Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis

The efficacy of gastric aspiration in reducing postoperative vomiting after oral and maxillofacial surgery: A meta-analysis

BACKGROUND

Gastric aspiration is applied in oral and maxillofacial procedures to reduce postoperative vomiting (POV), yet its clinical benefit remains largely uncertain. Our study aimed to determine the role of gastric aspiration in the amelioration of POV by a meta-analysis.

METHODS

With adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, global recognized databases, including PubMed, Embase, and Cochrane Central, were searched to obtain randomized controlled trials (RCTs) investigating the effects of gastric aspiration in oral and maxillofacial surgery. The incidence and the number of episodes of POV and the frequency of rescue antiemetic use were extracted as parametric data for pooled estimation. Funnel plots and Egger's test were utilized to assess bias. The recommendation of evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

After detailed evaluation, 5 RCTs containing 274 participants were eventually included. The results of pooled estimation indicated that gastric aspiration could not reduce the incidence of POV (risk ratio [95% CI] = 0.94 [0.73, 1.21], P = .621), the number of episodes of POV (standard mean difference [95% CI] = -0.13 [-0.45, 0.19], P = .431) or the frequency of rescue antiemetic use (RR [95% CI] = 0.86 [0.49, 1.52], P = .609). No publication bias was detected by the funnel plot and Egger test. The overall recommendation of evidence was rated low regarding each outcome.

CONCLUSION

Based on current evidence, gastric aspiration is not recommended for oral and maxillofacial surgery. Meanwhile, more large-scale high-quality RCTs are needed.

Jelly snakes to reduce early postoperative vomiting in children after adenotonsillectomy: The randomized controlled snakes trial

BACKGROUND

Despite the use of dual antiemetic agents, postoperative nausea and vomiting (PONV) occurs in an unacceptably large number of patients post-tonsillectomy. There has been increased interest in alternative and non-pharmacological treatments for PONV e.g., chewing gum. We investigated if chewing a large confectionary jelly snake had prophylactic antiemetic effects postoperatively in young children.

METHODS

Prospective, open-label randomised controlled trial of 240 patients, 2-16 years. Patients administered a confectionary jelly snake to chew postoperatively were compared with a control group. The primary outcome was the number of episodes of vomiting within 6 h of the operation on an intention-to-treat basis.

SECONDARY OUTCOMES

incidence of nausea, vomiting at 6 and 24 h, rescue antiemetic use, acceptability, delayed discharge.

RESULTS

233 patients were randomised to receive the confectionary snake (snake group, 118) or standard care (control group, 115). The number of vomiting episodes in 6 h was similar between groups on an intention-to-treat basis, with 39 episodes across 22 (19%) patients in the control group and 31 across 19 (16%) patients in the snake group (p = 0.666). From post anaesthetic care unit until 24 h there was no difference in doses of antiemetics or delayed discharge due to PONV. A secondary as per protocol analysis did not change this result.

CONCLUSIONS

Chewing of confectionery jelly snakes within one hour of waking following adenotonsillectomy with vapour-maintained anaesthesia and two prophylactic antiemetics did not further reduce the incidence of early vomiting.

REGISTRATION

prospective registration at the Australia and New Zealand Clinical Trials Registry (ACTRN12618000637246).

Comparative Efficacy of Granisetron and Droperidol After Orthognathic Surgery for Prophylaxis of Postoperative Nausea and Vomiting: A Retrospective Study

BACKGROUND

In the fall of 2021, granisetron was approved for postoperative nausea and vomiting (PONV) management in Japan. However, the comparative efficacy of droperidol and granisetron in the field of orthognathic surgery has not been determined.

PURPOSE

We compare the efficacy of droperidol and granisetron for PONV prophylaxis following orthognathic surgery.

STUDY DESIGN, SETTING, SAMPLE

We performed a retrospective cohort study of patients who underwent orthognathic surgery at a single institution from September 2020 to December 2022. Patients who had undergone Le Fort I osteotomy with sagittal split ramus osteotomy or isolated sagittal split ramus osteotomy were included. Patients were divided into three groups; the isolated droperidol (D), isolated granisetron (G), and droperidol with granisetron (DG) groups. General anesthesia was performed using total intravenous anesthesia for all patients; however, droperidol and granisetron were administered at the anesthesiologist's discretion.

PREDICTOR VARIABLE

PONV prophylactic therapy included isolated droperidol, isolated granisetron, and droperidol with granisetron administration.

OUTCOME VARIABLES

Postoperative nausea (PON) and postoperative vomiting (POV) were determined through medical examination within 48 hours following surgery. Secondary outcomes included complications due to droperidol and/or granisetron administration.

COVARIATES

Age, sex, body mass index, Apfel's score, duration of surgery, duration of anesthesia, intraoperative blood loss, and type of surgery.

ANALYSES

Statistical analysis was conducted using Fisher exact test, Mann-Whitney U test with Bonferroni correction for univariate comparison, and modified Poisson regression for comparison of PON and POV prophylactic efficacy for multivariate analyses. P values <.05 were considered statistically significant.

RESULTS

Our study included 218 participants. There were no significant differences in covariates between groups D (n = 111), G (n = 52), and DG (n = 55). No significant difference in PON incidence was observed between groups. However, POV incidence was significantly lower in group DG than group D (relative risk, 0.21; 95% confidence interval, 0.05 to 0.86; P = .03). No significant difference in complication incidence was observed between groups.

CONCLUSIONS AND RELEVANCE

Granisetron was as effective as droperidol for PONV management, while droperidol combined with granisetron was more effective than isolated droperidol for POV management. As compared to the use of each drug separately, their combination was considered safe, with no increase in complication rates.

[Postoperative nausea and vomiting-recommendations for its prevention and therapy in paediatric medicine]

Post-operative nausea and/or vomiting (PONV/POV) are among the biggest problems occurring in the paediatric recovery room and in the course of the following post-operative period. Apart from pain and emergence delirium, PONV is one of the main causes of post-operative discomfort in children. The DGAI Scientific Working Group on Paediatric Anaesthesia already worked out recommendations for the prevention and treatment of PONV in children years ago. These recommendations have now been revised by a team of experts, the current literature has been reviewed, and evidence-based core recommendations have been consented. Key elements of the new recommendations consist of effective individual measures for prevention and therapy, next to the implementation of a fixed dual prophylaxis in the clinical routine applicable to all children ≥ 3 years of age.

