Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after tonsillectomy: a quantitative systematic review

Posttonsillectomy Pain Relief and Wound Healing by Applying Bismuth Iodoform Paraffin Paste (BIPP) to Dissected Tonsillar Beds

Introduction  Tonsillectomy is one of the most common operations performed by otorhinolaryngology surgeons worldwide; however, the insufficient quality of the postoperative pain management and effective posttonsillectomy pain relief remain a clinical dilemma. Objective  To evaluate the efficacy of applying bismuth iodine paraffin paste (BIPP) to the dissected fossa as an adjuvant therapy for a better outcome in terms of posttonsillectomy pain management and due to its wound healing properties. Methods  The present is a prospective randomized control pilot study with 44 patients aged > 7 years who underwent tonsillectomy. The patients were divided into two groups: the control group and the group that had BIPP applied to the dissected tonsillar fossa. The visual analogue scale score and the post-onsillectomy percentage of tonsillar fossa epithelization were recorded and evaluated. Results  Both subjectively and objectively, there a was statistically significant pain-relieving effect in the BIPP group within the first 5 postoperative days ( p  < 0.05). From postoperative day 3 onward, the dissected area of the tonsillar fossa healed significantly faster in the BIPP group compared with the control group, and it became stable on day 14. Conclusion  The topical application of BIPP showed a better pain-relieving effect, it was safe, and hastened wound healing after tonsillectomy.

Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single-Center Retrospective Propensity-Matched Study

OBJECTIVE

To determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48 hours.

STUDY DESIGN

Single-center retrospective propensity-matched study.

SETTING

Quaternary pediatric hospital and ambulatory surgery center.

METHODS

Patients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K-) patients were calculated for the total cohort and a 1:1 propensity-matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers.

RESULTS

There were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity-matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K- patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K- patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72-1.69, P = 0.662) in the propensity-matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K- patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K- patients (OR 1.33, 95% CI 0.63-2.81, P = 0.451) in the propensity-matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses.

CONCLUSION

Ketorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.

Analgesic Effects and Safety of Dexmedetomidine Added to Nalbuphine or Sufentanil Patient-Controlled Intravenous Analgesia for Children After Tonsillectomy Adenoidectomy

Tonsillectomy is a frequently performed surgical procedure in children, requiring post-operative analgesia. This study evaluated the efficacy and safety of nalbuphine or sufentanil combined with dexmedetomidine for patient-controlled intravenous analgesia (PCIA) after pediatric tonsillectomy adenoidectomy. A total of 400 patients undergoing tonsillectomy with and without adenoidectomy were included in the study. Patients received a PCIA pump (0.5 mg/kg nalbuphine, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group ND (n = 200). Patients received a PCIA pump (2 μg/kg sufentanil, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group SD (n = 200). More stable hemodynamic changes were noted in Group ND than Group SD from 1 h to 48 h after operation. At 6, 12, 24, and 48 h after operation, the children in Group ND had higher Ramsay sedation scores than those in Group SD. The times to push the PCIA button in Group ND and Group SD were 2.44 ± 0.74 and 2.62 ± 1.00, showing significant differences (p = 0.041). The VASR scores of children in Group ND were significantly lower within 6, 12, and 24 h than those in Group SD (p &lt; 0.05). The VASC scores of children in Group ND were significantly lower within four time points (2, 6, 12, and 24 h) than those in Group SD (p &lt; 0.05). At 1st day after surgery, the children in Group ND had lower levels of serum ACTH, IL-6, and COR levels than those in Group SD (p &lt; 0.001). The incidence rates of nausea and vomiting, and pruritus were significantly higher in Group SD than Group ND (5.00% vs. 11.00%, p = 0.028; 1.00% vs. 4.50%, p = 0.032). The total incidence rate of adverse reactions was significantly higher in Group SD than Group ND (15.00% vs. 31.00%, p = 0.0001). The study demonstrated that dexmedetomidine added to nalbuphine PCIA enhanced the analgesic effects, attenuated the postoperative pain, and reduced the stress response after pediatric tonsillectomy adenoidectomy.

One institution's experience with self-audit of opioid prescribing practices for common cervical procedures

BACKGROUND

We aim to audit our institution's opioid prescribing practices after common cervical procedures.

METHODS

Retrospective cohort study from one medical center. Reviewed records from 2016-2019 for 472 patients who underwent one of several common cervical procedures. Data collected on demographics, perioperative details, in-hospital pain medication use, and opioids prescribed at discharge. Multivariable logistic regression was run.

RESULTS

In hospital, median daily milligram morphine equivalents (MME) was 4 (IQR 0-15). Median MME prescribed at discharge was 112.5 MME (IQR 75-150). 3/472 patients received NSAIDs. Predictors of decreased discharge MME were age 70 and older (OR 0.33, p = 0.037) and more recent year (compared to 2016, OR 0.23 [p = 0.031] for 2017, OR 0.13 [p = 0.001] for 2018, and OR 0.070 [p < 0.001] for 2019).

CONCLUSIONS

MME prescribed at discharge was 28 times the daily in-hospital MME. Only 3/472 patients received postoperative NSAIDs. Self-auditing of opioid prescribing practices identifies actionable items for change.

Comparison of Postoperative Analgesic Effects Between Nalbuphine and Fentanyl in Children Undergoing Adenotonsillectomy: A Prospective, Randomized, Double-Blind, Multicenter Study

Objective: There is no universal agreement on optimal pharmacological regimens for pain management during surgeries. The aim of this study to compare the postoperative analgesic effects of nalbuphine with fentanyl in children undergoing adenotonsillectomy.

Design, Setting, Participants: We conducted a prospective, randomized, double-blind, non-inferiority and multicenter trial in 311 patients admitted to four different medical facilities in China from October 2017 to November 2018.

Main Outcome Measure: The primary outcome was postoperative pain score. The secondary outcomes were as follows: the numbers of patients who developed moderate or severe pain (FLACC ≥4 points); time to first rescue analgesic top up and the actual number of rescue pain medicine given in pain control in post-anesthesia care unit (PACU), and additional analgesics requirement (received ≥2 rescue analgesics or/and other analgesics except study medications administered in PACU and ward); emergence and extubation time; Waking up time; time of PACU stay, and other side effects (desaturation, nausea/vomiting etc.).

Results: A total of 356 children were screened and 322 patients were randomized. The mean age was 5.8 (5.5, 6.1) in the nalbuphine group and 5.6 (5.3, 5.8) in the fentanyl group (p = 0.2132). FLACC score of nalbuphine group was lower than that of fentanyl group upon patients' arrival at PACU (p < 0.05). The time to first required rescue dose of pain drug for nalbuphine group was longer than for the fentanyl group (2.5 vs 1.2 h, p < 0.0001). Only one patient (0.6%) in nalbuphine group presented a slow respiratory rate (RR) at 9/min while 29 patients (18.5%) in fentanyl group developed slow RR ≤10/min in PACU. Meanwhile, SpO₂ was lower in the fentanyl group at 10 min after patients’ arrival in PACU (p < 0.05). The other profiles observed from these two drug groups were similar.

Conclusion: Nalbuphine provided better pain relief with minimal respiration depression than fentanyl in children undergoing Adenotonsillectomy.

Risk factors of post-tonsillectomy hemorrhage in adults

OBJECTIVE

Tonsillectomy is an essential surgery and is conducted on both children and adults. However, the risk factors of post-tonsillectomy hemorrhage for adult patients remain unclear. In this study, we analyzed post-tonsillectomy hemorrhage in adult patients.

METHODS

We retrospectively analyzed 325 adult patients who underwent a tonsillectomy between 2014 and 2018 in our facilities.

