| | - Rose J Eapen
- South Bay Pediatric Otolaryngology, Manhattan Beach, CA, 90266, USA
| | - Eileen M Raynor
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA.
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Sane S, Vash RA, Rahmani N, Talebi H, Golabi P, Kalashipour F, Heidari P, Hatami MF, Haki BK, Morwati S. Comparing the Effects of Pregabalin and Clonidine on Postoperative Pain in Tonsillectomy: A Randomized, Double-Blind, Prospective Clinical Trial. Rev Recent Clin Trials 2022; 17:RRCT-EPUB-126500. [PMID: 36154603 DOI: 10.2174/1574887117666220922092953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/21/2022] [Accepted: 08/16/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Tonsillectomy is one of the most common surgical procedures. This study compared the effect of Pregabalin and Clonidine on postoperative pain in adult patients undergoing elective tonsillectomy. METHODS This randomized, double-blind, prospective clinical trial was conducted among 92 patients aged 20 to 50. The clonidine group (C) was given 150 µg of clonidine tablet 90 minutes before surgery, and the pregabalin group (P) was given 300 mg of pregabalin tablet 90 minutes before surgery. The results were analyzed by SPSS 25, and statistical analysis consisted of chisquare, T-test, and χ2 tests, and a p-value less than 0.05 was considered significant. RESULTS The mean pain score and analgesic consumption scores in the pregabalin group were lower than in the clonidine group. According to the t-test, there was a significant difference between the two groups regarding pain score and analgesic consumption (p <0.05). Hemodynamic variation in both groups had no significant differences (p >0.05). CONCLUSION The present study showed that pregabalin reduced postoperative pain and analgesic consumption more effectively than clonidine.
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Affiliation(s)
- Shahryar Sane
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Science, Urmia, Iran
| | - Rahman Abbasi Vash
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Science, Urmia, Iran
| | - Nazila Rahmani
- College of Medical, Veterinary & Life Science, University of Glasgow, Glasgow, United Kingdom
| | - Hadi Talebi
- Department of Medicine, Isfahan University of medical sciences, Isfahan, Iran
| | - Parang Golabi
- Department of Anesthesiology, Omid Charity Hospital, Urmia University of Medical Science, Urmia, Iran
| | - Farid Kalashipour
- Department of Operating Room, Kurdistan University of Medical Sciences, Urmia, Iran
| | - Poneh Heidari
- Department of Medicine, Urmia University of Medical Science, Urmia, Iran
| | | | - Behzad Kazemi Haki
- Department of Anesthesiology, Urmia Imam Khomeini Hospital, Urmia University of Medical Science, Urmia, Iran
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Cordray H, Alfonso K, Brown C, Evans S, Goudy S, Govil N, Landry AM, Raol N, Smith K, Prickett KK. Sustaining standardized opioid prescribing practices after pediatric tonsillectomy. Int J Pediatr Otorhinolaryngol 2022; 159:111209. [PMID: 35749955 DOI: 10.1016/j.ijporl.2022.111209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/19/2022] [Accepted: 06/09/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes. METHODS A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure. RESULTS From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28). CONCLUSION An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.
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Affiliation(s)
- Holly Cordray
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kristan Alfonso
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Clarice Brown
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean Evans
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven Goudy
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Nandini Govil
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - April M Landry
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhila Raol
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen Smith
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Kara K Prickett
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
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Bérard-Giasson A, Brown KA, Agnihotram RV, Frigon C. Validation of the parent's postoperative pain measure with an age-appropriate reference pain scale for children 2-12 years old during a 14-day recovery after tonsillectomy: A prospective cohort study. Paediatr Anaesth 2022; 32:654-664. [PMID: 35120271 DOI: 10.1111/pan.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adenotonsillectomy is associated with severe postoperative pain. The parent's postoperative pain measure (PPPM), a 15-item instrument to measure a child's pain at home, has been validated with a seven-point faces scale in children 7-12 years and with the parents' global report of pain in children 2-6 years. AIMS Our primary objective was to validate the PPPM with a recommended age-appropriate pain scale in children 2-12 years after adenotonsillectomy. Our secondary objective was to reduce the PPPM components and validate this reduced PPPM. METHODS We recruited 319 children out of the 563 adenotonsillectomies performed between December 19, 2017, and December 18, 2018. Parents recorded administration of analgesics and their child's pain scores twice daily for 14 days: PPPM for all children and either the face, legs, arms, crying, consolability (FLACC) pain scale for children 2-3 years or the faces pain scale-revised (FPS-R) for children 4-12 years. In addition, parents recorded analgesics. RESULTS Among the 354 eligible children, 9% of parents declined. 252 (79%) families submitted pain diaries. The median age was 2.9 [2.5-3.3] years for FLACC (n = 114) and 5.6 [4.5-7.2] years for FPS-R (n = 138). Across the 14-day recovery period, Cronbach's alpha for PPPM was 0.77 to 0.87. Generalized linear mixed models evaluated the association between PPPM and reference pain scales after adjustment for potential confounders. Time of day and postoperative days were included as predictors in the models. PPPM was strongly associated with FLACC and FPS-R (beta coefficient = 0.4; p < 0.0001). The association decreased over time, and the reduction was more significant for FPS-R than FLACC (beta coefficient = -0.13 vs. -0.04, respectively; p < 0.0001). There was a positive association between PPPM and the use of analgesics. A reduction analysis eliminated items from the original PPPM: four for FLACC and five for FPS-R, suggesting age-related differences. The reduced PPPM instruments achieved similar associations with their respective reference pain scales (beta coefficient = 0.5; p < 0.0001). CONCLUSIONS This study extends previous work by validating the PPPM in children as young as 2 years with a recommended age-appropriate pain scale over 14-day convalescence after adenotonsillectomy. The reduced PPPM instruments differed in the two age groups. Future studies might explore these age-appropriate reduced PPPM instruments to assess pain at home following adenotonsillectomy.
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Affiliation(s)
- Annick Bérard-Giasson
- Department of Anesthesiology, McGill University Health Center, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Karen Ann Brown
- Department of Anesthesiology, McGill University Health Center, Montreal Children's Hospital, Montreal, Quebec, Canada
| | | | - Chantal Frigon
- Department of Anesthesiology, McGill University Health Center, Montreal Children's Hospital, Montreal, Quebec, Canada
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10
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The effect of telephone counseling and internet-based support on pain and recovery after tonsil surgery in children – a systematic review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2021.100027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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11
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Lagrange C, Jepp C, Slevin L, Drake-Brockman TFE, Bumbak P, Herbert H, von Ungern-Sternberg BS, Sommerfield D. Impact of a revised postoperative care plan on pain and recovery trajectory following pediatric tonsillectomy. Paediatr Anaesth 2021; 31:778-786. [PMID: 33788340 DOI: 10.1111/pan.14187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/03/2021] [Accepted: 03/22/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND A previous cohort of adenotonsillectomy patients at our institution demonstrated moderate-severe post-tonsillectomy pain scores lasting a median (range) duration of 6 (0-23) days and postdischarge nausea and vomiting affecting 8% of children on day 1 following surgery. In this subsequent cohort, we evaluate the impact of changes to our discharge medication and parental education on post-tonsillectomy pain and recovery profile. METHODS In this follow-on, prospective observational cohort study, all patients undergoing tonsillectomy at our institution during the study period were discharged with standardized analgesia. Parents received a revised education package and a medication diary which were not provided to the previous cohort. Pain scores, rates of nausea and vomiting, medication usage and unplanned representation rates were collected by telephone from parents. RESULTS Sixty-nine patients were recruited. Moderate-severe pain lasted a median (range) of 5 (0-12) days. Twenty-nine (42%) had pain scores ≥4/10 beyond postoperative day 7. By postoperative day 5, only 37 (53%) parents continued to administer regular analgesia. The median number of oxycodone doses used was 5 (0-22), and only 28 (41%) parents had disposed of leftover oxycodone within 1 month of surgery. Twenty-four (35%) patients experienced nausea or vomiting postdischarge. The median (range) time for return to normal activities was 6 (0-14) days. Thirty-two/sixty-nine (46%) patients had unplanned medical representations. Most occurred between postoperative day 5 and 7. Pain contributed to 16 (35%) representations. CONCLUSIONS Despite extensive changes to our discharge protocols parents continued to report a prolonged period of pain, post operative nausea and vomiting, and behavioral changes. Further work is required to examine barriers to compliance with simple analgesia and education in appropriate methods of opioid disposal.