Benefit-Risk Assessment of Off-Label Drug Use in Children: The Bravo Framework

A drug is granted a license for use after a thorough assessment of risks and benefits based on high-quality scientific proof of its efficacy and safety. Many drugs that are relevant to children are not licensed for use in this population implying that a thorough assessment of risks and benefits in the pediatric population has not been made at all, implying a negative risk-benefit balance in children, or implying insufficient information to establish the risk-benefit balance. Use of drugs without positive assessment of risks and benefits exposes children to potential lack of efficacy, unknown toxicity, and harm. To aid guideline committees and individual prescribers, we here present a tutorial of the Benefit and Risk Assessment for Off-label use (BRAvO) decision framework. This pragmatic framework offers a structured assessment of benefits and risks of off-label drug use, including a clinical pharmacological based approach to age-appropriate dose selection. As proof of concept and to illustrate the practical use, we have applied the framework to assess benefits and risks of off-label use of ondansetron for gastroenteritis-induced nausea and vomiting. The framework could also guide decisions on off-label use in other special populations (e.g., pregnant women, elderly, obese, or critically ill patients) where off-label drug use is frequent, thereby contributing to effective and safe pharmacotherapy.

Postoperative Nausea and Vomiting in Pediatric Patients

Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.

Incidence of postoperative vomiting in pediatric population undergoing anesthesia: a prospective cohort study

Introduction: Postoperative nausea and vomiting are frequent adverse effects of anesthesia and surgery. Impact is greater in pediatric populations compared to adults and the reported incidences are heterogeneous. Objective: To describe the incidence of postoperative vomiting in a pediatric population and to identify associated risk factors. Materials and methods: This prospective cohort study included 190 children aged 3 to 12 years undergoing surgery and anesthesia in a maternal and child health clinic in Bucaramanga (Colombia). The main outcome variable was postoperative vomiting. Data were analyzed using bivariate, multivariate analysis and logistic regression to assess the associated risk factors. Results: The overall incidence of postoperative vomiting was 18.95% (95% CI: 13.32 - 24.57), with a higher incidence at home vs. hospital (12.63% vs. 9.47%). After adjustment, associated risk factors were anesthesia time longer than 45 minutes (OR: 2.33; 95% CI: 1.10-4.90) and postoperative use of opioids (OR: 4.17; 95% IC: 1.65-10.5). The incidence of postoperative vomiting was higher in patients who underwent emergency surgery. Conclusion: This is the first study in Colombia that evaluates the incidence of postoperative vomiting in children. The incidence in our pediatric population is within the ranges reported worldwide. Associated risk factors were anesthesia time longer than 45 minutes and postoperative use of opioids. Further research is required in order to study emergency surgery as a potential risk factor.

An update on the management of PONV in a pediatric patient

Postoperative nausea and vomiting (PONV) is a major cause of patient dissatisfaction following anesthesia. The difficulty in diagnosing nausea in much of the pediatric population has led to an emphasis on anti-emetic prophylaxis for all. Assessment scores and prognostic tools enable the anesthesiologist to identify patients who are at a greater risk and appropriately apply more aggressive prophylactic, multi-drug strategies. New antiemetics emerging from other medical disciplines, particularly oncology, may have potential use in prophylaxis and treatment of nausea and vomiting in the pediatric surgical population. New agents, many of which have a long duration of action, will augment the anesthesiologist's ability to adequately prevent PONV, and to treat persistent nausea and vomiting that extend beyond the immediate post-operative period.

Hypopharyngeal packing during adenotonsillectomy by cold dissection in children: a randomized controlled trial

PURPOSE

Nausea and vomiting occur in up to 70% of children after adenotonsillectomy, ingested blood during procedure being one of the reasons for emesis. Hypopharyngeal packing (HP) is a common practice among otolaryngologists to prevent blood from being swallowed, but studies in nasal surgeries in adults failed to show efficacy of this technique in reducing postoperative nausea and vomiting (PONV). There are no studies evaluating the effect of HP in adenotonsillectomy in children. The aim of this study is to evaluate the efficacy HP during adenotonsillectomy in children in the prevention of PONV.

METHODS

This is a randomized, double-blinded, controlled trial. Children aged 4-16 years, scheduled for adenotonsillectomy due to sleep-disordered breathing were enrolled in Hospital da Criança Santo Antônio (Brazil). 192 participants were screened, while 129 were enrolled and completed follow-up for primary outcome. Patients were randomized in a consecutive manner to receive HP or not during adenotonsillectomy. PONV occurrence was assessed in the first 24 h after surgery in HP and control group and relative risk with 95% confidence interval was calculated.

RESULTS

There were 129 patients randomized, 64 in the HP and 65 in the control group. Female were 40.3% and mean ± SD age was 7.3 ± 2.9. Baseline characteristics and surgery variables were distributed similarly between the groups. Incidence of PONV was 20.3% in the HP and 23.1% in the control group. The relative risk for PONV was 0.88 (95% CI 0.46-1.70).

CONCLUSION

Our results suggest that there is no benefit of HP during adenotonsillectomy in children for the prevention of PONV.

TRIAL REGISTRATION

Brazilian Register of Randomized Trials (REBEC) identifier: RBR-3zjn27; Universal Trial Number U1111-1197-7461.

Effectiveness of intravenous lidocaine in preventing postoperative nausea and vomiting in pediatric patients: A systematic review and meta-analysis

BACKGROUND

Intravenous lidocaine in adults undergoing general anesthesia has been shown to reduce the incidence of postoperative nausea and vomiting (PONV). However, the anti-postoperative vomiting (POV) effect of lidocaine in pediatric patients remains unclear. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of intravenous lidocaine on prevention of POV/PONV.

METHODS

Six databases including trial registration sites were searched. Randomized clinical trials evaluating the incidence of POV/PONV after intravenous lidocaine compared with control were included. The primary outcome was the incidence of POV within 24 hours after general anesthesia. The incidence of POV was combined as a risk ratio with 95% confidence interval using a random-effect model. We used the I2 to assess heterogeneity. We evaluated the quality of trials using the Cochrane methodology, and we assessed quality of evidence using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events.