RESULTS

The average age of this study's population was 31.7 ± 10.5 years (range: 19-70 years), and 250 (76.9%) patients were male. Overall, post-tonsillectomy hemorrhage occurred in 71 (21.8%) patients and 5 (1.5%) patients required a second surgery for hemostasis. Post-tonsillectomy hemorrhage often occurred on postoperative day zero or six. Using multiple logistic regression analysis, current smoking status (odds ratio 3.491; 95% confidence interval 1.813-6.723), male sex (odds ratio 3.924; 95% confidence interval 1.548-9.944), and perioperative non-steroidal anti-inflammatory drug administration (odds ratio 7.930; 95% confidence interval 1.004-62.64) were revealed as overall post-tonsillectomy hemorrhage risk factors. To analyze the hemorrhage period after tonsillectomy, we categorized the post-tonsillectomy hemorrhage patients into the primary (bleeding within postoperative day one) and secondary hemorrhage (bleeding on or after postoperative day two) groups. The current smoking status and older age were risk factors for primary hemorrhage and the current smoking status and sex (male) were risk factors for secondary hemorrhage.

CONCLUSIONS

In this study, smoking status, sex, and perioperative non-steroidal anti-inflammatory drug administration were the clinical risk factors for adult post-tonsillectomy hemorrhage. Thus, smoking cessation is, at least, mandatory for patients who receive tonsillectomy to avoid post-tonsillectomy hemorrhage.

LEVEL OF EVIDENCE

4.

Effects of Gabapentin Suspension and Rectal Acetaminophen on Postoperative Pain of Adenotonsillectomy in Children

Introduction

Adenotonsillectomy is the main treatment for symptomatic tonsillar hypertrophy with postoperative pain as the most common associated complication. The present study aimed to compare the efficacy of gabapentin with that reported for acetaminophen on the postoperative pain of adenotonsillectomy in children.

Materials and Methods

In this double-blind clinical trial, a total of 60 children within the age range of 7-15 years undergoing adenotonsillectomy were randomly allocated to two groups of gabapentin (n=30) and acetaminophen (n=30). The first group received a 10 mg/kg dose of gabapentin suspension preoperatively and placebo (suppository) after the intubation. The second group received a 40 mg/kg dose of acetaminophen suppository and placebo suspension simultaneous with that in the case group. Using the pain scale (based on the score of visual analog scale, prescribed drugs, dosage as well as incidence of postoperative nausea and vomiting were recorded 0, 2, 4, 6, 12, and 24 h after the surgery. The data were analyzed using SPSS software (version 22.0). A p-value less than 0.05 was considered statistically significant.

Results

There was no significant difference between the two groups considering the pain scores at 0, 2, 4, 6, 12, and 24 h after the surgery. In addition, the trend of pain intensity statistically decreased within 0 to 24 h in both acetaminophen (P<0.001) and gabapentin (P<0.001) groups. No statistically significant difference was observed between the two groups regarding the postoperative incidence of nausea and vomiting.

Conclusion

The obtained results of the present study showed that the administration of gabapentin and acetaminophen significantly reduced the postoperative pain of tonsillectomy and need for narcotics in these patients after the surgery. However, in this study, there was no particular reported superiority for any of the two groups in terms of the effects of gabapentin suspension and rectal acetaminophen.

Systematic review of analgesics and dexamethasone for post-tonsillectomy pain in adults

BACKGROUND

Intense pain can last several days after tonsillectomy. It is often undertreated and improved analgesic strategies that can be safely used at home are needed.

METHODS

We conducted a systematic review and meta-analysis on the effectiveness of systemic medications used for post-tonsillectomy pain in adult and adolescent (13 yr old) patients. Studies were identified from PubMed, the Cochrane Library, and by hand searching reference lists from studies and review articles. Randomised, double-blind, placebo-controlled studies reporting on pain intensity or use of rescue analgesia were included.

RESULTS

Twenty-nine randomised controlled trials representing 1816 subjects met the inclusion criteria. Follow-up time was ≤24 h in 15 studies, in which the majority were taking nonsteroidal anti-inflammatory drugs. Thirteen studies were suitable for meta-analysis. In pooled analysis, paracetamol, dexamethasone, and gabapentinoids reduced pain intensity on the day of operation. In individual studies, ketoprofen, ibuprofen, lornoxicam, parecoxib, rofecoxib, indomethacin and dextromethorphan reduced pain intensity, need for rescue analgesics, or both on the day of operation. Oral celecoxib for 2 postoperative weeks or i.v. ketamine on the day of operation were not effective at the studied doses. Dexamethasone in multiple doses provided analgesia beyond 1 postoperative day. Pain was moderate to strong in both study and control groups during the first postoperative week.

CONCLUSIONS

Single analgesics and dexamethasone provide only a weak to moderate effect for post-tonsillectomy pain on the day of operation and thus a multimodal analgesic strategy is recommended. Short follow-up times and clinical heterogeneity of studies limit the usefulness of results.

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period

Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.

Use of prescription drugs and risk of postoperative red blood cell transfusion in breast cancer patients: a Danish population-based cohort study

BACKGROUND

Several frequently used prescription drugs may affect bleeding risk. We investigated use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), and statins and risk of postoperative red blood cell transfusion in breast cancer patients.

METHODS

Using Danish population-based registries, we identified a cohort of women who underwent surgery for primary breast cancer (n = 22,238) during 2005-2012 and ascertained their use of aspirin, NSAIDs, SSRIs, and statins. For each drug, patients were categorized as users if they filled ≥1 prescription in the 60 days prior to surgery. We calculated the 14-day risk of red blood cell transfusion and relative risks (RRs) with 95% confidence intervals (CIs), comparing users with nonusers for each drug and adjusting for age, cancer stage, and Charlson Comorbidity Index score.

RESULTS

In our cohort, 1385 (6.2%) women were aspirin users, 1794 (8.0%) were NSAID users, 1110 (4.9%) were SSRI users, and 2053 (9.1%) were statin users. The overall risk of red blood cell transfusion was 1.3%. The 14-day risk of RBC transfusion was 3.5% among aspirin users versus 1.1% among aspirin nonusers (adjusted RR = 1.9, 95% CI: 1.4-2.7), and 1.8% among SSRI users versus 1.2% among SSRI nonusers (adjusted RR = 1.2, 95% CI: 0.7-1.9). Red blood cell transfusion risk was increased among NSAID users, but not in a sensitivity analysis with a 30-day exposure window. Red blood cell transfusion risk was not increased among SSRI and statin users.

CONCLUSIONS

Primary breast cancer surgery confers a low risk of RBC transfusion. Still, use of aspirin and possibly NSAIDs, but not SSRIs and statins, is associated with increased red blood cell transfusion. This increased risk is not explained by differences in age, stage, or comorbidity level.

Pediatric Adenotonsillectomy in a Low Resource Setting: Lessons and Implications

Objectives:

To examine the practices related paediatric adenotonsillectomy in our setting especially in relation to blood request and transfusion, routine investigations, post-operative analgesic practice and complications.

Methods:

We reviewed the record of paediatric patients who had adenotonsillectomy in our facility over a 5-year period to obtain relevant information to our study.

Results:

There were 33 males and 19 females with mean age of 3.27 ± 2.76 years. Sinus tachycardia was found in 11(21.2 %) of the subjects and T wave anomaly in 1(1.9%) of the subject. Thirty-five (67.3%) patient had adenotonsillectomy, 13(25.0 %) adenoidectomy only and 4(7.7%) tonsillectomy only. Majority of the patients (24, 46.2%) were classified as ASA physical status I. Pre-operative blood request rate was high (49, 94.3%) though the transfusion rate was 1.9 % (1 patient). Acetaminophen combined with other analgesics was used for post-operative analgesia for most of the patients. There was significant weight gain post-operatively among patient

Conclusions:

Cold steel adenotonsillectomy is safe and effective in our environment. We believe that there is no justification for routine pre-operative blood request as a preconditions for surgery. We also like to suggest that post-operative pain management be streamlined taking into consideration the available analgesics in our setting.