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Affiliation(s)
- Claudia Lagrange
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia
| | - Catherine Jepp
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia
| | - Lliana Slevin
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia
| | - Thomas F E Drake-Brockman
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | - Paul Bumbak
- Department of Otolaryngology-Head and Neck Surgery, Perth Children's Hospital, Perth, WA, Australia
| | - Haley Herbert
- Department of Otolaryngology-Head and Neck Surgery, Perth Children's Hospital, Perth, WA, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
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12
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Mchugh T, Brown KA, Daniel SJ, Balram S, Frigon C. Parental Engagement of a Prototype Electronic Diary in an Ambulatory Setting Following Adenotonsillectomy in Children: A Prospective Cohort Study. CHILDREN-BASEL 2021; 8:children8070559. [PMID: 34209559 PMCID: PMC8303765 DOI: 10.3390/children8070559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/09/2021] [Accepted: 06/26/2021] [Indexed: 11/19/2022]
Abstract
Adenotonsillectomy is performed in children on an outpatient basis, and pain is managed by parents. A pain diary would facilitate pain management in the ambulatory setting. Our objective was to evaluate the parental response rate and the compliance of a prototype electronic pain diary (e-diary) with cloud storage in children aged 2–12 years recovering from adenotonsillectomy and to compare the e-diary with a paper diary (p-diary). Parents recorded pain scores twice daily in a pain diary for 2 weeks post-operation. Parents were given the choice of an e-diary or p-diary with picture message. A total of 208 patients were recruited, of which 35 parents (16.8%) chose the e-diary. Most parents (98%) chose to be contacted by text message. Eighty-one families (47%) returned p-diaries to us by mail. However, the response rate increased to 77% and was similar to that of the e-diary (80%) when we included data texted to the research phone from 53 families. The proportion of diaries with Complete (e-diary:0.37 vs. p-diary:0.4) and Incomplete (e-diary:0.43 vs. p-diary:0.38) data entries were similar. E-diaries provide a means to follow patients in real time after discharge. Our findings suggest that a smartphone-based medical health application coupled with a cloud would meet the needs of families and health care providers alike.
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Affiliation(s)
- Tobial Mchugh
- Department of Otorhinolaryngology, McGill University Health Center, Montreal Children’s Hospital, Montréal, QC H4H 3J1, Canada; (T.M.); (S.J.D.)
| | - Karen A. Brown
- Department of Anesthesiology, McGill University Health Center, Montreal Children’s Hospital, Montréal, QC H4H 3J1, Canada; (K.A.B.); (S.B.)
| | - Sam J. Daniel
- Department of Otorhinolaryngology, McGill University Health Center, Montreal Children’s Hospital, Montréal, QC H4H 3J1, Canada; (T.M.); (S.J.D.)
| | - Sharmila Balram
- Department of Anesthesiology, McGill University Health Center, Montreal Children’s Hospital, Montréal, QC H4H 3J1, Canada; (K.A.B.); (S.B.)
| | - Chantal Frigon
- Department of Anesthesiology, McGill University Health Center, Montreal Children’s Hospital, Montréal, QC H4H 3J1, Canada; (K.A.B.); (S.B.)
- Correspondence:
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13
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Alm F, Lööf G, Blomberg K, Ericsson E. Establishment of resilience in a challenging recovery at home after pediatric tonsil surgery-Children's and caregivers' perspectives. PAEDIATRIC & NEONATAL PAIN 2021; 3:75-86. [PMID: 35547595 PMCID: PMC8975210 DOI: 10.1002/pne2.12051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/13/2021] [Accepted: 04/25/2021] [Indexed: 12/29/2022]
Abstract
The objective of this study was to explore children's and caregivers’ experiences and management of postoperative recovery at home after tonsil surgery. The study had an explorative qualitative design with an inductive approach. Twenty children (5‐12 years of age) undergoing tonsillectomy or tonsillotomy with or without adenoidectomy participated along with their caregivers in semi‐structured interviews at a mean time of 28 days after surgery. The interviews were analyzed with content analysis. One main category emerged from the interviews: children and caregivers struggle to establish resilience in a challenging recovery. The families’ resilience relied on their situational awareness and capacity to act, which in turn formed a basis for the ability to return to normal daily life. Children and caregivers described the recovery as an evident interruption of daily life which had an impact on the children's physical and psychological well‐being. Both children and caregivers described the pain as a central concern. The families used different pharmacological and complementary strategies to manage the pain, which in some cases were complex. Some families said that the analgesics were insufficient in preventing breakthrough pain, and spoke about a lack of support as well as inadequate and contradictory information from healthcare staff. Caregivers also expressed uncertainty, ambivalence, or anxiety about the responsibility associated with their child's recovery. To optimize and support the recovery after tonsil surgery, it is crucial to obtain knowledge of children's and caregivers’ perspectives of postoperative recovery at home. The results indicate that the postoperative period included several troublesome experiences for which neither the children nor the caregivers were informed or prepared. The experience of pain was significant, and often complex to manage. To increase families’ resilience, the information provided by healthcare professionals needs to be broadened. Multidisciplinary teamwork is necessary to achieve this goal.
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Affiliation(s)
- Fredrik Alm
- Department of Anaesthesia and Intensive Care School of Health Sciences Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Gunilla Lööf
- Department of Paediatric Anaesthesia and Intensive Care Astrid Lindgren Children's Hospital Karolinska University Hospital Stockholm Sweden
| | - Karin Blomberg
- School of Health Sciences Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Elisabeth Ericsson
- School of Health Sciences Faculty of Medicine and Health Örebro University Örebro Sweden
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14
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Adler AC, Chandrakantan A, Dang TV, Lee AD, Austin PF. Parental Assessment of Pain Control Following Pediatric Circumcision: Do Opioids Make a Difference? Urology 2021; 154:263-267. [PMID: 33412222 DOI: 10.1016/j.urology.2020.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine whether a postoperative prescription for opioids affects parental assessment of pain control following pediatric circumcision. METHODS This postoperative survey assessed the parental assessment of pain control in 199 patients, ages<18 years undergoing circumcision. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 2018 to January 2020. Postoperative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for postoperative analgesia based on the surgical preference. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric circumcision as poor or inadequate based on the postoperative analgesic regimen. RESULTS Of the 502 surveys sent, the response rate was 40% (199/502) of those who received the survey email, and 64% (199/308) for those who opened the email. Between the opioid and nonopioid groups, there was no difference in, race/ethnicity (Caucasian; 28% vs 37%; P = .43) or insurance status (insured; 51% vs 45%; P = .44). The proportion of parents who rated their child's pain as poor or inadequately controlled following circumcision was relatively rare:5.5% and 1.1% in the nonopioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following circumcision were 61% and 53% in the nonopioids and opioid groups, respectively. CONCLUSION The results of this study indicate that nonopioid analgesic regimens following pediatric circumcision were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric circumcision is feasible and does not result in worse parental satisfaction with the analgesic plan.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children's Hospital; Baylor College of Medicine, Houston, TX.