RESULTS AND DISCUSSION

Six trials with 849 patients were included, of whom 433 received intravenous lidocaine. Three trials evaluated the incidence of POV, and 3 evaluated the incidence of PONV. The overall incidence of POV within 24 hours after anesthesia was 45.9% in the lidocaine group and 63.4% in the control group (risk ratio, 0.73; 95% confidence interval, 0.53-1.00; I2 = 32%; p = 0.05). The incidence of PONV within 24 hours after anesthesia was 3.73% in the lidocaine group and 4.87% in the control group (RR, 0.76; 95% CI, 0.36-1.59; I2 = 0%; p = 0.47). The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, imprecision, and possible publication bias.

CONCLUSION

Our meta-analysis suggests that intravenous lidocaine infusion may reduce the incidence of POV, however, the evidence quality was "very low." Further trials with a low risk of bias are necessary.

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

OBJECTIVE

The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA).

STUDY DESIGN

Online survey.

METHOD

A sample of pediatric anesthesiologists received the survey by email.

RESULTS

110 respondents were included. 46.4% worked in a free-standing children's hospital and 32.7% worked in a children's facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children's hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA (P < 0.05).

CONCLUSION

Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.

Intra-operative lidocaine in the prevention of vomiting after elective tonsillectomy in children: A randomised controlled trial

BACKGROUND

Postoperative vomiting (POV) is a frequent complication of tonsillectomy in children. In adult patients undergoing abdominal surgeries, the use of intravenous lidocaine infusion can prevent POV.

OBJECTIVE

To evaluate the anti-emetic effect of an intravenous lidocaine infusion used as an adjuvant to general anaesthesia, in children undergoing elective ear, nose and throat surgery.

DESIGN

Double-blind, randomised, controlled study.

SETTING

Hospital-based, single-centre study in Chile.

PATIENTS

ASA I-II children, aged 2 to 12 years, scheduled for elective tonsillectomy.

INTERVENTION

We standardised the induction and maintenance of anaesthesia. Patients were randomly allocated to lidocaine (1.5 mg kg intravenous lidocaine over 5 min followed by 2 mg kg h) or 0.9% saline (at the same rate and volume). Infusions were continued until the end of the surgery.

MAIN OUTCOME MEASURES

Presence of at least one episode of vomiting, retching or both in the first 24 h postoperatively (POV).

SECONDARY OUTCOMES

Plasma concentrations of lidocaine and postoperative pain.

RESULTS

Ninety-two children were enrolled. Primary outcome data were available for 91. In the Lidocaine group, 28 of 46 patients (60.8%) experienced POV, compared with 37 of 45 patients (82.2%) in the Saline group [difference in proportions 21.3% (95% confidence interval (CI) 2.8 to 38.8), P = 0.024]. The intention-to-treat analysis showed that when we assumed that the patient in the Saline group lost to follow-up did not have POV, the difference in proportions decreased to 19.6% (95% CI, 0.9 to 37.2), with an unadjusted odds ratio of 0.38 (95% CI, 0.15 to 0.97, P = 0.044). The odds of having POV were 62% less likely in those patients receiving lidocaine compared with patients in the Saline group. The mean lidocaine plasma concentration was 3.91 μg ml (range: 0.87 to 4.88).

CONCLUSION

Using an intravenous lidocaine infusion as an adjuvant to general anaesthesia decreased POV in children undergoing elective tonsillectomy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01986309.

Audit of perioperative pain management in paediatric patients following tonsillectomy at a tertiary hospital in Johannesburg

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.

Randomized trial of acupuncture with antiemetics for reducing postoperative nausea in children

BACKGROUND

Postoperative nausea and vomiting (PONV) is common after tonsillectomy in children. There is evidence that perioperative acupuncture at the pericardium 6 (P6) point is effective for preventing PONV in adults. Our goal was to determine if intraoperative acupuncture at the P6 point, in addition to usual antiemetics, is more effective than antiemetics alone in preventing PONV in children.

METHODS

In a randomized double-blind trial, 161 children age 3 through 9 years undergoing tonsillectomy with or without adenoidectomy were randomized to either bilateral acupuncture at P6 plus antiemetics (n = 86) or antiemetics only (n = 75). All participants received ondansetron 0.15 mg/kg and dexamethasone 0.25 mg/kg, up to 10 mg. The presence of nausea, retching, emesis and administration of additional antiemetics were recorded during phases I and II of PACU recovery. Follow-up calls occurred on postoperative day 1 (POD 1).

RESULT

During phase I and II recovery, the incidence of PONV was significantly less with acupuncture than without (7.0% vs 34.7%, RR: 0.2, 95% CI: 0.09-0.46; P < 0.001). The difference in PONV was driven by less nausea in the acupuncture group (5.0% vs 24.0%), with no difference in vomiting between the two groups. In the first 24 hours, PONV occurred in 36.1% with acupuncture and 49.3% without; these values did not differ significantly (P = 0.09).

CONCLUSIONS

Children receiving acupuncture plus antiemetic therapy had less risk of developing nausea during phase I and II recovery, but there was no difference in PONV on POD 1. Acupuncture may reduce nausea in the PACU, even when combined with antiemetics.

Dexamethasone Reduces the Incidence of Postoperative Nausea and Vomiting in Children Undergoing Endoscopic Adenoidectomy under General Anesthesia Without Increasing the Risk of Postoperative Hemorrhage

Background

Postoperative nausea and vomiting (PONV) is a common complication of pediatric anesthesia, but the overall incidence of PONV in patients undergoing adenoidectomy is unknown. The aim of this controlled study was to compare the effect of dexamethasone administration with placebo to reduce PONV in children undergoing endoscopic adenoidectomy under general anesthesia.

Material/Methods

A randomized placebo-controlled study included 118 pediatric patients who underwent elective endoscopic adenoidectomy under general anesthesia. A dexamethasone-treated (0.15 mg/kg) group (Group D) (n=56) and a placebo group (Group C) (n=62) were randomly assigned. The incidence of nausea and vomiting was recorded on the day of surgery. Postoperative nausea was assessed according to illustrated Baxter Animated Retching Faces (BARF) scale. The Face, Legs, Activity, Cry, and Consolability (FLACC) scale (scores between 0–10) was used to assess pain. Follow-up was performed on the 14^th postoperative day by a telephone call.