The Effect of Administration of Ketamine and Paracetamol Versus Paracetamol Singly on Postoperative Pain, Nausea and Vomiting After Pediatric Adenotonsillectomy

BACKGROUND

Tonsillectomy is one of the most common surgeries in children and posttonsillectomy pain and agitation management is a great challenge for anesthesiologists.

OBJECTIVES

The aim of this study was to compare the efficacy of a single dose of ketamine combined with paracetamol with paracetamol alone in the management of postoperative pain in tonsillectomy.

MATERIALS AND METHODS

In this study, the subjects were randomly allocated into the two groups: the ketamine and control. Intravenous paracetamol infusion (15 mg/kg) was started 15 minutes before the end of surgery in both groups, continued with the IV injection of ketamine (0.25 mg/kg) in the ketamine group and an equal volume of saline in the control group. Using the children's hospital of eastern Ontario (CHEOPS) pain scale, pain and agitation score and also the incidence of nausea and vomiting after the surgery were recorded in 0.5, 6 and 12 hours after the operation. Data were analyzed using SPSS software version 16 and P value less than 0.05 was considered as statistically significant in all cases.

RESULTS

There was no significant difference between the two groups considering demographic data (age, sex distribution, weight and height). The CHEOPS pain scales were significantly lower in the ketamine group compared to the control group at 0.5 and 6 hours after the surgery (P = 0.003 and P = 0.023, respectively). There was no significant difference in the CHEOPS scale at 12 hours after the surgery, dose of adjuvant analgesic and the incidence of nausea and vomiting after the surgery between the two groups.

CONCLUSIONS

According to the results of the current study, postoperative analgesia in children was improved in the ketamine group. Therefore, for better management of posttonsillectomy pain, low-dose ketamine administration with paracetamol is recommended.

Celecoxib pharmacogenetics and pediatric adenotonsillectomy: a double-blinded randomized controlled study

Background

Pediatric adenotonsillectomy (A&T) is associated with prolonged pain and functional limitation. Celecoxib is an effective analgesic in adult surgery patients; however, its analgesic efficacy on pain and functional recovery in pediatric A&T patients is unknown.

Methods

During 2009-2012, children (age 2-18 yr) scheduled for elective A&T were enrolled in a single-centre double-blind randomized controlled trial. Study participants received either oral placebo or celecoxib 6 mg·kg⁻¹ preoperatively, followed by 3 mg·kg⁻¹ twice daily for five doses. The primary outcome was the mean “worst 24-hr pain” scores during postoperative days (PODs) 0-2 on a 100-mm visual analogue scale (VAS). Secondary outcomes for PODs 0-7 included co-analgesic consumption, adverse events, and functional recovery. The impact of the CYP2C9*3 allele – associated with reduced celecoxib hepatic metabolism – on recovery was considered.

Results

Of the 282 children enrolled, 195 (celecoxib = 101, placebo = 94) were included in the primary outcome analysis. While on treatment, children receiving celecoxib experienced a modest reduction in the average pain experienced over PODs 0-2 (7 mm on a VAS; 95% confidence interval [CI]: 0.3 to 14; P = 0.04) and a “clinically significant” reduction (≥ 10 mm on a VAS; P ≤ 0.01) on PODs 0 and 1. During PODs 0-2, the mean acetaminophen consumption was lower in the celecoxib group vs the placebo group (78 mg·kg⁻¹; 95% CI: 68 to 89 vs 97 mg·kg⁻¹; 95% CI: 85 to 109, respectively; P = 0.03). No differences in adverse events, functional recovery, or satisfaction were observed by POD 7. The CYP2C9*3 allele was associated with less pain and improved functional recovery.

Conclusions

A three-day course of oral celecoxib reduces early pain and co-analgesic consumption; however, an increase in dose, dose frequency, and duration of dose may be required for sustained pain relief in the pediatric setting. The CYP2C9*3 allele may influence recovery. This trial was registered at: ClinicalTrials.gov: NCT00849966.

Electronic supplementary material

The online version of this article (doi:10.1007/s12630-015-0376-1) contains supplementary material, which is available to authorized users.

Comparing parecoxib and ketorolac as preemptive analgesia in patients undergoing posterior lumbar spinal fusion: a prospective randomized double-blinded placebo-controlled trial

Background

Poor postoperative pain control is frequently associated with complications and delayed discharge from a hospital. Preemptive analgesia is one of the methods suggested for reducing postoperative pain. Opioids are effective for pain control, but there known addictive properties make physicians cautious about using them. Parecoxib and ketorolac are potent non-opioid NSAIDs that are attractive alternative drugs to opioids to avoid opioid-related side effects. However, there are no good head-to-head comparisons between these two drugs in the aspect of preemptive analgesic effects in lumbar spinal fusion surgery. This study aimed to compare the efficacy in terms of postoperative pain control and safety of parecoxib with ketorolac as preemptive analgesia in posterior lumbar spinal fusion patients.

Methods

A prospective, double-blinded randomized controlled trial was carried out in patients undergoing posterior lumbar spinal fusion, who were randomized into 3 groups (n = 32). Parecoxib, ketorolac or a placebo was given to each patient via injection around 30 minutes prior to incision. The efficacy of postoperative pain control was assessed by a verbal numerical rating score (0–10). And various postoperative things were monitored for analysis, such as total opioid consumption, complications, and estimated blood loss.

Results

Both the ketorolac and parecoxib groups showed significantly better early postoperative pain reduction at the postanesthesia care unit (PACU) than the control group (p < 0.05). There were no differences between the pain scores of ketorolac and parecoxib at any time points. Complications and bleeding were not significantly different between all three groups.

Conclusions

Preemptive analgesia using both ketorolac and parecoxib showed a significantly better early postoperative pain control in the PACU than the control group in patients undergoing lumbar spinal fusion.

Trial registration

ClinicalTrials.gov NCT01859585. Registered 15 May 2013.

The effectiveness of pregabalin for post-tonsillectomy pain control: a randomized controlled trial

BACKGROUND

Although various analgesics have been used, postoperative pain remains one of the most troublesome aspects of tonsillectomy for patients.

OBJECTIVE

The aim of the present study was to evaluate the effectiveness of premedication using pregabalin compared with placebo (diazepam) on postoperative pain control in patients undergoing tonsillectomy.

METHODS

Forty-eight adult patients were randomly divided into a control group and a pregabalin group. Preoperatively, patients in the control group received 4 mg diazepam orally as placebo, whereas those in the pregabalin group received 300 mg pregabalin orally. All participants were provided with patient-controlled analgesia using fentanyl for 24 hours after surgery. Postoperative pain treatment included acetaminophen 650 mg three times daily for 8 postoperative days. The primary outcome measure was the total amount of patient-controlled fentanyl consumption after tonsillectomy. Secondary outcome measures were the number of injections of ketorolac tromethamine (each 30 mg) requested by patients, pain scores, overall satisfaction scores, drowsiness, nausea, dizziness, headache, and vomiting after the surgery. P < 0.05 was considered statistically significant.

RESULTS

The total amount of fentanyl demanded decreased significantly in the pregabalin group (P < 0.001). There were no significant differences in the number of ketorolac tromethamine injections, pain scores, overall satisfaction scores, drowsiness, nausea, dizziness, headache, and vomiting between the two groups.

CONCLUSION

Administration of 300 mg pregabalin prior to tonsillectomy decreases fentanyl consumption compared with that after 4 mg diazepam, without an increased incidence of adverse effects.

TRIAL REGISTRATION

KCT0001215.