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children's Hospital; Baylor College of Medicine, Houston, TX
| | | | - Andrew D Lee
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children's Hospital
| | - Paul F Austin
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital; Baylor College of Medicine, Houston, TX
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15
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Moreno-Galvan A, Marron JM, Marsiglio AM. How should we approach parental refusals of opioids on behalf of children in the perioperative setting? A practical approach based on ethical theory. Paediatr Anaesth 2020; 30:852-858. [PMID: 32485043 DOI: 10.1111/pan.13941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 01/18/2023]
Abstract
In the midst of the current opioid epidemic, we have encountered more parents who are concerned about the use of opioids in the perioperative setting. Some parents have completely refused the use of opioids on behalf of their children. How should we approach this treatment refusal? This article describes ethical theory related to the refusal of treatment by parents on behalf of their children, and when it is justified to override parental decisions. We propose a decision-making framework that focuses on improving communication and considering alternatives. Assessment of harm to the child from avoiding opioids, as well as potential harms from overriding parental autonomy must be undertaken prior to considering overriding parents.
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Affiliation(s)
- Anna Moreno-Galvan
- Rady Children's Hospital, San Diego, California, USA.,Part of this work was completed while employed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jonathan Michael Marron
- Dana Farber Cancer Institute, Boston, Massachusetts, USA.,Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Maree Marsiglio
- Part of this work was completed while employed at Boston Children's Hospital, Boston, Massachusetts, USA.,UCSF Benioff Children's Hospital, San Francisco, California, USA
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16
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Dezfouli SMM, Khosravi S. Pain in child patients: A review on managements. Eur J Transl Myol 2020; 30:8712. [PMID: 32782752 PMCID: PMC7385698 DOI: 10.4081/ejtm.2019.8712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/15/2019] [Indexed: 12/14/2022] Open
Abstract
Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.
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Affiliation(s)
| | - Shaqayeq Khosravi
- (1) Department of Emergency Medicine, School of Medicine, Iran University of Medical Sciences, Aliasghar children Hospital, Tehran, Iran
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17
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Adler AC, Mehta DK, Messner AH, Salemi JL, Chandrakantan A. Parental assessment of pain control following pediatric adenotonsillectomy: Do opioids make a difference? Int J Pediatr Otorhinolaryngol 2020; 134:110045. [PMID: 32304855 DOI: 10.1016/j.ijporl.2020.110045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 03/16/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Postoperative prescribing of opioids following pediatric adenotonsillectomy can have negative consequences including unnecessary opioid exposure and potential for respiratory depression. While guidelines from The American Academy of Otolaryngology/Head & Neck Surgery recommend treatment of post adenotonsillectomy pain using acetaminophen and ibuprofen, many providers continue to prescribe opioids and may do so, in part with concern for parental dissatisfaction with post-operative analgesia. Our aim was to determine whether a post-operative prescription for opioids affects parental assessment of pain control following pediatric adenotonsillectomy. METHODS This post-operative survey assessed the parental assessment of pain control in 324 patients, ages 1-17 years undergoing adenotonsillectomy. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 1, 2018 through March 31, 2019. Post-operative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for post-operative analgesia based on the attending surgeons prescribing preferences. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric adenotonsillectomy as poor or inadequate based on the post-operative analgesic regimen including opioids. RESULTS Of the 798 surveys sent, the response rate was 42% (324/775) of those who received the survey email, and 69% (324/470) for those who opened the email. Between the opioid and non-opioid groups, there was no difference in gender (male; 48% vs. 51.3%; p = 0.58), race/ethnicity (white; 53% vs. 46%; p = 0.35) or insurance status (insured; 62% vs. 50.9%; p = 0.06). The proportion of parents who rated their child's pain as poor or inadequately controlled following adenotonsillectomy was relatively rare: 9% and 5% in the non-opioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following adenotonsillectomy were 58% and 50% in the non-opioids and opioid groups respectively. CONCLUSION The results of this study indicate that non-opioid analgesic regimens following pediatric adenotonsillectomy were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric adenotonsillectomy is feasible and does not result in worse parental satisfaction with the analgesic plan.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, USA; Baylor College of Medicine, USA.
| | - Deepak K Mehta
- Department of Otolaryngology; Baylor College of Medicine, USA; Department of Pediatric Otolaryngology; Texas Children's Hospital, USA; Baylor College of Medicine, USA
| | - Anna H Messner
- Department of Otolaryngology; Baylor College of Medicine, USA; Department of Pediatric Otolaryngology; Texas Children's Hospital, USA; Baylor College of Medicine, USA
| | - Jason L Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA; College of Public Health, University of South Florida, Tampa, FL, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, USA; Baylor College of Medicine, USA
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18
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Abstract
Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.
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19
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Chua KP, Harbaugh CM, Brummett CM, Bohm LA, Cooper KA, Thatcher AL, Brenner MJ. Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children. JAMA Otolaryngol Head Neck Surg 2019; 145:911-918. [PMID: 31393537 DOI: 10.1001/jamaoto.2019.2107] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Practice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced. Objective To assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids. Design, Setting, and Participants This cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children. Main Outcomes and Measures The percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids. Results Among 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications. Conclusions and Relevance These findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
| | - Calista M Harbaugh
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor.,Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Lauren A Bohm
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Karen A Cooper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Aaron L Thatcher
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
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O'Brien DC, Desai Y, Schubart J, Swanson RT, Chung S, Parekh U, Carr MM. Effect of intra-op morphine on children with OSA undergoing tonsillectomy. Int J Pediatr Otorhinolaryngol 2019; 125:141-146. [PMID: 31306896 DOI: 10.1016/j.ijporl.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 07/07/2019] [Accepted: 07/07/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES 1. To compare outcomes after tonsillectomy for pediatric patients with obstructive sleep apnea (OSA) given morphine intra-operatively and post operatively compared to those who were not - specifically Recovery Room (RR) time, length of stay (LOS), Emergency Department (ER) visits. STUDY DESIGN Retrospective case series with chart review. SETTING Tertiary care children's hospital. SUBJECTS AND METHODS All children between 1 and 17 years old who had undergone tonsillectomy in a single institution from 2013 to 2016. Comparison between children who had received morphine intra-operatively was made for outcomes. RESULTS 556 patients were included, 73 patients had morphine intraoperatively and 483 did not; these latter children were older (8.8 vs 6.5 years, P < 0.001), and had fewer episodes of obstructive apnea and hypopnea (AHI 4.47 vs 10.15, p = 0.003) than children who did not receive intra-op morphine. There were no differences in co-morbidities including asthma, whether they had a sleep study, time in the operating room, emergence time, RR time, airway complications, IMC/PICU admission for respiratory distress, ER visits, readmissions, bleeding or post-discharge nurse phone calls. There was a longer LOS (25.9 vs 21.4 h, P = 0.011) for the group receiving intra-op morphine. CONCLUSION Children with OSA who receive intra-op morphine have a longer LOS suggesting that its use should be examined more closely in this population.