Results

Overall prevalence of postoperative nausea was 25% (30/118) and postoperative vomiting was 14% (17/118). In the first 24 hours following surgery, in Group D, the incidence of nausea and vomiting was 13% and 7%, respectively; in Group C, without pharmacological prophylaxis, the incidence of postoperative nausea and vomiting was 37%, and 21%, respectively.

Conclusions

A prospective controlled study in children undergoing endoscopic adenoidectomy under general anesthesia showed that dexamethasone (0.15 mg/kg) significantly reduced the incidence of PONV without increasing the risk of postoperative hemorrhage. Dexamethasone is a safe method for the prevention of PONV that may be recommended in pediatric anesthesiology.

Total intravenous anesthesia vs single pharmacological prophylaxis to prevent postoperative vomiting in children: A systematic review and meta-analysis

BACKGROUND

Postoperative nausea and postoperative vomiting are frequent but often missed complications after general anesthesia in pediatric patients. Because inhaled anesthetics are known to trigger postoperative vomiting, total intravenous anesthesia is often administered in high-risk children to avoid the use of inhalational anesthesia. Since inhalational anesthesia might be advantageous in some situations, the question is raised whether administration of pharmacological prophylaxis offers equal protection from postoperative vomiting compared with total intravenous anesthesia alone.

AIM

The aim of this systematic review was to compare total intravenous anesthesia with single-drug pharmacological prophylaxis for the protection of postoperative vomiting in pediatric patients.

METHODS

We conducted a systematic review (EMBASE, MEDLINE, and CENTRAL) with meta-analysis on randomized controlled trials including patients <18 years of age undergoing general anesthesia, with one group receiving propofol-based total intravenous anesthesia and another group receiving inhalational anesthesia with single pharmacological prophylaxis. Primary outcome was the overall incidence for postoperative vomiting. Secondary outcomes included early and late postoperative vomiting, the need for postoperative antiemetic medication, time to first oral intake, duration of stay in the postanesthesia care unit, and any adverse events defined as such by the respective authors. Risk ratios (RR) or mean differences (MD) with 95% confidence intervals (95% CI) were calculated using a random effects model with inverse variance weighting.

RESULTS

Four randomized controlled trials including 558 children were included in the final analysis. All patients underwent strabismus surgery. Total intravenous anesthesia and single pharmacological prophylaxis were equally effective in preventing overall postoperative vomiting (RR 0.99 [95% CI 0.77; 1.27]; 4 trials), as well as vomiting in the early (1.48 [0.78; 2.83]; 4 trials) and late (0.89 [0.56;1.42]; 2 trials) postoperative period. There was no difference in the need for postoperative antiemetic medication. Although patients resumed drinking and eating significantly earlier following total intravenous anesthesia (MD -1.40 hours [-2.01; -0.80], P < .001), the duration of PACU stay did not differ between groups. The incidence of intraoperative oculocardiac reflex was the only reported adverse event, which was more likely to occur after total intravenous anesthesia (1.86 [1.01; 3.41]).

CONCLUSION

Single pharmacological prophylaxis appears equally effective compared with total intravenous anesthesia in preventing postoperative vomiting in pediatric patients. However, during strabismus surgery, total intravenous anesthesia increases the risk for bradycardia due to oculocardiac reflex. Thus, when anesthesia is maintained with inhalational anesthetics, its emetogenic effects can sufficiently be compensated by the addition of a single prophylactic antiemetic medication.

Ultrasound assessment of gastric contents in children undergoing elective ear, nose and throat surgery: a prospective cohort study

Ultrasound examination of the gastric antrum allows reliable assessment of gastric contents and volume. Postoperative assessment of gastric contents before recovery from anaesthesia could help the physician to choose the most appropriate extubation technique after surgery in children. In this prospective observational study, we assessed whether significant changes occurred in gastric contents during the intra-operative period in children undergoing elective ear, nose and throat (ENT) surgery. Children aged between six months and 16 years were recruited consecutively. Ultrasound examination of the antrum was performed before induction of anaesthesia and at the end of surgery before tracheal extubation, and included quantitative and qualitative assessment of gastric contents. The mean (SD) gastric volume was 0.28 (0.30) ml.kg^-1 before surgery and 0.27 (0.30) ml.kg^-1 after surgery, p = 0.82. No solid contents were identified in the antrum, and the gastric volume was < 1.5 ml.kg^-1 in all patients during both ultrasound examinations. Our results suggest that, after elective ENT surgery, children are not at risk of a full stomach before tracheal extubation, and that pulmonary aspiration of blood that may occur after elective ENT surgery is probably not related to regurgitation of ingested blood from the stomach.

Postoperative nausea and vomiting after general anesthesia for oral and maxillofacial surgery

Background

Postoperative nausea and vomiting (PONV) is one of the most common postoperative complications. Despite this, few papers have reported the incidence and independent risk factors associated with PONV in the context of oral and maxillofacial surgery (OMFS). Therefore, we sought to determine the incidence of PONV, as well as to identify risk factors for the condition in patients who had undergone OMFS under general anesthesia.

Methods

A total of 372 patients' charts were reviewed, and the following potential risk factors for PONV were analyzed: age, sex, body mass index, smoking status, history of PONV and/or motion sickness, duration of anesthesia, amount of blood loss, nasogastric tube insertion and retention and postoperative opioid used. Univariate analysis was performed, and variables with a P-value less than 0.1 were entered into a multiple logistic regression analysis, wherein P-values < 0.05 were considered significant.

Results

The overall incidence of PONV was 25.26%. In the multiple logistic regression analysis, the following variables were independent predictors of PONV: age < 30 years, history of PONV and/or motion sickness, and anesthesia duration > 4 h. Furthermore, the number of risk factors was proportional to the incidence of PONV.

Conclusions

The incidence of PONV in patients who have undergone OMFS varies from center to center depending on patient characteristics, as well as on anesthetic and surgical practice. Identifying the independent risk factors for PONV will allow physicians to optimize prophylactic, antiemetic regimens.