Lung inflammatory response syndrome after cardiac-operations and treatment of lornoxicam

The majority of patients survive after extracorporeal circulation without any clinically apparent deleterious effects. However, disturbances exist in various degrees sometimes, which indicate the harmful effects of cardiopulmonary bypass (CPB) in the body. Several factors during extracorporeal circulation either mechanical dependent (exposure of blood to non-biological area) or mechanical independent (surgical wounds, ischemia and reperfusion, alteration in body temperature, release of endotoxins) have been shown to trigger the inflammatory reaction of the body. The complement activation, the release of cytokines, the leukocyte activation and accumulation as well as the production of several "mediators" such as oxygen free radicals, metabolites of arachidonic acid, platelet activating factors (PAF), nitric acid, and endothelin. The investigation continues today on the three metabolites of lornoxicam (the hydroxylated metabolite and two other metabolites of unknown chemical composition) to search for potential new pharmacological properties and activities.

Comparison of the effects of lornoxicam versus diclofenac in pain management after cardiac surgery: A single-blind, randomized, active-controlled study

BACKGROUND

Inadequate pain management after cardiac surgery may result 10 in increased morbidity and length of hospital stay. Although opioids are the mainstay of postoperative analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs) may be used instead to avoid the adverse effects (AEs) associated with opioids. Lornoxicam is a newly developed NSAID, the use of which is increasing. However, lornoxicam has not been studied for use in pain management after cardiac surgery.

OBJECTIVE

The objective of this study was to compare the efficacy and tolerability 10 of lornoxicam and diclofenac sodium, an NSAID well established for use in pain management after major surgery, in pain management after coronary artery bypass grafting (CABG).

METHODS

This single-blind, randomized, active-controlled study was conducted 10 at the Gaziantep University Hospital, Gaziantep, Turkey. Adult patients scheduled to undergo valve or CABG surgery for the first time were included. Patients were premedicated with diazepam 10 mg PO at 10 PM on the evening before surgery. General anesthesia was induced using fentanyl, midazolam, and propofol, and maintained using fentanyl and isoflurane in pure oxygen. After extubation and when they stated that they felt pain, patients were randomly assigned to 1 of 2 treatment groups: lornoxicam 8 mg IM q8h or diclofenac 75 mg IM q12h, for 48 hours. Meperidine 1 mg/kg IM was given for additional analgesia when needed (rescue medication). Pain relief was assessed using an I1-point visual analog scale (0 = no pain to 10 = worst pain imaginable) immediately before the first injection (baseline), and at 15 and 30 minutes and 1, 2, 3, 4, 6, 12, 18, 24, and 48 hours after the first injection. Sedation was assessed using a 5-point scale (0 = awake and alert to 4 = deep sedation) at the same time points. Tolerability was assessed by monitoring of AEs using patient interview and laboratory analyses.

RESULTS

Forty patients were enrolled in the study (30 men, 10 women; 10 mean [SD] age, 54.4 [11.1 ] years; 20 patients per treatment group). The demographic and clinical characteristics and mean baseline pain relief scores were statistically similar between the 2 treatment groups. The mean pain relief scores at 15 and 30 minutes were statistically similar to baseline values in the 2 treatment groups. However, the mean pain relief scores at ≥1 hour after the first injection were significantly lower compared with baseline values (both groups, P < 0.05 at time points ≥1 hour). No significant between-group differences in mean pain relief scores were found at any time point. The overall mean pain relief scores were statistically similar between the 2 treatment groups. The mean sedation scores were significantly higher at 30 minutes, 1 hour, and 2 hours after the first injection in the diclofenac group compared with the lornoxicam group (all, P < 0.05). No AEs were observed. The need for rescue medication was statistically similar between the 2 treatment groups (lornoxicam, 2 patients; diclofenac, 3 patients).

CONCLUSIONS

In this study of adult patients who underwent CABG, the efficacy 10 of lornoxicam and diclofenac were similar in postoperative pain management. Both study drugs were well tolerated.

Lornoxicam versus tramadol for post-operative pain relief in patients undergoing ENT procedures

Background:

Pain following ear-nose and throat surgery is one of the most important complaints for which, several drugs are used. This prospective, randomized, double-blind controlled trial was designed to compare the analgesic effect of tramadol versus lornoxicam for post-operative pain relief in patients undergoing ENT surgical procedures.

Methods:

One hundred and twenty patients of ASA class I-II, who had undergone elective ENT surgical procedures under general anesthesia, were assigned in a randomized manner into three equal groups. Group L received lornoxicam8 mg IV, Group T received tramadol 1 mg/kg IV and Group C received IV saline after induction of anesthesia before the start of the surgery. Post-operative pain was assessed using the visual analogue scale (VAS) and sedation level was evaluated during stay in the post-anesthesia care unit with a four-point sedation scale. Intraoperative blood loss was estimated using the Five-Point Scale. Adverse events in the first 24 h post-operative were recorded.

Results:

The VAS pain scores were significantly higher in Group C as compared with those in Groups L and T at 30 min and 1, 2, 4and 6 h post-operatively, with no significant difference between Group L and Group T. The amount of morphine consumption post-operatively was significantly lower in Group L (5.2 ± 2.5 mg) and Group T (5.0 ± 2.0 mg) as compared with that in Group C (7.4 ± 2.3 mg) (P = 0.001). The time for the first analgesic requirement was significantly less in Group L (92.62 ± 24.23 min) and Group T (88 ± 21.43 min) as compared with that in Group C (42.82 ± 25.61 min), with no significant difference between the other two groups. Estimated intraoperative blood loss score by the surgeons showed no significant difference between the three groups. The most frequent side-effects in the three groups were nausea and vomiting, and their incidence was significantly higher in the placebo group as compared with the other two groups.

Conclusion:

Tramadol 1 mg/kg was comparable to lornoxicam 8 mg for post-operative pain relief in patients undergoing ENT surgical procedures; both drugs helped to reduce the post-operative opioid requirement and consequently minimized the related adverse effects of the opioids.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

How to make tonsillectomy a safer procedure: the anaesthetist's view

Anaesthetists use specific drugs peri-operatively to try to decrease the incidence and severity of postoperative pain and of postoperative nausea and vomiting. These drugs are usually administered pre-operatively with the premedication, or intra-operatively when the patient is still anaesthetised. The aim of this approach is to prevent the occurrence of intolerable pain or to avoid any nausea or vomiting symptoms which may be clearly unpleasant for the patient and which interfere with the patient's well-being, recovery and satisfaction. However, since most of these drugs are given prophylactically, and since not all patients will actually be suffering from intolerable pain or severe nausea and vomiting symptoms postoperatively, many patients will receive these drugs unnecessarily. Thus, for the individual patient, the risk of suffering from drug-related adverse reactions without profiting from any benefit may be relevant. Perhaps a 'wait-and-see' approach should be considered; especially non-steroidal anti-inflammatory drugs or dexamethasone should not be given pre-operatively to all patients but should be provided exclusively to those in whom alternative analgesics (for instance, paracetamol combined with a weak opioid) or alternative anti-emetics (for instance, a setron or droperidol) have failed or are associated with unacceptable adverse effects. There is no evidence that prophylactic administration of an analgesic or an anti-emetic is more efficacious than the therapeutic administration. An interesting alternative to achieve satisfactory posttonsillectomy analgesia may be with local anaesthesia swabs that are applied onto the wound.

Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Systematic review of methods used in meta-analyses where a primary outcome is an adverse or unintended event

BACKGROUND

Adverse consequences of medical interventions are a source of concern, but clinical trials may lack power to detect elevated rates of such events, while observational studies have inherent limitations. Meta-analysis allows the combination of individual studies, which can increase power and provide stronger evidence relating to adverse events. However, meta-analysis of adverse events has associated methodological challenges. The aim of this study was to systematically identify and review the methodology used in meta-analyses where a primary outcome is an adverse or unintended event, following a therapeutic intervention.

METHODS

Using a collection of reviews identified previously, 166 references including a meta-analysis were selected for review. At least one of the primary outcomes in each review was an adverse or unintended event. The nature of the intervention, source of funding, number of individual meta-analyses performed, number of primary studies included in the review, and use of meta-analytic methods were all recorded. Specific areas of interest relating to the methods used included the choice of outcome metric, methods of dealing with sparse events, heterogeneity, publication bias and use of individual patient data.

