Preoperative peritonsillar lornoxicam infiltration is not superior to intravenous lornoxicam for pain relief following tonsillectomy in adults

Systematic Review and Meta-Analysis of the Association Between Non-Steroidal Anti-Inflammatory Drugs and Operative Bleeding in the Perioperative Period

BACKGROUND

It is increasingly recognized that non-opioid analgesia is an important analgesia in the perioperative period. Specifically, NSAIDs (nonsteroidal anti-inflammatory drugs) have been touted as an adjunct, or even replacement, for opioids. However, uptake of NSAIDs has been slow due to concern for side effects, including bleeding. We sought to understand the risk of bleeding caused by NSAIDs in the perioperative period.

STUDY DESIGN

A physician-librarian team performed a search of electronic databases (MEDLINE, EMBASE), using search terms covering the targeted intervention (use of NSAIDs) and outcomes of interest (surgical complications, bleeding), limited to English language articles of any date. We performed a systematic review and meta-analysis of the data.

RESULTS

A total of 2,521 articles were screened, and 229 were selected on the basis of title and abstract for detailed assessment. Including reference searching, 74 manuscripts met inclusion criteria spanning years 1987-2019. These studies included 151,031 patients. Studies included 12 types of NSAIDs, the most common being ketorolac, diclofenac, and ibuprofen, over a wide-range of procedures, from otorhinolaryngology (ENT), breast, abdomen, plastics, and more. More than half were randomized control trials. The meta-analyses for hematoma, return to the operating room for bleeding, and blood transfusions showed no difference in risk in any of 3 categories studied between the NSAID vs non-NSAID groups (p = 0.49, p = 0.79, and p = 0.49, respectively). Quality scoring found a wide range of quality, with scores ranging from lowest quality of 12 to highest quality of 25, out of a total of 27 (average = 16).

CONCLUSIONS

NSAIDs are unlikely to be the cause of postoperative bleeding complications. This literature covers a large number of patients and remains consistent across types of NSAIDs and operations.

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.

Barbed reposition pharyngoplasty in multilevel robotic surgery for obstructive sleep apnoea

The surgical treatment of obstructive sleep apnoea in patients who are non-compliant with continuous positive airway pressure therapy still represents a valid alternative. In recent years, the multilevel approach is becoming more diffuse in routine surgical practice, especially since the introduction of transoral robotic surgery. Barbed reposition pharyngoplasty in multilevel robotic surgery for OSA may represent a valid option to surgically approach the soft palate. Herein, we describe the technique and preliminary results of our experience.

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.

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.

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

BACKGROUND

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

OBJECTIVE OF REVIEW

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

SEARCH STRATEGY

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

EVALUATION METHOD

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

RESULTS

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

CONCLUSIONS

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

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.

Intravenous lornoxicam is more effective than paracetamol as a supplemental analgesic after lower abdominal surgery: a randomized controlled trial

BACKGROUND

The aim of this prospective, randomized, double-blind study was to determine the more effective supplemental analgesic, paracetamol or lornoxicam, for postoperative pain relief after lower abdominal surgery.

METHODS

Sixty patients scheduled for lower abdominal surgery under general anesthesia were randomly allocated to receive either isotonic saline (control group), intravenous paracetamol 1 g every 6 h (paracetamol group), or lornoxicam 16 mg then 8 mg after 12 h (lornoxicam group). Additionally pain was treated postoperatively with morphine patient-controlled analgesia. Postoperative pain scores measured by the verbal pain score (VPS), morphine consumption, and the incidence of side effects were measured at 1, 2, 4, 8, 12, and 24 h postoperatively.

RESULTS

Morphine consumption at 12 and 24 h was significantly lower in the lornoxicam group (19.25 ± 5.7 mg and 23.1 ± 6.5 mg) than in the paracetamol group (23.4 ± 6.6 mg and 28.6 ± 7.6 mg). Both treatment groups had less morphine consumption than the control group (28.5 ± 5 mg and 38.1 ± 6.6 mg) at 12 and 24 h, respectively. Additionally, VPS was reduced in the paracetamol and the lornoxicam groups compared with the control group both at rest and on coughing. Further analysis revealed that VPS in the lornoxicam group was significantly lower than that in the paracetamol group only during coughing. Drug-related side effects were comparable in all groups.

CONCLUSIONS

Lornoxicam is superior to paracetamol for postoperative analgesia after lower abdominal surgery. However, paracetamol could be an alternative supplemental analgesic whenever an NSAID is unsuitable.

TRIAL REGISTRATION

clinicaltrials.gov.identifier:NCT01564680.