Ondansetron for pediatric concussion; a pilot study for a randomized controlled trial

Objectives

Assess the feasibility of a study evaluating one dose of oral ondansetron to decrease post-concussion symptoms at one week and one month following concussion in children aged 8 to 17 years old.

Method

This was a pilot study for a randomized, triple-blind controlled trial of one dose of either ondansetron or placebo performed in a tertiary care pediatric emergency department. Participants were children aged 8 to 17 years who sustained a concussion in the previous 24 hours and visited a single emergency department. The outcome of interest was an increase from pre-concussion baseline of at least 3 symptoms from the Post-Concussion Symptom Inventory, measured at one week and at one month following concussion. The primary outcome was to determine the proportion of children who completed the assessment at one week following the intervention. Secondary outcome was the proportion of children who completed the assessment at one month following the intervention. All children, care givers, and those assessing the outcomes were blinded to the group assignment.

Results

Of the 218 children presenting with a concussion during the study period, we screened 108 and found 36/108 (33%) eligible to participate and 16/108 (14.8%) agreed to participate. All enrolled patients were compliant with the intervention and follow-up.

Conclusion

In our study population, approximately one-third of the screened concussion patients were eligible to participate and approximately one half of those eligible agreed to participate. Our study found that most enrolled patients preferred electronic follow-up; the noncompliance rate was minimal.

Safety and efficacy of pre-incisional peritonsillar lornoxicam in paediatric post-tonsillectomy pain: a prospective double-blind, placebo-controlled, split-body clinical study

OBJECTIVES

To evaluate the risk of peri-operative bleeding and re-intervention with peritonsillar lornoxicam infiltration in paediatric tonsillectomy.

DESIGN

Prospective, randomised, double-blinded, placebo-controlled, split-body study.

SETTING

University hospital.

PARTICIPANTS

A total of 68 patients (7-15 years), ASA I-II, scheduled for tonsillectomy divided into two groups (n = 34) to receive bilateral peritonsillar saline infiltration (placebo group) or peritonsillar saline infiltration in one tonsil (placebo side) and 8 mg lornoxicam in the other tonsil (intervention side; study group). Drugs were administered after induction of anaesthesia and before start of surgery.

MAIN OUTCOME MEASURES

Intra-operative and postoperative bleeding score, platelet aggregometry before and 30 min after study drug administration, the verbal rating pain scale, time to first postoperative analgesic request, total analgesic consumption during 1st 24 h postoperative and adverse effects were evaluated.

RESULTS

The difference in bleeding score between groups did not reach our definition of statistical significance (P < 0.05). Platelet aggregometry tests did not change significantly with time between groups. Lower postoperative pain scores, longer time to first analgesic request (372.76 ± 82.15 versus 64.89 ± 25.76 min P < 0.001) and lower paracetamol consumption (421.76 ± 125.63 versus 690.29 ± 141.47 mg, P < 0.001) were recorded in study group compared with control group. No patient required hospital re-admission or re-operation because of postoperative tonsillar bed bleeding.

CONCLUSIONS

The lack of significant complications suggests that pre-incisional peritonsillar lornoxicam followed by intravenous paracetamol rescue analgesia may be safe for tonsillectomy in children. To avoid conflict with intra-operative bleeding, postoperative infiltration of lornoxicam is recommended.

Acupuncture as an Antiemetic in Children who Underwent Adenoidectomy and/or Tonsillectomy

OBJECTIVE

Postoperative vomiting (POV) is one of the most common problems following general anaesthesia, and many factors, either solely or in combination, may play a role in aetiology. Acupuncture is a technique that the World Health Organization has accepted as a complementary treatment. This study presents our experience with acupuncture for POV treatment in a study of paediatric tonsillectomy cases.

METHODS

The study included ASA I-II patients (n=70) aged 2-14 years who underwent tonsillectomy and/or adenoidectomy under general anaesthesia. The patients were randomly divided into the following two groups: control and study group. In the study group, an acupuncture needle was intraoperatively applied to the P6 acupuncture point for 20 min. Antiemetics were not administered to either group because of the standard applications in the preoperative period. The patients were postoperatively evaluated by nurses who were unaware about the techniques used in either group.

RESULTS

No statistically significant difference was determined between the groups with regard to age, sex, nature of the operation, duration of anaesthesia, duration of the operation, surgical method and ASA scores. A statistically significant difference was determined between the groups with respect to vomiting rates. The acupuncture group presented with 0.28-times fewer vomiting episodes than the control group.

CONCLUSION

The results of the study demonstrate that acupuncture has an apparent antiemetic efficacy in POV. Its routine use for POV may improve postoperative comfort and reduce drug use for prophylactic or therapeutic purposes.

Efficacy and safety of acupuncture in children: an overview of systematic reviews

In recent years, acupuncture has increasingly being integrated into pediatric health care. It was used on ~150,000 children (0.2%). We aim to update the evidence for the efficacy and safety of acupuncture for children and evaluate the methodological qualities of these studies to improve future research in this area. We included 24 systematic reviews, comprising 142 randomized controlled trials (RCTs) with 12,787 participants. Only 25% (6/24) reviews were considered to be high quality (10.00 ± 0.63). High-quality systematic reviews and Cochrane systematic reviews tend to yield neutral or negative results (P = 0.052, 0.009 respectively). The efficacy of acupuncture for five diseases (Cerebral Palsy (CP), nocturnal enuresis, tic disorders, amblyopia, and pain reduction) is promising. It was unclear for hypoxic ischemic encephalopathy, attention deficit hyperactivity disorder, mumps, autism spectrum disorder (ASD), asthma, nausea/vomiting, and myopia. Acupuncture is not effective for epilepsy. Only six reviews reported adverse events (AEs) and no fatal side effects were reported. The efficacy of acupuncture for some diseases is promising and there have been no fatal side effects reported. Further high-quality studies are justified, with five diseases in particular as research priorities.