RESULTS

The 166 included reviews were published between 1994 and 2006. Interventions included drugs and surgery among other interventions. Many of the references being reviewed included multiple meta-analyses with 44.6% (74/166) including more than ten. Randomised trials only were included in 42.2% of meta-analyses (70/166), observational studies only in 33.7% (56/166) and a mix of observational studies and trials in 15.7% (26/166). Sparse data, in the form of zero events in one or both arms where the outcome was a count of events, was found in 64 reviews of two-arm studies, of which 41 (64.1%) had zero events in both arms.

CONCLUSIONS

Meta-analyses of adverse events data are common and useful in terms of increasing the power to detect an association with an intervention, especially when the events are infrequent. However, with regard to existing meta-analyses, a wide variety of different methods have been employed, often with no evident rationale for using a particular approach. More specifically, the approach to dealing with zero events varies, and guidelines on this issue would be desirable.

Preoperative administration of etoricoxib in patients undergoing hip replacement causes inhibition of inflammatory mediators and pain relief

OBJECTIVE

Administering cyclooxygenase-2 inhibitors preoperatively appears attractive since these drugs reduce post-operative pain, but do not increase the risk of post-operative bleeds, asthmatic attacks and stress-related gastrointestinal ulcers. In a former investigation, we could show that post-operative administration of etoricoxib reduces prostaglandin production in wound fluid, but the onset of action is variable due to delayed post-operative absorption.

METHODS

In this study, we investigated the preoperative administration of etoricoxib in patients undergoing hip replacement. They received 120 mg etoricoxib or placebo 2 h before surgery and 1 day after in a double-blinded, randomized, parallel group design.

RESULTS

A total of 11 patients were randomized (placebo n = 5; verum n = 6). We found high and constant levels of the drug in blood, central nervous system and wound fluid already at the end of surgery (t(max) < 2 h). This was accompanied by inhibition of prostaglandin production in the wound tissue (treatment p < 0.05), suppression of interleukin 6 increase in plasma (treatment p < 0.01), and - despite existing standard pain relief procedures - higher satisfaction with analgesics (time vs. treatment p < 0.05) and less demand for opioids (treatment p < 0.01) and intrathecal bupivacaine (treatment p = 0.05) administration.

CONCLUSION

Administration of etoricoxib 2 h before surgery allows for an effective drug concentration in critical tissues, a reduction of the production of pro-inflammatory mediators and for better pain relief.

Comparison of different loading dose of celecoxib on postoperative anti-inflammation and analgesia in patients undergoing endoscopic nasal surgery-200 mg is equivalent to 400 mg

OBJECTIVE

To demonstrate the efficacy and noninferiority of loading dose of celecoxib 200 mg compared with 400 mg in pain management after endoscopic nasal surgery.

DESIGN

A prospective randomized controlled study.

SETTING

A university hospital.

PATIENTS

Consecutive 120 patients undergoing endoscopic nasal surgery under general anesthesia were randomly assigned to three groups of 40 patients each, celecoxib 400 mg, celecoxib 200 mg, or a control group with no celecoxib.

INTERVENTIONS

Patients received different doses of celecoxib as described 1 hour before anesthesia. Two celecoxib groups received celecoxib 200 mg every 12 hours until the fifth day after surgery.

OUTCOME MEASURES

Noninferiority could be claimed if the lower limit of the confidence interval (CI) for pain score difference was greater than -0.6. At 0, 6, and 48 hours after surgery, prostaglandin E2 (PGE2) and thromboxane A2 (TXA2) to prostaglandin I2 (PGI2) ratios were measured from incision drainage and in plasma.

RESULTS

Estimated difference between two loading doses for pain scores over 5 days was 0.275 (95%CI -0.255 to 0.805, P > 0.05), indicating the noninferiority of celecoxib 200-400 mg. Local PGE2 at 6 hours and 48 hours positively correlated with pain scores, with correlation coefficients 0.371 (P = 0.005) and 0.288 (P = 0.033). Systemic TXA2 to PGI2 ratios did not differ among groups.

CONCLUSIONS

An initial dose of celecoxib 200 mg was equivalent to celecoxib 400 mg with regard to the margin previously specified at -0.6 in reducing moderate postoperative pain in endoscopic nasal surgery both in analgesic efficacy and anti-inflammatory property. One hundred and twenty patients were included in this prospective randomized controlled study. Patients treated with celecoxib had lower pain scores than controls, pain scores correlating with local PGE2 level. An initial dose of celecoxib 200 mg was equivalent to 400 mg in reducing moderate pain after endoscopic nasal surgery.

Hemorrhage rate after coblation tonsillectomy: a meta-analysis of published trials

After the surgical procedure of tonsillectomy, hemorrhage ranks among its serious postoperative complications. In this systematic review, we analyze hemorrhage following tonsillectomies performed using the coblation technique. 24 prospective, randomized, and controlled studies were included in the meta-analysis. Data of 796 patients who had undergone coblation tonsillectomy were analyzed. Hemorrhages occurred in 33 patients: 2 classified as primary and 26 as secondary hemorrhages. 5 could not be classified into either group. Overall, the total hemorrhage rate for the coblation procedure was 4.1% with a 95% confidence interval from 2.8 to 5.5%. The overall hemorrhage rate of 4.1% found in this meta-analysis shows that coblation is a safe and effective technique for tonsillectomies with a secondary bleeding rate similar to what is reported for comparable techniques such as bipolar diathermia.

The effect of ibuprofen on postoperative hemorrhage following tonsillectomy in children

The objective of the study was to evaluate the effect of ibuprofen on hemorrhage after tonsillectomy in children. All charts of children, who underwent tonsillectomy with or without adenoidectomy, were reviewed. The age at the time of surgery ranged between 3 and 16 years (mean age = 7.55 ± 3.01 years). Children were divided into two groups based on the drugs used for postoperative pain relief. Group I received paracetamol after surgery. Group II received ibuprofen after surgery. A total of 62 patients received ibuprofen and 109 patients were given paracetamol. Post-tonsillectomy hemorrhage occurred in seven (4.1%) children, primary hemorrhage was noted in five patients and secondary hemorrhage occurred in two patients. While 3 of 62 children (4.8%) who were given ibuprofen had postoperative hemorrhage, 4 of 109 patients (3.7%) who were given paracetamol had hemorrhage There was no significant difference in hemorrhage rates between these two groups (p > 0.05). Hemorrhage following tonsillectomy is rare and frequently occurs in the early postoperative period. There is no significant increased risk of hemorrhage after ibuprofen administration and it can be used safely for post-tonsillectomy pain relief.

[Hemorrhage rates following coblation tonsillectomy. A meta-analysis of published trials]

BACKGROUND

With over 100,000 cases annually, tonsillectomy is one of the most frequently performed ENT surgical procedures in Germany. Hemorrhage ranks among its serious postoperative complications. In this systematic review, we analyze hemorrhage following tonsillectomies performed using coblation technique.

METHODS

Of the 135 studies identified, 38 could be included in the analysis, most being prospective randomized controlled studies. Data from 6290 patients were gathered.

RESULTS

Of all tonsillectomies performed, hemorrhages occurred in 355 patients. Of these, 256 cases could be classified as 41 primary and 215 secondary hemorrhages. Overall, the total hemorrhage rate for the coblation procedure was 4.9% (95%-CI: 0.044-0.054) for the fixed effects model.

CONCLUSION

Significantly higher rates of postoperative hemorrhage were found in a few studies, yet they were well above the 95% confidence interval of 4.4-5.4% of the literature. These studies could possibly be interpreted in terms of an autodidactic learning process. As with any surgical technique, proper training is essential.

Acute pain management in children

The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal.