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Affiliation(s)
- Daniel C O'Brien
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Yuti Desai
- Drexel University, Philadelphia, PA, USA
| | - Jane Schubart
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Robert T Swanson
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Scott Chung
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Uma Parekh
- Department of Anesthesiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Michele M Carr
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, USA.
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22
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Reducing Readmissions Post-tonsillectomy: A Quality Improvement Study on Intravenous Hydration. J Healthc Qual 2019; 40:217-227. [PMID: 29864070 DOI: 10.1097/jhq.0000000000000143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Dehydration is a potentially preventable complication post-tonsillectomy and can result in an Emergency Department visit and/or readmission. Our objectives were to identify risk factors for dehydration readmissions and develop interventions to prevent them. METHODS We used retrospective chart reviews to determine if increased intravenous (IV) hydration post-tonsillectomy prevented hospital readmissions for dehydration. All children aged 1-18 years who underwent tonsillectomy between July 1, 2007 and September 30, 2015 were included in this quality improvement study. Using the Pediatric Health Information System database, patients who experienced a readmission for dehydration within 72 hours of surgery were identified and validated with internal data. We analyzed the pre-implementation and post-implementation readmission rates after standardization of increased IV fluids (1.5 times maintenance). An interrupted time series analysis was used to estimate the effects of our hydration initiative. RESULTS Of 11,157 patients who underwent tonsillectomy during the study period, 96 (0.9%) met the criteria for readmissions for dehydration. The pre-implementation readmission rate was 1% compared to 0.2% post-implementation, a reduction of 82%. CONCLUSIONS The hydration initiative was associated with a significant decrease in hospital readmissions. This safe, low-cost, easy-to-implement approach to preventing dehydration post-tonsillectomy could be explored at other institutions.
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Martin SD, John LD. Framework to Explain the Progression of Pain in Obese or Overweight Children Undergoing Tonsillectomy. J Perianesth Nurs 2019; 34:1106-1119. [PMID: 31307907 DOI: 10.1016/j.jopan.2019.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/27/2019] [Accepted: 03/31/2019] [Indexed: 12/16/2022]
Abstract
An estimated 100,000 obese (OB) and overweight (OW) children undergo tonsillectomy each year in the United States. Pain management in this population is particularly challenging because of weight-based dosing, clinician fears, potential for airway obstruction, and genetic differences. A framework is proposed to explain factors involved in the post-tonsillectomy pain (PTP) experience in OB and OW children. The tonsillectomy, the body's inflammatory state, and mechanical stressors comprise influencing factors in PTP progression. Clinician-delivered medication doses, genetic variants of drug metabolism, and soothing factors serve as mediating factors in the progression of PTP. Postanesthesia care unit (PACU) nurses may use this framework to better understand PTP progression in OB and OW children. PACU nurses may manipulate certain mediating factors discussed in this framework to moderate PTP progression in OB and OW children. Researchers may use this framework to support future research to improve PTP management in OB and OW children.
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24
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Carr MM, Schaefer EW, Schubart JR. Post-Tonsillectomy Outcomes in Children With and Without Narcotics Prescriptions. EAR, NOSE & THROAT JOURNAL 2019; 100:124-129. [PMID: 31304781 DOI: 10.1177/0145561319859303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine differences in outcomes after tonsillectomy in children who received outpatient narcotics prescriptions compared to those who did not. METHODS The MarketScan database was analyzed for claims made for 14 days following tonsillectomy/adenotonsillectomy between 2008 and 2012 for privately insured children 1 to 17 years. Post-op bleeding, dehydration, emergency department (ED) visits, readmissions, and mean total costs for the 14 days after tonsillectomy were compared. RESULTS Of the 294 795 patients included, 60.9% received a narcotic prescription. Acetaminophen/hydrocodone bitartrate was received by 53.2% of the group receiving narcotic drugs, 42.5% received acetaminophen/codeine phosphate, 3.0% received acetaminophen/oxycodone hydrochloride, and 0.5% received oxycodone hydrochloride alone. Children who had been prescribed narcotics had significantly higher percentages of bleeding complications (2.7% vs 2.5%, P < .001), and ED visits (6.8% vs 6.6%, P < .001) within 14 days, but a lower percentage of readmissions (1.0% vs 1.5%, P < .001). No significant difference was observed between groups for dehydration. There were some age-related differences. The mean total health-care costs for 14 days post-op were the same in each group, except for the 4- to 6-year-olds, where the narcotic group had higher costs (US $7060 vs US $5840, P = .006). CONCLUSION In this large-scale study, we found small but statistically significant differences in outcomes related to use of narcotics. The only outcome that benefitted the narcotics group was a lower readmission rate.
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Affiliation(s)
- Michele M Carr
- Department of Otolaryngology, 53422West Virginia University, Morgantown, WV, USA
| | - Eric W Schaefer
- Department of Surgery, 8082The Pennsylvania State University, Hershey, PA, USA
| | - Jane R Schubart
- Department of Surgery, 8082The Pennsylvania State University, Hershey, PA, USA.,Department of Public Health Sciences, 8082The Pennsylvania State University, Hershey, PA, USA
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Verschueren S, van Aalst J, Bangels AM, Toelen J, Allegaert K, Buffel C, Vander Stichele G. Development of CliniPup, a Serious Game Aimed at Reducing Perioperative Anxiety and Pain in Children: Mixed Methods Study. JMIR Serious Games 2019; 7:e12429. [PMID: 31199333 PMCID: PMC6592492 DOI: 10.2196/12429] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/20/2019] [Accepted: 04/05/2019] [Indexed: 12/15/2022] Open
Abstract
Background An increasing number of children undergo ambulatory surgery each year, and a significant proportion experience substantial preoperative anxiety and postoperative pain. The management of perioperative anxiety and pain remains challenging in children and is inadequate, which negatively impacts the physical, psychosocial, and economic outcomes. Existing nonpharmacological interventions are costly, time consuming, vary in availability, and lack benefits. Therefore, there is a need for an evidence-based, accessible, nonpharmacological intervention as an adjunct to existing pharmacological alternatives to reduce perioperative anxiety and pain in children undergoing ambulatory surgery. Technology-enabled interventions have been proposed as a method to address the unmet need in this setting. In particular, serious games hold a unique potential to change health beliefs and behaviors in children. Objective The objective of this research was to describe the rationale, scientific evidence, design aspects, and features of CliniPup, a serious game aimed at reducing perioperative anxiety and pain in children undergoing ambulatory surgery. Methods The SERES Framework for serious game development was used to create the serious game, CliniPup. In particular, we used a mixed methods approach that consisted of a structured literature review supplemented with ethnographic research, such as expert interviews and a time-motion exercise. The resulting scientific evidence base was leveraged to ensure that the resulting serious game was relevant, realistic, and theory driven. A participatory design approach was applied, wherein clinical experts qualitatively reviewed several versions of the serious game, and an iterative creative process was used to integrate the applicable feedback. Results CliniPup, a serious game, was developed to incorporate a scientific evidence base from a structured literature review, realistic content collected during ethnographic research such as expert interviews, explicit pedagogical objectives from scientific literature, and game mechanics and user interface design that address key aspects of the evidence. Conclusions This report details the systematic development of CliniPup, a serious game aimed at reducing perioperative anxiety and pain in children undergoing ambulatory surgery. Clinical experts validated CliniPup’s underlying scientific evidence base and design foundations, suggesting that it was well designed for preliminary evaluation in the target population. An evaluation plan is proposed and briefly described.