Swedish guidelines for the treatment of pain in tonsil surgery in pediatric patients up to 18 years

BACKGROUND

Surgery of the tonsils often causes severe pain lasting for many days as been shown by data from the National Tonsil Surgery Register in Sweden. Tonsillotomy is associated with fewer readmissions due to bleeding, number of days requiring analgesics and health care contacts due to pain compared to tonsillectomy. The register data demonstrate the necessity of better-evidenced based pain treatment guidelines for tonsil-surgery.

OBJECTIVES

To develop evidenced based pain treatment guidelines for tonsil-surgery in Sweden.

METHODS

The evidence based guidelines were designed by an updated literature review and from the clinical expertise in the pediatric pain field, which thereafter were reviewed by ENT-doctors and anesthetists from each ENT-clinic in Sweden.

RESULTS

A multimodal pain treatment approach is advocated, including premedication and administration during anesthesia, with paracetamol (acetaminophen), clonidine and betamethasone. If not given as a premedication the combination can be administered intravenously in the initial phase of anesthesia. At the end of surgery, if no bleeding problems, cox-inhibitors can be given. After discharge from hospital, the recommendations for pain relief are paracetamol combined with cox-inhibitors (ibuprofen, diclofenac) and if needed oral clonidine in favor of opioids. When pain intensity decreases, discontinue the analgesic treatment in the following order: opioid, clonidine, paracetamol and at last ibuprofen. The need for analgesic treatment after tonsillectomy is usually 5-8 days, after tonsillotomy only 3-5 days. Parents are recommended to contact the hospital if the child has difficulties in drinking or eating adequately and/or suffers from pain despite taking the recommended medication regularly.

CONCLUSIONS

Swedish guidelines for tonsil-surgery provide practical evidence-based pain treatment recommendations.

Narrative Review of Perioperative Acupuncture for Clinicians

Acupuncture is one of the oldest forms of the natural healing arts. The exact mechanisms of action are unknown at this time; however, current theories to explain the benefits experienced after acupuncture include Traditional Chinese Medicine and Western medicine concepts. Acupuncture may improve the quality of perioperative care and reduce associated complications. Perioperative acupuncture is apparently effective in reducing preoperative anxiety, postoperative nausea and vomiting, and postoperative pain. The Pericardium-6 (P-6; Nei Guan), Yintang (Extra 1), and Shenmen acupuncture points are the most studied and effective acupuncture points in reducing preoperative anxiety, postoperative nausea and vomiting, and postoperative pain experiences. Intraoperatively administered acupuncture may reduce immunosuppression in patients and lessen intraoperative anesthetic requirements, although the clinical usefulness of acupuncture in the intraoperative period remains inconclusive. Perioperative acupuncture is a promising intervention, but additional studies are needed to further understand and define acupuncture's role throughout the perioperative period and determine its clinical usefulness. The purpose of this article is to provide a brief clinical review concerning acupuncture and its application for common issues that occur in the perioperative period.

Postoperative nausea and vomiting in pediatric anesthesia

PURPOSE OF REVIEW

Postoperative nausea and vomiting (PONV) has a high incidence in children and requires prophylactic and therapeutic strategies.

RECENT FINDINGS

PONV can be reduced by the avoidance of nitrous oxide, volatile anesthetics, and the reduction of postoperative opioids. The use of dexamethasone, 5-HT3 antagonists, or droperidol alone is potent, but combinations are even more effective to reduce PONV. Droperidol has a Food and Drug Administration warning. Hence, dexamethasone and 5-HT3 antagonists should be preferred as prophylactic drugs. It is further reasonable to adapt PONV prophylaxis to different risk levels. Prolonged surgery time, inpatients, types of surgery (e.g. strabismus and ear-nose-throat surgery), and patients with PONV in history should be treated as high risk, whereas short procedures and outpatients are to be treated as low risk.

SUMMARY

Concluding from the existing guidelines and data on the handling of PONV in children at least 3 years, the following recommendations are given: outpatients undergoing small procedures should receive a single prophylaxis, outpatients at high risk a double prophylaxis, inpatients with surgery time of more than 30 min and use of postoperative opioids should get double prophylaxis, and inpatients receiving a high-risk surgical procedure or with other risk factors a triple prophylaxis (two drugs and total intravenous anesthesia). Dimenhydrinate can be used as a second choice, whereas droperidol and metoclopramide can only be recommended as rescue therapy.

Confronting the challenges of effective pain management in children following tonsillectomy

Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregiver's at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.

Efficacy of prophylactic dexamethasone in prevention of postoperative nausea and vomiting

Objective: Many trials have been conducted with regard to the relative benefits of prophylactic anti-emetic interventions given alone or in combination, yet the results remain unknown. This study reviewed the efficacy of a single prophylactic dose of dexamethasone on postoperative nausea or vomiting (PONV) after abdominal hysterectomy.

Methods: In a prospective study of 100 women undergoing total abdominal hysterectomy (TAH) under general anesthesia, the dexamethasone group (n = 50) received a single dose (8 mg) immediately after the operation, and the saline group (n = 50) received a dose of saline as a placebo, in addition to conventional management. The incidence of nausea, vomiting, the need for an anti-emetic and patient satisfaction with the management of PONV were evaluated during the first 24 postoperative hours.

Results: The overall frequency of nausea during the initial postoperative 24 in the dexamethasone and saline groups were 12% and 18%, respectively, and vomiting was 10% and 16%, respectively (P = 0.001). However, there was a lower need for a rescue anti-emetic drugs in the dexamethasone group (18% vs 24%), but it was not statistically significant (P = 0.06).

Conclusion: The results of this study indicate that a single prophylactic dose of dexamethasone after an operation can reduce postoperative nausea and vomiting.

Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis

Summary In children undergoing tonsillectomy, dexamethasone is recommended to reduce the risk of postoperative nausea and vomiting while non-steroidal anti-inflammatory drugs (NSAIDs) are used for pain relief. We aimed to determine whether children who receive dexamethasone or dexamethasone with NSAID are more likely to experience haemorrhage post-tonsillectomy. Randomized and non-randomized studies in which children undergoing tonsillectomy received dexamethasone or dexamethasone and NSAID were sought within bibliographic databases and selected tertiary sources. The risk of bias assessment and evaluation of haemorrhage rate data collection and reporting were assessed using the Cochrane Risk of Bias Tool and McHarm tool. Synthesis methods comprised pooled estimate of the effect of dexamethasone on the risk of haemorrhage rate using the Peto odds ratio (OR) method. The pooled estimate for haemorrhage rate in children who received dexamethasone was 6.2%, OR 1.41 (95% confidence interval 0.89-2.25, P=0.15). There was risk of bias and inconsistent data collection and reporting rates of haemorrhage in many of the included studies. Clinical heterogeneity was observed between studies. The pooled analysis did not demonstrate a statistically significant increase in the risk of post-tonsillectomy haemorrhage with dexamethasone with/without NSAID use in children. However, the majority of the included studies were not designed to investigate this endpoint, and thus large studies which are specifically designed to collect data on haemorrhage rate are needed.

Anaesthetic Management in Obstructive Sleep Apnoea Syndrome for Adenotonsillectomy

The anaesthetic management of adenotonsillectomy in children with obstructive sleep apnoea syndrome is characteristic due to respiratory and cardiac side effects. A detailed physical examination in the preoperative period should be performed, including children's respiratory and cardiac systems. If they have an active infection, surgery should be postponed until the end of medical treatment. Preparation for difficult airway management should be done in the preoperative period. In this case, we presented a report of two children who had obstructive sleep apnoea syndrome, with airway management performed at the right lateral position to prevent the pharyngeal collapse and rapid sequence intubation performed using a short-acting muscle relaxant.

Gastric Decompression Decreases Postoperative Nausea and Vomiting in ENT Surgery

There is a passive blood flow to the stomach during oral and nasal surgery. It may cause postoperative nausea and vomiting (PONV). We researched the relationship between gastric decompression (GD) and severity of PONV in ear, nose, and throat (ENT) surgery. 137 patients who have been into ENT surgery were included in the study. In Group I (n = 70), patients received GD after surgery before extubation; patients in Group II (n = 67) did not receive GD. In postoperative 2nd, 4th, 8th, and 12th hours, the number and ratio of patients demonstrating PONV were detected to be significantly more in Group II as compared to Group I. PONV was also significantly more severe in Group II as compared to Group I. In Group I, the PONV ratio in the 2nd hour was significantly more for those whose amounts of stomach content aspired were more than 10 mL as compared to those whose stomach content aspired was less than 10 mL. In the 4th, 8th, and 24th hours, there is no statistically significant difference between the stomach content aspired and PONV ratio. GD reduces the incidence and severity of PONV in ENT surgery.

Consensus guidelines for the management of postoperative nausea and vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Common post-operative complications in children

The exact incidence of common post-operative complications in children is not known. Most common one is post-operative nausea and vomiting followed by respiratory complications leading to hypoxia. Cardiac complications are less in children without associated congenital cardiac anomaly. Post-operative shivering, agitation and delirium are seen more often in children anaesthetised with newer inhalational agents like sevoflurane and desflurane. Urinary retention in the post-operative period could be influenced by anaesthetic drugs and regional blocks. The purpose of this article is to review the literature and present to the postgraduate students comprehensive information about the current understanding and practice pattern on various common complications in the post-operative period. Extensive literature was searched with key words of various complications from Pubmed, Google scholar and specific journal, namely paediatric anaesthesia. The relevant articles, review article meta-analysis and editorials were the primary source of information for this article.

Adjunctive atropine versus metoclopramide: can we reduce ketamine-associated vomiting in young children? a prospective, randomized, open, controlled study

OBJECTIVES

Pediatric procedural sedation and analgesia (PPSA) with ketamine administration occurs commonly in the emergency department (ED). Although ketamine-associated vomiting (KAV) is a less serious complication of ketamine administration, it seems to be cumbersome and not uncommon. The authors evaluated the incidence of KAV and the prophylactic effect of adjunctive atropine and metoclopramide in children receiving ketamine sedation in the ED setting.

METHODS

This prospective, randomized, open, controlled study was conducted in children receiving ketamine sedation in the ED of a university-affiliated, tertiary hospital with 85,000 ED visits, including 32,000 pediatric patients from October 2010 to September 2011. The primary outcome was a measure of the incidence of KAV in the ED and after discharge according to the adjunctive drug administered. Secondary outcome measures included the time to resumption of a normal diet after ketamine sedation.

RESULTS

Of the 1,883 children administered ketamine for primary wound repair during the study period, a convenience sample of 338 patients aged 4 months to 5 years was enrolled. The incidences of KAV were 28.4% in the ketamine alone group, 27.9% in the ketamine with adjunctive atropine group, and 31.2% in the ketamine with adjunctive metoclopramide group (p = 0.86). The vomiting rate after discharge was 9.2% in the ketamine alone group. The nothing-by-mouth (NPO) status before sedation did not influence the incidence of KAV in any of the groups. Mean times to resumption of normal diet after ketamine administration were 7 hours 59 minutes in the ketamine alone group, 7 hours 35 minutes in the ketamine with atropine group, and 8 hours 1 minute in the ketamine with metoclopramide group (p = 0.64).

CONCLUSIONS

 In this study, a high rate (28.4%) of KAV was observed, consistent with prior reports using the intramuscular (IM) route. However, the authors were unable to reduce KAV using adjunctive atropine or metoclopramide. Parents or caregivers should be given more detailed discharge instructions about vomiting and diet considering the relatively long time to resuming a normal diet after ketamine sedation and the fact that KAV often occurred after ED discharge.

Dexamethasone versus ondansetron in combination with dexamethasone for the prophylaxis of postoperative vomiting in pediatric outpatients: a double-blind, randomized, placebo-controlled clinical trial

OBJECTIVES

To determine the frequency of postoperative vomiting (POV) in children submitted to outpatient surgery and to compare the efficacy of antiemetic drugs in preventing this complication.

BACKGROUND

Nausea and vomiting are common in the immediate postoperative period following anesthetic and surgical procedures. Compared to adults, pediatric patients are more likely to develop postoperative nausea and vomiting, the incidence of which ranges from 8.9% to 42%.