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

BACKGROUND

Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice.

METHODS

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008.

RESULTS

Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks.

CONCLUSIONS

Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

The effectiveness of gabapentin on post-tonsillectomy pain control

Postoperative pain is one of the most troublesome aspects of tonsillectomy for patients. Although various analgesics have been administered for pain control following tonsillectomy, it has still not been effectively controlled. Therefore, this study was conducted to evaluate the effectiveness of premedication using gabapentin on postoperative pain control in patients undergoing tonsillectomy. A total of 58 adult patients were randomly divided into a control group and a gabapentin group. Patients in the control group received an oral placebo preoperatively, whereas those in the gabapentin group received an oral dose of gabapentin preoperatively. All participants were provided with patient-controlled analgesia using fentanyl for 48 h after surgery. The total amount of fentanyl injected and the number of injections of dicolfenac sodium (75 mg each) requested by each of the group was then compared. Pain assessment was performed using a visual analog scale during resting periods (rVAS) and during swallowing (sVAS) for 9 days after the operation. The number of dicolfenac sodium injections and the total amount of fentanyl injected decreased significantly in the gabapentin group (P < 0.01). The sVAS of the gabapentin group was also significantly lower than that of the control group at 2 and 4 h after surgery, but there were no significant differences in the sVAS observed between the two groups for the remainder of the postoperative period. There were no significant differences in the rVAS observed between the two groups throughout the postoperative period. Thus, premedication with gabapentin decreased post-tonsillectomy pain. So the addition of gabapentin prior to tonsillectomy may have an adjunctive role in pain control.

The effects of nonsteroidal anti-inflammatory drugs on platelet function and severity of upper gastrointestinal haemorrhage

Nonsteroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal (GI) damage primarily due to the inhibition of prostaglandin synthesis in gastric mucosa, which is an important factor in mucosa protection. Platelets are a cardinal feature of vascular repair. A variety of angiogenic stimulators are stored in platelets and are released during clotting at the wound. When there is a defect in any of these functions and/or platelet number, haemostasis is usually impaired and there may be an associated increased risk and severity of bleeding. While the mechanism of mucosal injury and bleeding are well documented with the use of NSAIDs, very little is known about the platelet function abnormalities and their effects on severity of upper GI bleedings. We performed a prospective analysis of 49 patients who had a history of NSAIDs use to investigate the association between the platelet function impairment associated with NSAIDs and severity of upper GI haemorrhages. Thirty-six of 49 patients (73.5%) had deteriorated platelet function. Mean severity score of patients with deteriorated platelet functions was 3.39, and that of patients with normal platelet functions was 2.46. Mean severity score was statistically significantly higher in patients with deteriorated platelet functions. In conclusion, impaired platelet functions associated with NSAIDs may cause more severe upper GI bleeding. Clinicians should be alert for GI complications especially in older patients and in those with a history of ulcer bleeding.

Pain therapy in children and adolescents

INTRODUCTION

In children, acute pain occurs predominantly during infectious illnesses or after surgery. Chronic pain, especially headache and abdominal pain, is becoming increasingly common among children and adolescents.

METHODS

Selective literature review, also including evidence-based guidelines and recommendations.

RESULTS

Simple self-reporting and behavioral pain scales are easy to use to assess the intensity of acute pain. To evaluate chronic pain, on the other hand, more complicated, multi-dimensional instruments are necessary (e.g., semi-structured interviews). The most commonly used analgesics are ibuprofen and paracetamol (acetaminophen). When paracetamol is used, its narrow therapeutic window should be kept in mind. Perioperative pain should be treated with balanced analgesia involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids, and regional anesthesia. Chronic pain in children can only be treated successfully over the long term with multidisciplinary team intervention based on this biopsychosocial model.

DISCUSSION

Pain not only causes children momentary suffering but also threatens to impair their normal development. Therefore, every effort should be made to prevent pain and to treat it effectively once it arises.

Intravenous Parecoxib Rapidly Leads to COX-2 Inhibitory Concentration of Valdecoxib in the Central Nervous System

Evidence in animal studies supports widespread induction of cyclooxygenase-2 (COX-2) in the central nervous system (CNS) following tissue injury, probably mediated by cytokines, transducing the signal across the blood-brain barrier. CNS COX-2 blockade is a possible therapeutic target for drugs that are able to reach adequate CNS levels and abolish the prostaglandin E2-induced central sensitization. This human pharmacokinetic study investigated valdecoxib cerebrospinal fluid (CSF) and plasma concentrations over time in 37 patients following 40 mg of single-dose intravenous parecoxib. High-performance liquid chromatography/tandem mass spectrometry analysis was performed. Valdecoxib was first detectable in the CSF at 15 min postdosing, increased rapidly until 50 min, and thereafter remained between 6 and 14 ng/ml. This is the first human study demonstrating CNS COX-2 inhibitor penetration as early as 15 min. CSF valdecoxib concentration rapidly reached in vitro IC50 (inhibitory concentration 50) (1.57 ng/ml) by 17 min and remained consistently higher thereafter.

Management of postoperative nausea and vomiting in children

Postoperative nausea and vomiting (PONV) continues to be a frequent and important cause of morbidity in children. Postoperative vomiting (POV) is more commonly studied in children than postoperative nausea because of a child's inability to effectively express distress after experiencing nausea. POV is problematic in children and is one of the leading postoperative complaints from parents and the leading cause of readmission to the hospital. POV occurs twice as frequently in children as in adults, increasing until puberty and then decreasing to adult incidence rates. Gender differences are not seen before puberty. POV remains a main cause of morbidity in children because severe vomiting can be associated with dehydration, postoperative bleeding, pulmonary aspiration, and wound dehiscence. While children have an increased potential for dehydration and the resulting physiologic impairments, other associated results such as a delay in hospital discharge or an overnight or longer hospital admission also must be considered. The two most common emetogenic surgical procedures evaluated in children are strabismus repair and adenotonsillectomy. The approach to the management of PONV and POV in children is similar to that in adults. However, as the rate of POV is more frequent in children than in adults, more children are candidates for antiemetic prophylaxis. The management approach is multifactorial and involves proper preoperative preparation, risk stratification, rational selection of antiemetic prophylaxis, choice of anesthesia technique, and a plan for postoperative antiemetic therapy. It is important to identify children at moderate-to-high risk for POV as prophylactic antiemetic therapy is useful in these children. Antiemetics of choice for POV in children include dexamethasone, dimenhydrinate, perphenazine, ondansetron, dolasetron, granisetron, and tropisetron. The serotonin (5-hydroxytryptamine; 5-HT(3)) antagonists are the antiemetic drugs of first choice for POV prophylaxis in children because as a group they have greater efficacy for preventing vomiting than nausea. The 5-HT(3) antagonists can be effectively combined with dexamethasone with an increase in efficacy. If possible, regional anesthesia should be considered. For those undergoing general anesthesia, the baseline POV risk should be reduced. Children at moderate-to-high PONV risk should receive combination therapy with two or three prophylactic antiemetics from different antiemetic drug classes. Reference to and the use of PONV guidelines and management algorithms help improve cost-effective postoperative care.

Apnea in a child after oral codeine: a genetic variant - an ultra-rapid metabolizer

We present a case of a 29 months old previously healthy child who experienced apnea resulting in brain injury following a dose of acetaminophen and codeine 2 days after an uneventful anesthetic for tonsillectomy. A genetic polymorphism leading to ultra-rapid metabolism of codeine into morphine resulted in narcosis and apnea. This paper discusses the use of codeine for pain relief, obstructive sleep apnea, the alteration of the CYP2D6 gene and the resulting effect on drug metabolism.

The efficacy of intravenous or peritonsillar infiltration of ketamine for postoperative pain relief in children following adenotonsillectomy

BACKGROUND

A few previous studies have suggested the efficacy of i.v. ketamine for postoperative pain relief in children after adenotonsillectomy, but none has investigated the efficacy of peritonsillar infiltration of ketamine in these children.