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Affiliation(s)
| | - June van Aalst
- Division of Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | | | - Jaan Toelen
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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26
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Buffel C, van Aalst J, Bangels AM, Toelen J, Allegaert K, Verschueren S, Vander Stichele G. A Web-Based Serious Game for Health to Reduce Perioperative Anxiety and Pain in Children (CliniPup): Pilot Randomized Controlled Trial. JMIR Serious Games 2019; 7:e12431. [PMID: 31199324 PMCID: PMC6592396 DOI: 10.2196/12431] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/29/2019] [Accepted: 04/15/2019] [Indexed: 12/21/2022] Open
Abstract
Background As pediatric ambulatory surgeries are rising and existing methods to reduce perioperative anxiety and pain are lacking in this population, a serious game for health (SGH), CliniPup, was developed to address this unmet need. CliniPup was generated using the SERES framework for serious game development. Objective The goal of the research was to clinically evaluate CliniPup as an adjunct therapy to existing pharmacological interventions aimed at reducing perioperative anxiety and pain in children undergoing ambulatory surgery. Methods CliniPup was evaluated in a prospective randomized controlled pilot trial in 20 children aged 6 to 10 years who underwent elective surgery and their parents. Study participants were randomly assigned to the test (n=12) or control group (n=8). Children in the test group played CliniPup 2 days prior to surgery, and children in the control group received standard of care. On the day of surgery, pediatric anxiety was measured with the modified Yale Preoperative Anxiety Scale and parental anxiety was assessed with the State-Trait Anxiety Inventory. Pediatric postoperative pain was assessed by the Wong-Baker Faces Pain Rating Scale. Child and parent user experience and satisfaction were also evaluated in the test group using structured questionnaires. Results Despite the small sample, preoperative anxiety scores were significantly lower (P=.01) in children who played CliniPup prior to surgery compared to controls. Parental preoperative anxiety scores were also lower in the test group (P=.10) but did not reach significance. No significant differences were observed in postoperative pain scores between groups (P=.54). The evaluation of user experience and satisfaction revealed that both children and parents were satisfied with CliniPup and would recommend the game to peers. Conclusions Results of the pilot trial introduce CliniPup as a potentially effective and attractive adjunct therapy to reduce preoperative anxiety in children undergoing ambulatory surgery with a trend toward positive impact on parental preoperative anxiety. These results support the use of the SERES framework to generate an evidence-based SGH that results in positive health outcomes for patients. Based on these preliminary findings, we propose a research agenda to further develop and investigate this tool. Trial Registration ClinicalTrials.gov NCT03874442; https://clinicaltrials.gov/ct2/show/NCT03874442 (Archived by WebCite at http://www.webcitation.org/78KZab8qc)
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Affiliation(s)
| | - June van Aalst
- Division of Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | | | - Jaan Toelen
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
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27
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Mogane PM, Mashinini M, Lundgren C. Audit of perioperative pain management in paediatric patients following tonsillectomy at a tertiary hospital in Johannesburg. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2019. [DOI: 10.36303/sajaa.2019.25.2.2196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: Adenotonsillectomy remains one of the most frequently performed surgical procedures in children. Despite improvements in anaesthetic and surgical techniques, severe pain is reported in as many as 25–50% of children. Pain assessment and knowledge of drug pharmacodynamics and pharmacokinetics in the paediatric patient, is a prerequisite for optimal care. Much has been written on perioperative pain management following tonsillectomy. However, no consensus has been reached on what the ideal analgesic regimen should be. This audit is a review of current practice at Chris Hani Baragwanath Academic Hospital. It aims to identify problems and develop possible solutions to improve anaesthetic practice.
Methods: A prospective, contextual, descriptive study design using a data collection sheet was used on paediatric patients presenting for tonsillectomy.
Results: Eighty-five patients aged three to 12 years of age, with ASA grading I or II, were enrolled in the study. The choice of anaesthetic was variable with a combination of simple analgesics, opioids and adjuvants. This affected postoperative pain scores. Snare dissection and monopolar cautery haemostasis, was the standard surgical technique. Surgical seniority influenced the duration of tonsillectomy, with an effect on postoperative pain scores.
Conclusions: Audits are necessary to evaluate what resources are needed to optimise care. The occurrence of pain after tonsillectomy continues to be poorly managed. Appropriate premedication and fasting of clear fluids for no more than two hours, needs to be introduced. Where possible surgical technique should involve bipolar cautery and be limited to less than 45 minutes. A preemptive, multimodal, opioid-sparing anaesthetic should be routinely practised.
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28
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Bupivacaine infiltration in children for postoperative analgesia after tonsillectomy. Eur J Anaesthesiol 2019; 36:206-214. [DOI: 10.1097/eja.0000000000000950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Xin Y, Li X, Du J, Cheng J, Yi C, Mao H. Efficacy of Telephone Follow-Up in Children Tonsillectomy with Day Surgery. Indian J Pediatr 2019; 86:263-266. [PMID: 30547424 DOI: 10.1007/s12098-018-2813-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/18/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Day surgery for tonsillectomy has become more and more popular in China. However, many parents face difficulties to cope up with the pain and side effects after surgery. The present study was aimed to examine the efficacy of telephone follow-up on children's post-discharge recovery after tonsillectomy. METHODS In this prospective study, the sample consisted of 863 children randomly assigned to receive clinic visit after discharge or 1 to 14 d' telephone follow-up after discharge. During the follow-up, the research nurse or parents assessed each child's status, identified problems, and provided needed follow-up care. Key outcomes were pain intensity, postoperative complication, and unanticipated contact with the health care system. RESULTS Compared with clinical visit, children in telephone follow-up group presented with less pain in early stage after surgery and better food and drink intake. The prevalence of hemorrhage, nausea, vomiting, fever and dizziness had no difference between the groups. Telephone follow-up also reduced unanticipated healthcare services. CONCLUSIONS The present study suggested that a follow-up telephone call is a safe and cost-effective method of postoperative management for pediatric patients who have undergone tonsillectomy.
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Affiliation(s)
- Yan Xin
- Department of ENT, Affiliated Renhe Hospital of China, Three Gorges University, Second Clinical Medical College of China, No. 410 Yiling Road, Yi Chang, Hubei, China
| | - Xin Li
- Department of ENT, Affiliated Renhe Hospital of China, Three Gorges University, Second Clinical Medical College of China, No. 410 Yiling Road, Yi Chang, Hubei, China.
| | - JinDong Du
- Department of ENT, Affiliated Renhe Hospital of China, Three Gorges University, Second Clinical Medical College of China, No. 410 Yiling Road, Yi Chang, Hubei, China
| | - Jie Cheng
- Department of ENT, Affiliated Renhe Hospital of China, Three Gorges University, Second Clinical Medical College of China, No. 410 Yiling Road, Yi Chang, Hubei, China
| | - ChunYan Yi
- Department of ENT, Affiliated Renhe Hospital of China, Three Gorges University, Second Clinical Medical College of China, No. 410 Yiling Road, Yi Chang, Hubei, China
| | - HuaDong Mao
- Department of ENT, Affiliated Renhe Hospital of China, Three Gorges University, Second Clinical Medical College of China, No. 410 Yiling Road, Yi Chang, Hubei, China
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Ridgway R, Dumbarton T, Brown Z. Update on ENT anaesthesia in children. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2019. [DOI: 10.1016/j.mpaic.2018.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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31
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The Use of Codeine and Tramadol in the Pediatric Population-What is the Verdict Now? J Pediatr Health Care 2019; 33:117-123. [PMID: 30545525 DOI: 10.1016/j.pedhc.2018.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/23/2018] [Indexed: 12/21/2022]
Abstract
Codeine and tramadol are opioid analgesics approved for the management of pain in the United States. Both agents are metabolized in the liver to active compounds via the cytochrome P450 2D6 enzyme. Case reports of pediatric patients with overactive CYP2D6 enzymes have been reported. These ultra-rapid metabolizers experience an increase in the production of active metabolites of codeine and tramadol, which can lead to oversedation, respiratory depression, and death. In 2017, the U.S. Food and Drug Administration updated their warnings regarding codeine and tramadol use in the pediatric population, making their use contraindicated in patients under the age of 12 years.