METHODS

This double-blind, randomized, placebo-controlled clinical trial included 129 children. The participants were randomized into three prophylactic treatment groups: dexamethasone (n = 43), ondansetron in combination with dexamethasone (n = 44), and placebo (n = 42). The variables studied were the frequency of POV and the incidence of vomiting after the patient had been discharged from hospital, the need for antiemetic rescue therapy in the postanesthesia care unit (PACU), need for hospitalization, and the time the patient remained in the PACU. A significance level of 5% was adopted.

RESULTS

Postoperative vomiting occurred in 12.4% of the children, with no statistically significant difference between the groups: 6.8% in the group receiving ondansetron combined with dexamethasone, 14.3% in the placebo group, and 14% in the group that received dexamethasone alone (P = 0.47). Furthermore, no significant difference was found between the groups with respect to the time the children remained in the PACU, and only five patients reported having vomited following discharge from hospital.

CONCLUSIONS

The prophylactic use of antiemetic drugs failed to reduce the incidence of POV in pediatric outpatient surgery with a low emetic potential; therefore, routine prophylaxis may be unnecessary.

Effect of systemic steroids on post-tonsillectomy bleeding and reinterventions: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the risk of postoperative bleeding and reintervention with the use of systemic steroids in patients undergoing tonsillectomy.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, Cochrane Library, Scopus, Web of Science, Intute, Biosis, OpenSIGLE, National Technical Information Service, and Google Scholar were searched. References from reviews identified in the search and from included studies were scanned.

REVIEW METHODS

Randomised controlled trials comparing the administration of systemic steroids during tonsillectomy with any other comparator were eligible. Primary outcome was postoperative bleeding. Secondary outcomes were the rate of admission for a bleeding episode, reintervention for a bleeding episode, blood transfusion, and mortality.

RESULTS

Of 1387 citations identified, 29 randomised controlled trials (n=2674) met all eligibility criteria. Seven studies presented a low risk of bias, but none was specifically designed to systematically identify postoperative bleeding. Administration of systemic steroids did not significantly increase the incidence of post-tonsillectomy bleeding (29 studies, n=2674 patients, odds ratio 0.96 (95% confidence interval 0.66 to 1.40), I&sup2;=0%). We observed a significant increase in the incidence of operative reinterventions for bleeding episodes in patients who received systemic steroids (12, n=1178, 2.27 (1.03 to 4.99), I&sup2;=0%). No deaths were reported. Sensitivity analyses were consistent with the findings.

CONCLUSIONS

Although systemic steroids do not appear to increase bleeding events after tonsillectomy, their use is associated with a raised incidence of operative reinterventions for bleeding episodes, which may be related to increased severity of bleeding events. Systemic steroids should be used with caution, and the risks and benefits weighed, for the prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their condition of use.

A comparison between dexamethasone and methylprednisolone for vomiting prophylaxis after tonsillectomy in inpatient children: a randomized trial

BACKGROUND

The frequent incidence of postoperative vomiting in children undergoing tonsillectomy, in addition to the occurrence of severe pain, may delay postoperative oral intake and lead to increased risk of dehydration. Thus, prophylactic therapy is indicated in this high-risk group. Glucocorticoids, such as dexamethasone and methylprednisolone, have anti-inflammatory and antiemetic properties with dexamethasone being frequently used. We hypothesized that methylprednisolone should be noninferior to dexamethasone for the prevention of vomiting in children after tonsillectomy.

METHODS

We designed a randomized double-blind trial to compare the efficacy of a single prophylactic dose of 0.5 mg/kg dexamethasone with a dose of 2.5 mg/kg methylprednisolone on the incidence of postoperative vomiting during the first 24 hours (primary outcome) in children undergoing total or partial tonsillectomy with a noninferiority margin set at 9%. One hundred sixty children undergoing total or partial tonsillectomy under general anesthesia were randomly assigned to receive either IV dexamethasone 0.5 mg/kg (n = 79) or methylprednisolone 2.5 mg/kg (n = 81) after induction of anesthesia. Secondary analysis of all studied outcomes was also performed according to the type of surgery.

RESULTS

An intention-to-treat analysis showed an overall incidence of vomiting of 30% in the dexamethasone group and of 22% in the methylprednisolone group (difference: 8%, 95% confidence interval [CI]: -5% to 21%). A per protocol analysis showed an incidence of vomiting of 32% and 23%, respectively (difference: 9%, and 95% CI of the difference: -5 to 23%, P(sup) = 0.28). The time and quality of oral intake and the duration of IV hydration, as well as pain and satisfaction scores and the need for analgesics, were similar between the 2 groups. The incidence of vomiting was also similar in patients who had total versus partial tonsillectomy; however, time to first oral intake, duration of IV hydration, and the need for analgesics were less with better satisfaction scores in partial versus total tonsillectomy patients.

CONCLUSION

Methylprednisolone is at worst 5% less effective than dexamethasone by the intention-to-treat analysis, and by the per protocol analysis. Thus, it is noninferior to dexamethasone in preventing vomiting after tonsillectomy in children.

Ambulatory anesthesia aspects for tonsillectomy and abrasion in children

PURPOSE OF REVIEW

Tonsillectomy is a very common procedure, but with risks or challenges, both for the surgeon and anesthesiologist. Many places have considerable experience and expertise with this procedure, and a lot of clinical studies are continuously being presented.

RECENT FINDINGS

Most preoperative aspects are covered, including indications, preoperative risk assessment, premedication, anesthetic induction and maintenance, as well as recovery function and side-effects; such as bleeding, agitation, pain, nausea and sleep apnea. Controversies exist as to ambulatory versus in-patient care, laryngeal mask airway versus endotracheal intubation, use of local anesthetic infiltration and use of glucocorticoids.

SUMMARY

Preoperative evaluation should identify increased bleeding risk, potential airway problems, ongoing infection and symptoms of obstructive sleep apnea.Intravenous propofol is most often used for anesthetic induction, although inhalational sevoflurane is a valid alternative. Laryngeal mask airway or endotracheal tube may both be used safely and effectively; the choice will depend upon the routine and experience of the team. Paracetamol and NSAIDs are useful baseline medication for nonopioid multimodal postoperative pain treatment and prophylaxis. Similar with local anesthesia infiltration and dexamethasone medication, although somewhat more disputed. Dexamethasone is also useful for nausea/vomiting prophylaxis, together with ondansetron and also propofol for anesthesia maintenance.