METHODS

This randomized, placebo-controlled study evaluated the effects of peritonsillar infiltration of ketamine in children undergoing adenotonsillectomy. Ninety ASA I-II children were randomized three groups of 30 each. Group I received: 2 ml i.v. saline, group II received i.v. ketamine (0.5 mgxkg(-1)) and group III received a local peritonsillar infiltration of ketamine (0.5 mgxkg(-1)). All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy. Modified Hannallah pain scale [observational pain scores (OPS)], nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at first, 15th, 30th and 60th min postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, vomiting and bleeding.

RESULTS

Group I had higher OPS scores than group II and group III. Group II and group III had comparable scores, which were not statistically significant (P > 0.05). Group II had higher sedation score at 15th min (P = 0.015). Thirty-two children, 19 of whom were in group I had rescue analgesia in postanesthesia care unit (P < 0.05) and the time to first analgesic requirement was significantly shorter in group I than the other groups (P = 0.006). Group II and group III also had less pain than group I at home (P = 0.023).

CONCLUSIONS

Low dose ketamine given i.v. or by peritonsillar infiltration perioperatively provides efficient pain relief without side-effects in children undergoing adenotonsillectomy.

The effect of gabapentin on post-operative pain following tonsillectomy in adults

BACKGROUND

The aim of the present study was to investigate whether a combination of rofecoxib and gabapentin could improve pain relief and reduce opioid requirements, compared with rofecoxib alone, during the first 5 days after tonsillectomy.

METHODS

In a randomized, double-blind, placebo-controlled study, 49 patients received gabapentin 1200 mg pre-operatively, followed by gabapentin 2 x 600 mg on the day of operation and gabapentin 3 x 600 mg for the next 5 days, or placebo. Both groups were given rofecoxib 50 mg daily. In the post-operative care unit, intravenous morphine was administered in doses of 2.5 mg on request. From 4 h to 5 days post-operatively, ketobemidone was offered as escape drug. Pain at rest and during swallowing, and side-effects, were assessed using a four-point verbal rating scale.

RESULTS

As a result of the global withdrawal of rofecoxib, the study had to be terminated prematurely. This report comprises the results from 22 patients in the gabapentin group and 27 patients in the placebo group. Gabapentin reduced ketobemidone requirements during the first 24 h post-operatively [4.5 mg (standard deviation, 3.0 mg) in the placebo group vs. 2.0 mg (standard deviation, 2.0 mg) in the gabapentin group; P < 0.003]. Gabapentin induced more dizziness (P < 0.002), gait disturbance (P < 0.02) and vomiting (P < 0.05) during days 0-5 than placebo. No other statistically significant differences were observed.

CONCLUSION

Gabapentin reduced opioid requirements in the first 24 h after tonsillectomy. The benefits of the reduced opioid intake may be overshadowed by the drawbacks of side-effects.

Tramadol vs morphine during adenotonsillectomy for obstructive sleep apnea in children

BACKGROUND

Optimal analgesia for children undergoing adenotonsillectomy for obstructive sleep apnea (OSA) is controversial. Tramadol may represent a superior choice over morphine in this group, with a potential to cause less postoperative sedation and respiratory depression. Optimal perioperative analgesia may allow expensive and time-consuming preoperative work-up and postoperative monitoring to be rationalized.

METHODS

Sixty-six children were randomized to receive either perioperative tramadol or morphine in this double blinded, prospective, controlled trial. Postoperative sedation, pain, respiratory events, and vomiting were then compared between groups.

RESULTS

There was no significant difference between the two groups in sedation scores 1 h after arrival in recovery (P = 0.24) or at any other time up to 6 h postoperation. There was also no evidence of a difference between the groups in pain scores up to 6 h postoperation. There were fewer episodes of postoperative desaturation (<94%) in the tramadol group up to 3 h postoperation, with 26% fewer episodes in the tramadol group during the second hour postoperation (P = 0.02). Overall, there was a trend toward fewer desaturation episodes in the tramadol group.

CONCLUSIONS

Tramadol may be a suitable drug for children undergoing adenotonsillectomy for OSA. Further work is required to investigate this.

Preoperative greater occipital nerve block in total thyroidectomy patients can reduce postoperative occipital headache and posterior neck pain

Patients undergoing thyroidectomy with neck fully extended usually experience occipital headache and posterior neck pain. We have attempted to evaluate the effect of preoperative greater occipital nerve (GON) block on occipital headache and posterior neck pain after thyroidectomy. Eighty-two patients undergoing elective total thyroidectomy were randomly allocated to two groups. In block group, bilateral GON blocks with 0.25% bupivacaine were performed. The control group did not have any prior block. Occipital headache and posterior neck stiffness were assessed using the visual analogue scale (VAS) and verbal rating scale. VAS of occipital headache and posterior neck pain in block group was significantly lower compared to that in the control group at postoperative 12 and 24 hours (p < 0.05). In addition, the proportion of patients reporting moderate or severe occipital headache and posterior neck pain at postoperative 12 and 24 hours in block group was significantly lower than that in control group (p < 0.001). No side effects were observed during and after GON block. We conclude that preoperative GON block with 0.25% bupivacaine is an effective technique to reduce occipital headache and posterior neck pain after thyroid surgery.

Ketoprofen and tramadol for analgesia during early recovery after tonsillectomy in children

BACKGROUND

Pain following tonsillectomy is often intense. Nonsteroidal anti-inflammatory drugs and opioids are effective, but both can cause adverse effects. Tramadol may be a viable alternative for post-tonsillectomy pain. This study was designed to compare the analgesic effects of ketoprofen and tramadol during the early recovery period after tonsillectomy.

METHODS

Forty-five ASA class I children (9-15 years) were randomized to receive either saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)) after induction of anesthesia. Upon completion of surgery, the study treatment was continued as a 6 h intravenous (i.v.) infusion of another dose of saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)). Postoperatively, each patient received rescue analgesia with patient-controlled analgesia (PCA) device programmed to deliver 0.5 microg.kg(-1) bolus doses of fentanyl. Postoperative pain was assessed using Visual Analog Scale (VAS) during swallowing. Intraoperative blood loss was measured.

RESULTS

The total number of requests of PCA-fentanyl was significantly less in ketoprofen group compared with tramadol and placebo groups (P = 0.035 and P = 0.049, respectively, in pairwise comparisons) and the VAS scores for pain were significantly lower in ketoprofen group compared with tramadol (P = 0.044) or placebo groups (P = 0.018) during the first six postoperative hours. Measured intraoperative blood loss was greater in ketoprofen-treated patients than in those receiving placebo (P = 0.029).

CONCLUSION

A dose of 4 mg.kg(-1) of i.v. ketoprofen provided good pain relief with moderate supplemental PCA-fentanyl requirements during the first six postoperative hours after tonsillectomy in children whereas the effects of 2 mg.kg(-1) of i.v. tramadol did not differ from those of placebo.

An evaluation of pain and postoperative nausea and vomiting following the introduction of guidelines for tonsillectomy

BACKGROUND

Tonsillectomy and adenotonsillectomy have a high incidence of postoperative pain, and postoperative nausea and vomiting (PONV). Pain is traditionally controlled with morphine but this increases the risk of PONV and may cause respiratory depression. Antiemetics reduce PONV but their routine use has been questioned on safety grounds.

METHOD

After determining the current anesthetic management of elective tonsillectomy and adenotonsillectomy patients in our hospital, guidelines were developed to avoid the routine use of morphine and antiemetics. The effect on pain and PONV was then evaluated over a 3 month period. Postoperative pain was scored using the Oucher visual analog scale and nausea scored using a five point scale.