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The impact of platelet-rich plasma therapy on short-term postoperative outcomes of pediatric tonsillectomy patients. Eur Arch Otorhinolaryngol 2018; 276:489-495. [PMID: 30460402 DOI: 10.1007/s00405-018-5211-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/14/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION To compare the short-term outcomes of pediatric patients who underwent tonsillectomy alone vs. tonsillectomy plus platelet-rich plasma (PRP) therapy in terms of postoperative pain, appetite status, analgesia requirement, and bleeding complications. MATERIALS AND METHODS This study included a total of 80 pediatric tonsillectomy patients (53.8% female, 46.2% male, aged 4-16 years), who were randomly allocated into tonsillectomy alone (TA group; n = 40) and tonsillectomy plus PRP therapy (TPRP group, n = 40) groups. Patient demographic data (age, gender) and postoperative data of visual analog scale (VAS) pain scores (postoperative 2nd hour, 1-10 days), appetite scores (postoperative 1-7 days), and analgesia requirement (postoperative 1-10 days) and bleeding complications were recorded. RESULTS A significant gradual decrease was noted in pain scores starting from the 3rd postoperative day reaching 0.0 ± 0.0 and 0.50 ± 0.88 on Day 10 in the TPRP and TA groups, respectively (p < 0.001 for each). Compared to the TA group, the TPRP group was associated with significantly lower pain scores (Day 1 to Day 10), better appetite scores (Day 1 to Day 6), a lower requirement for analgesia (Day1 to Day 10) and fewer common bleeding complications (1 vs. 4 patients) in the postoperative period (p < 0.001 for each). CONCLUSION In conclusion, this study of pediatric tonsillectomy patients revealed the superiority of tonsillectomy with PRP over tonsillectomy alone in terms of effectiveness in reducing post-tonsillectomy pain and improving appetite status, together with a lower requirement for analgesia and a reduced risk of post-tonsillectomy bleeding during the first 10 postoperative days.
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Effect of changing postoperative pain management on bleeding rates in tonsillectomy patients. Am J Otolaryngol 2018; 39:445-447. [PMID: 29655490 DOI: 10.1016/j.amjoto.2018.03.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 03/22/2018] [Accepted: 03/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To review rates of post-tonsillectomy hemorrhage (PTH) at a quaternary medical center, including the impact of narcotic versus nonsteroidal anti-inflammatory drug (NSAID) postoperative pain management. MATERIALS AND METHODS A retrospective review was performed of tonsillectomies conducted at a single institution between 1/1/2013 and 1/1/2017. The rates of PTH and subsequent intervention were calculated. These were categorized into patients having surgery pre- and post-July 1, 2015, the former group receiving narcotics and the latter ibuprofen with acetaminophen. RESULTS Of 1351 total tonsillectomies, 3.04% had PTH requiring return to the hospital. 0.74% required no further surgical intervention, whereas 2.30% required secondary surgical control. The bleed rate prior to July 2015 was 3.15%, with 1.05% non-surgical bleeds and 2.10% requiring surgery. Post-July 2015, the bleed rate was 2.92%, with 0.44% non-surgical bleeds and 2.49% requiring surgery. There were no statistically significant differences between the two groups with respect to overall, non-surgical, and surgical hemorrhage rates (p > 0.05). Of the total bleeds, the need for secondary surgery in the narcotic group was 66.7% and 85% in the NSAID group (p = 0.18). During the study period, 36 patients with PTH had their initial tonsillectomy performed at outside institutions; 53% required surgical intervention. CONCLUSIONS Secondary hemorrhage remains a significant cause of morbidity in post-tonsillectomy patients, often requiring surgical intervention. This review found no increased bleeding risk associated with use of ibuprofen and acetaminophen as opposed to narcotic pain relief. LEVEL OF EVIDENCE III.
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Keefe KR, Byrne KJ, Levi JR. Treating pediatric post-tonsillectomy pain and nausea with complementary and alternative medicine. Laryngoscope 2018; 128:2625-2634. [PMID: 29729030 DOI: 10.1002/lary.27231] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/15/2018] [Accepted: 03/21/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Although tonsillectomy is a common and largely safe procedure, pain management in children remains a controversial topic. In addition to the challenge of choosing appropriate analgesia, there is often low parent and child adherence. This article presents a review, and evaluates the potential role, of a range of complementary and alternative therapies that may be sought out by parents. METHODS A literature review of complementary and alternative interventions performed using PubMed, Cochrane Library, and EMBASE, supplemented by searches from Google and hand searches of cross-references of selected articles, yielded 32 studies for qualitative analysis. RESULTS The studies included for analysis investigated a wide variety of alternative treatment modalities: acupuncture and related therapies, aromatherapy, homeopathy, honey, intravenous fluid, speech therapy, hyaluronic acid, behavioral therapies, ice/cold, hydrogen peroxide rinse, and chewing gum. CONCLUSION At this time, stronger conclusions cannot be made about the therapies investigated because there are many methodology limitations of the studies analyzed. However, our results suggest merit for these treatments as adjuvant therapies that can enhance analgesia and decrease requirements of controversial medications. Honey and acupuncture have the greatest amount of evidence for postoperative pain and nausea; however, all interventions examined were cost-effective and safe. We recommend against hydrogen peroxide rinses and chewing gum. Laryngoscope, 2625-2634, 2018.
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Affiliation(s)
| | - Kevin J Byrne
- Boston University School of Medicine, Boston, Massachusetts, U.S.A
| | - Jessica R Levi
- Boston University School of Medicine, Boston, Massachusetts, U.S.A.,Boston Medical Center, Boston, Massachusetts, U.S.A
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Clark CM, Schubart JR, Carr MM. Trends in the management of secondary post-tonsillectomy hemorrhage in children. Int J Pediatr Otorhinolaryngol 2018; 108:196-201. [PMID: 29605354 DOI: 10.1016/j.ijporl.2018.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 03/02/2018] [Accepted: 03/04/2018] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Christine M Clark
- Department of Otolaryngology-Head and Neck Surgery, Georgetown University, Washington DC, USA
| | - Jane R Schubart
- Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, PA, USA; Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Michele M Carr
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, WV 26501, USA.
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Chua KP, Shrime MG, Conti RM. Effect of FDA Investigation on Opioid Prescribing to Children After Tonsillectomy/Adenoidectomy. Pediatrics 2017; 140:peds.2017-1765. [PMID: 29146621 DOI: 10.1542/peds.2017-1765] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In August 2012, the Food and Drug Administration investigated the safety of codeine use by children after tonsillectomy and/or adenoidectomy, culminating in a black box warning in February 2013. The objective of this study was to evaluate the association between the investigation and opioid prescribing to children undergoing these surgeries. METHODS We identified 362 992 privately insured children in the 2010-2015 Truven MarketScan Commercial Claims and Encounters database who underwent tonsillectomy and/or adenoidectomy. Using an interrupted time series design, we estimated level and slope changes in the proportion of children with ≥1 prescription fills for codeine and ≥1 fills for an alternative opioid, such as hydrocodone, within 7 days of surgery. RESULTS The investigation was associated with a significant -13.3 (95% confidence interval: -14.5 to -12.1) percentage point level change in the proportion of children with ≥1 prescription fills for codeine after tonsillectomy and/or adenoidectomy. Despite this drop, 5.1% of children had ≥1 prescription fills for codeine in December 2015. The investigation was not associated with significant level changes in alternative opioid prescribing, although the proportion of children receiving alternative opioids increased during the study period because of other factors. CONCLUSIONS The Food and Drug Administration investigation substantially decreased codeine prescribing to children after tonsillectomy and/or adenoidectomy. However, 1 in 20 children undergoing these surgeries were still prescribed codeine in December 2015 despite its well-documented safety and efficacy issues.
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Affiliation(s)
- Kao-Ping Chua
- Section of Academic Pediatrics, Departments of Pediatrics, .,Public Health Sciences and.,Department of Pediatrics and Communicable Diseases, Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Mark G Shrime
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, and.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Rena M Conti
- Public Health Sciences and.,Pediatric Hematology/Oncology, University of Chicago, Chicago, Illinois
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Goldman JL, Ziegler C, Burckardt EM. Otolaryngology practice patterns in pediatric tonsillectomy: The impact of the codeine boxed warning. Laryngoscope 2017; 128:264-268. [DOI: 10.1002/lary.26719] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Julie L. Goldman
- Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders; University of Louisville School of Medicine; Louisville Kentucky U.S.A
| | - Craig Ziegler
- University of Louisville Office of Graduate Medical Education; University of Louisville School of Medicine; Louisville Kentucky U.S.A
| | - Elizabeth M. Burckardt
- Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders; University of Louisville School of Medicine; Louisville Kentucky U.S.A
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Comparison of topical ropivacaine with and without ketamine on post-surgical pain in children undergoing tonsillectomy: a randomized controlled double-blind study. J Anesth 2017; 31:559-564. [PMID: 28409242 DOI: 10.1007/s00540-017-2353-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Tonsillectomy in pediatric patients may cause severe postoperative pain. Topical local anesthetics are an easy and safe way to control post-tonsillectomy pain, but there is no benefit during the early postoperative stage. Topical ketamine shows a good effect on early stage postoperative pain. We compared the effect of topical ropivacaine with and without ketamine on post-tonsillectomy pain. METHODS Patients aged 3-7 years undergoing tonsillectomy were selected to participate in the study. Our study was performed in a randomized, placebo-controlled, double-blind manner. Patients were randomly assigned to one of two groups using computer-generated random numbers. The researchers who assessed the pain score, the caregivers, and the patient were blinded to group assignment. One group received topical ropivacaine with saline (RS group) and the other group received topical ropivacaine with 20 mg ketamine (RK group) on the tonsillar bed. Pain scores using the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 15 min and 30 min, and at 1, 2, 4, 8, 16 and 24 h were recorded. Rescue analgesic requirement and complications were also recorded. RESULTS A total of 66 patients were randomly assigned to the RS group (n = 33) and the RK group (n = 33). The mCHEOPS scores were significantly lower in the RK group at 15 min (P = 0.046). The mCHEOPS scores of the two groups decreased with time, but there was no intergroup interaction. The RS group received more analgesics until 1 h after surgery and the RK group received more analgesics during 1-24 h after surgery. There were no differences in adverse outcomes. CONCLUSIONS Topical ropivacaine with ketamine can reduce immediate postoperative pain and analgesic requirement better than ropivacaine alone.
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Is celecoxib a useful adjunct in the treatment of post-tonsillectomy pain in the adult population? A randomised, double-blind, placebo-controlled study. The Journal of Laryngology & Otology 2017; 131:S18-S28. [PMID: 28164777 DOI: 10.1017/s0022215116009476] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of celecoxib for pain management in post-tonsillectomy adult patients. DESIGN A randomised, double-blind, placebo-controlled, phase 3 clinical trial was conducted in an adult population (aged 18-55 years), with a parallel group design using an allocation ratio of 1:1. METHODS Eighty patients underwent elective tonsillectomy or adenotonsillectomy, operated on by one surgeon. They were discharged home with randomly assigned celecoxib or placebo, together with regular post-tonsillectomy medications (paracetamol and Endone). Pain scores were measured from post-operative days 1 to 10. All patients were assessed on post-operative days 5, 12 and 28. RESULTS There were no statistically significant differences in the daily or overall pain scores, the total intake of Endone, or the time taken to achieve freedom from pain after tonsillectomy between the study arms (n = 40 each arm). The celecoxib-treated group experienced significantly more vomiting (celecoxib vs placebo p < 0.001 (Mann-Whitney test), confidence interval = 0.57 to 0.76). CONCLUSION Celecoxib usage was associated with significantly more vomiting and did not reduce narcotic analgesia requirement post-tonsillectomy.
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Rodríguez MC, Villamor P, Castillo T. Assessment and management of pain in pediatric otolaryngology. Int J Pediatr Otorhinolaryngol 2016; 90:138-149. [PMID: 27729121 DOI: 10.1016/j.ijporl.2016.09.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/10/2016] [Accepted: 09/13/2016] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Maria Claudia Rodríguez
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Perla Villamor
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia.
| | - Tatiana Castillo
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
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Abstract
Concern for illicit and restricted drug use in otolaryngology is similar to other surgical specialties with a few notable exceptions. Many illicit drugs are consumed transnasally. Repeated nasal exposure to stimulants or narcotics can cause local tissue destruction that can present as chronic rhinosinusitis or nasoseptal perforation. Further, the Food and Drug Administration has taken a stance against codeine for pediatric patients undergoing adenotonsillectomy. They have identified an increased risk of death postoperatively with these medications. Because codeine has been the most commonly prescribed narcotic, this has shifted the standard practice.
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Affiliation(s)
- Nathan J Gonik
- Department of Otolaryngology Head and Neck Surgery, ENT Clinic, Children's Hospital of Michigan, Wayne State University School of Medicine, 3rd Floor Carl's Building, 3901 Beaubien Avenue, Detroit, MI 48201, USA.