RESULTS

We analysed 34 cases to determine our current practice and 37 cases to evaluate the effect of introducing guidelines. Postguidelines, the median Oucher pain score at 4 h was 10, and at 8, 12, 16 h was zero. Despite receiving no antiemetics, only two children vomited (5%) after introduction of guidelines.

CONCLUSION

Guidelines which use a combination of paracetamol, nonsteroidal anti-inflammatory drugs and fentanyl, provide excellent analgesia with minimal PONV after elective tonsillectomy and adenotonsillectomy. As a result the routine use of morphine and antiemetics can be avoided.

Efficacy of oral rofecoxib versus intravenous ketoprofen as an adjuvant to PCA morphine after urologic surgery

BACKGROUND

Adjunctive use of nonsteroidal anti-inflammatory drugs has become increasingly popular in the perioperative period because of their opioid-sparing effects. This randomized, controlled, double-dummy study was designed to evaluate the cost-effectiveness of using oral rofecoxib as an alternative to intravenous ketoprofen for pain management in patients undergoing urologic surgery.

METHODS

Seventy patients were randomly assigned to receive either a placebo (Control) or rofecoxib 50 mg po (Rofecoxib) 1 h prior to surgery. After a standardized spinal anesthetic, patients in the Control group received ketoprofen 100 mg IV q 8 h for 24 h, while the Rofecoxib group received an equivolume of saline at 8-h intervals for 24 h. Both groups were allowed to self-administer morphine (1 mg IV boluses) using a PCA delivery system. The need for 'rescue' analgesic medication, as well as pain scores [using an 11-point verbal rating scale (VRS) (0 = none to 10-severe)], were recorded at 1, 2, 6, 12, and 24-h intervals after surgery. In addition, the incidences of side-effects were recorded at the end of the study period.

RESULTS

Total amount of morphine required in the initial 24-h postoperative period was nonsignificantly reduced in the Rofecoxib group (29 +/- 2 vs. 37 +/- 4 mg). More importantly, the percentage of patients reporting moderate-to-severe pain (VRS score > or =4) during the study period was lower in the Rofecoxib group (12 vs. 22%, P < 0.05). The daily cost of rofecoxib (USD 1.14 for 50-mg dose) was also significantly less than ketoprofen (USD 3.06 for three 100-mg doses).

CONCLUSION

Premedication with oral rofecoxib (50 mg) is a cost-effective alternative to the parenteral nonselective NSAID, ketoprofen (100 mg q 8 h), when used as an adjuvant to PCA morphine for pain management after urologic surgery.

Diclofenac and metabolite pharmacokinetics in children

BACKGROUND

Data concerning metabolism of diclofenac in children are limited to intravenous and enteric coated oral formulations. There are no data examining diclofenac or its hydroxyl metabolite pharmacokinetics after rectal administration in children.

METHODS

Infants (n = 26) undergoing tonsillectomy were given diclofenac 2 mg.kg(-1) followed by 1 mg.kg(-1) 8 h as suppository formulation for postoperative analgesia. Serum was assayed for diclofenac, 4'-hydroxydiclofenac and 5'-hydroxydiclofenac concentrations during the procedure and 1, 2 and 4 h postoperatively. The formation clearances of diclofenac to hydroxyl metabolites were estimated using nonlinear mixed effects models. A single compartment, first order absorption and first order elimination model was used to describe diclofenac pharmacokinetics. Published data from 11 children given enteric-coated diclofenac tablets were used to assess relative bioavailability.

RESULTS

Mean (sd) age and weight of the patients were 4.5 (1.5) years and 20.5 (4.1) kg. The formation clearance to 4'-hydroxydiclofenac (% CV) and to 5'-hydroxydiclofenac were 8.41 (8.1) and 3.41 (113) l.h(-1) respectively, standardized to a 70 kg person using allometric '1/4 power' models. Clearance by other routes contributed 33.0 (64) l.h(-1) 70 kg(-1). Elimination clearance of hydroxyl metabolites was fixed at 27.5 l.h(-1) 70 kg(-1). The volumes of distribution of parent diclofenac and its hydroxyl metabolite were 22.8 (19.0) and 45.3 (l.70) kg(-1). The suppository formulation had an absorption half-life of 0.613 (33.2) h with a lag time of 0.188 (24.9) h. Interoccasion variability of formation clearance to 4'-hydroxydiclofenac, diclofenac volume of distribution, absorption half-time and lag time for the suppository was 36%, 55%, 14% and 119%, respectively. The relative bioavailability of the suppository compared with an enteric-coated tablet was 1.26.

CONCLUSION

The formation clearance of the active metabolite 4'-hydroxydiclofenac contributed 19% of total clearance (44.82 l.h(-1) 70 kg(-1)). The rectum is a suitable route for administration of diclofenac in children 2-8 year of age and was associated with a higher relative bioavailabilty than enteric-coated tablets and an earlier maximum concentration (50 vs. 108 min). This pharmacokinetic profile renders diclofenac suppository a suitable formulation for short duration surgery.

[Non-opioid analgesics for perioperative pain therapy. Risks and rational basis for use]

Non-opioid analgesics play a central role in the management of postoperative pain. In this review, the pharmacology, the analgesic efficacy and the side-effects of non-opioid analgesics are summarized. First, the pharmacology of diclofenac, acetyl salicylic acid, dipyrone, acetaminophen and the COX-2 inhibitors is described. Second, the analgesic efficacy of non-opioid analgesics is analyzed for moderate pain (e.g. ambulatory surgery) and for moderate to severe pain (e.g. abdominal surgery-in combination with opioids). There is limited evidence for an additive analgesic effect of two non-opioid analgesics. Third, the major side-effects of non-opioid analgesics are discussed in relation to the pathophysiology, the frequency and the clinical relevance of these effects. In particular, side-effects on the gastrointestinal tract (ulcus formation), on coagulation (bleeding and thrombosis), on the renal (renal insufficiency), the pulmonary (bronchospasm) and the hematopoetic systems (agranulocytosis) are described. Recommendations for the clinical use of non-opioid analgesics for perioperative pain therapy are given.

A systematic review of COX-2 inhibitors compared with traditional NSAIDs, or different COX-2 inhibitors for post-operative pain

BACKGROUND

We have reviewed the analgesic efficacy of cyclooxygenase-2 (COX-2) inhibitors compared with traditional non-steroidal anti-inflammatory drugs (NSAIDs), different COX-2 inhibitors, and placebo in post-operative pain.

METHODS

Randomized controlled trials were evaluated. Outcome measures were pain scores and demand for supplementary analgesia 0-24 h after surgery.

RESULTS

Thirty-three studies were included in which four COX-2 inhibitors, rofecoxib 50 mg, celecoxib 200 and 400 mg, parecoxib 20, 40 and 80 mg, and valdecoxib 10, 20, 40, 80 mg were evaluated. Ten of these studies included 18 comparisons of rofecoxib, celecoxib, or parecoxib with NSAIDs. Rofecoxib 50 mg and parecoxib 40 mg provided analgesic efficacy comparable to that of the NSAIDs in the comparisons, and with a longer duration of action after dental surgery but possibly not after major procedures. Celecoxib 200 mg and parecoxib 20 mg provided less effective pain relief. Four studies included five comparisons of rofecoxib 50 mg with celecoxib 200 and 400 mg. Rofecoxib 50 mg provided superior analgesic effect compared with celecoxib 200 mg. Data on celecoxib 400 mg were too sparse for firm conclusions. Thirty-three studies included 62 comparisons of the four COX-2 inhibitors with placebo and the COX-2 inhibitors significantly decreased post-operative pain.

CONCLUSION

Rofecoxib 50 mg and parecoxib 40 mg have an equipotent analgesic efficacy relative to traditional NSAIDs in post-operative pain after minor and major surgical procedures, and after dental surgery these COX-2 inhibitors have a longer duration of action. Besides, rofecoxib 50 mg provides superior analgesic effect compared with celecoxib 200 mg.