| | - Martin H Bluth
- Department of Pathology, Wayne State University School of Medicine, 540 East Canfield, Detroit, MI 48201, USA; Consolidated Laboratory Management Systems, 24555 Southfield Road, Southfield, MI 48075, USA
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Pfaff JA, Hsu K, Chennupati SK. The Use of Ibuprofen in Posttonsillectomy Analgesia and Its Effect on Posttonsillectomy Hemorrhage Rate. Otolaryngol Head Neck Surg 2016; 155:508-13. [DOI: 10.1177/0194599816646363] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 04/05/2016] [Indexed: 11/16/2022]
Abstract
Objective To determine the effect of ibuprofen on posttonsillectomy bleeding when compared with codeine in posttonsillectomy analgesia. Study Design Case series with chart review. Setting Tertiary care children’s hospital, Philadelphia, Pennsylvania. Subjects and Methods On July 1, 2012, our institution transitioned from acetaminophen with codeine to ibuprofen for posttonsillectomy analgesia. Pediatric patients (0-18 years old) who underwent surgery from July 1, 2010, to June 30, 2012, were placed in the codeine cohort, and those who underwent surgery from July 1, 2012, to June 30, 2014, were placed in the ibuprofen cohort. Results A total of 6014 patients underwent tonsillectomy between July 1, 2010, and June 30, 2014, and 211 patients presented for posttonsillectomy hemorrhage during the same period. The incidence of readmission for posttonsillectomy hemorrhage was 3.4% and 3.6% ( P = .63; odds ratio [OR] = 1.07; 95% confidence interval [95% CI]: 0.811-1.410) for the codeine and ibuprofen groups, respectively, and the incidence of second operation for control of posttonsillectomy bleeding for the codeine and ibuprofen groups was 1.9% and 2.2% ( P = .54; OR = 1.117; 95% CI: 0.781-1.600), respectively. Patients aged 11 to 18 years demonstrated a higher incidence of posttonsillectomy bleeding events overall. When age is controlled, multivariate logistic regression demonstrated no statistically significant increase in posttonsillectomy bleeding events among pediatric patients treated with ibuprofen versus patients treated with codeine (readmission: P = .617; OR = 0.932; 95% CI: 0.707-1.228; reoperation: P = .513; OR = 0.887; 95% CI: 0.618-1.272). Conclusion Age is an independent risk factor for posttonsillectomy bleeding. When age is controlled, there is no statistically significant increase in the incidence of posttonsillectomy bleeding events among patients treated with ibuprofen when compared to patients treated with codeine.
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Affiliation(s)
- Julia A. Pfaff
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
- St Christopher’s Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Kevin Hsu
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
- St Christopher’s Hospital for Children, Philadelphia, Pennsylvania, USA
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Abstract
PURPOSE OF REVIEW This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations. RECENT FINDINGS Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions. SUMMARY Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.
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Rivard J, Yu L, Tremblay S, Lebel D. [Not Available]. Can J Hosp Pharm 2016; 69:244-248. [PMID: 27403005 PMCID: PMC4924946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Julie Rivard
- Pharm. D., est résidente en pharmacie à la Faculté de pharmacie de l'Université de Montréal et au Département de pharmacie du Centre hospitalier universitaire Sainte-Justine. Elle est aussi membre de l'Unité de recherche en pratique pharmaceutique du Centre hospitalier universitaire Sainte-Justine
| | - Lavina Yu
- Pharm. D., est résidente en pharmacie à la Faculté de pharmacie de l'Université de Montréal et au Département de pharmacie du Centre hospitalier universitaire Sainte-Justine. Elle est aussi membre de l'Unité de recherche en pratique pharmaceutique du Centre hospitalier universitaire Sainte-Justine
| | - Stéphanie Tremblay
- B. Pharm., M. Sc., travaille au Département de pharmacie et est membre de l'Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, et elle est clinicienne associée à la Faculté de pharmacie, Université de Montréal, Montréal, Québec
| | - Denis Lebel
- B. Pharm., M. Sc., MBA, FCSHP, travaille au Département de pharmacie et est membre de l'Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, et il est clinicien associé à la Faculté de pharmacie, Université de Montréal, Montréal, Québec
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Carotid artery pseudoaneurysm: A rare complication following tonsillectomy. Int J Pediatr Otorhinolaryngol 2015; 79:2428-32. [PMID: 26545795 DOI: 10.1016/j.ijporl.2015.08.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/19/2015] [Accepted: 08/21/2015] [Indexed: 11/20/2022]
Abstract
Tonsillectomy is one of the most common surgical procedures performed in children. The most frequent complications are dehydration and bleeding. We present the case of a 6 year old child who developed an internal carotid artery pseudoaneurysm following elective tonsillectomy, necessitating urgent coil embolization and stenting. This is the first reported case in the pediatric population of a vascular injury that manifested in a delayed fashion (6 months) after routine tonsillectomy, and is also one of the youngest reported cases. It is imperative for the otolaryngologist to be aware of this rare complication.
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Görges M, Whyte SD, Sanatani S, Dawes J, Montgomery CJ, Ansermino JM. Changes in QTc associated with a rapid bolus dose of dexmedetomidine in patients receiving TIVA: a retrospective study. Paediatr Anaesth 2015; 25:1287-93. [PMID: 26507917 DOI: 10.1111/pan.12780] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical indications for the perioperative use of dexmedetomidine in pediatric anesthesia are accumulating. However, in 2013, dexmedetomidine was added to the list of medications with possible risk of prolonging the QT interval and/or inducing Torsades de Pointes. Unfortunately, current evidence for dexmedetomidine-induced QT prolongation is sparse and somewhat contradictory. OBJECTIVE The purpose of this study was to evaluate temporal changes in corrected QT interval (QTc) after a rapid bolus administration of dexmedetomidine under total intravenous anesthesia (TIVA) with a standardized propofol and remifentanil administration. METHODS Electrocardiography (ECG) and corresponding trend data were extracted from automated electronic data capture of physiological monitoring. Ten-second epochs of ECG data were extracted in 1-min intervals for 12 min, starting 1 min before dexmedetomidine bolus administration, and ending 10 min after. QT intervals were extracted using an automated routine in MATLAB, and corrected for heart rate (HR) using Bazett's (QTcB) and Fridericia's formulas (QTcF). QTcB and QTcF were compared using Wilcoxon signed-rank test between baseline measurements and the subsequent four interval values. RESULTS Data from 21 subjects (17 male) with median (range) age 7.1 (5.4-9.5) yr, weight 23.6 (16.2-36.7) kg, and height 121 (103-140) cm were analyzed. Bolus administration of dexmedetomidine reduced HR in all subjects (median 22%), and caused transient reduction of QT interval, with its peak at 1-min postbolus administration: QTcB (median reduction 30.7 ms, P < 0.001) or QTcF (median reduction 15.4 ms, P = 0.001); QT shortening became statistically insignificant 4 min following dexmedetomidine bolus administration for QTcB and 2 min for QTcF. CONCLUSION In this study, a rapid bolus of dexmedetomidine transiently shortened corrected QT intervals. However, these effects are confounded by dexmedetomidine-induced bradycardia. These findings should be confirmed in pediatric studies without concomitant TIVA administration and with optimized correction of baseline HR.
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Affiliation(s)
- Matthias Görges
- Department of Electrical and Computer Engineering, The University of British Columbia, Vancouver, BC, Canada
| | - Simon D Whyte
- Department of Anesthesiology, Pharmacology, and Therapeutics, The University of British Columbia, Vancouver, BC, Canada
| | - Shubhayan Sanatani
- Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Joy Dawes
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - Carolyne J Montgomery
- Department of Anesthesiology, Pharmacology, and Therapeutics, The University of British Columbia, Vancouver, BC, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology, and Therapeutics, The University of British Columbia, Vancouver, BC, Canada
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Mishra P, Foley D, Rutlede E, Allford M. Is day surgery failing our children? J Paediatr Child Health 2015; 51:960-1. [PMID: 26428421 DOI: 10.1111/jpc.12958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Prabal Mishra
- Paediatric Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - David Foley
- Paeditrics Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Eoghan Rutlede
- Anaesthetics, Capital and Coast District Health Board, Wellington, New Zealand
| | - Mark Allford
- Anaesthetics, Capital and Coast District Health Board, Wellington, New Zealand
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