A new analgesia regimen after (adeno) tonsillectomy in children: a pilot study

Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

OBJECTIVE

Postoperative pain is the most common morbidity associated with tonsillectomy. Opioids are frequently used in multimodal posttonsillectomy analgesia regimens; however, concerns regarding respiratory depression, drug-drug interactions, and medication misuse necessitate responsible opioid stewardship among prescribing surgeons. It is unclear if intentionally reducing opioid prescription doses negatively affects the patient experience.

METHODS

A quality improvement team reviewed all posttonsillectomy opioid prescriptions at a pediatric ambulatory surgery center between January and June 2021 (preintervention, 163 patients). Following this review, we performed an opioid education session for surgeons and studied opioid prescribing habits between July and December 2021 (Plan-Do-Study-Act [PDSA] 1, 152 patients). We then implemented a standardized prescription protocol of 7 doses of oxycodone per patient and again reviewed prescriptions between January and June 2022 (PDSA 2, 178 patients). The following measures were evaluated: initial number of opioid doses prescribed, need for refills, 7-day emergency department (ED) visits, and readmissions.

RESULTS

Each intervention reduced the average number of initial oxycodone doses per patient (12.2 vs 9.2 vs 6.9 doses, P < .001). There were no changes in the rate of refill requests, 7-day ED visits, and readmissions, by descriptive or Statistical Process Control analyses.

DISCUSSION

In 2 PDSA cycles, we achieved a 43% reduction in the number of doses of oxycodone prescribed following tonsillectomy. We did not observe any increased rates in balancing measures, which are surrogates for unintentional effects of PDSA changes, including refills, ED presentations, and readmission rates.

IMPLICATIONS FOR PRACTICE

Directed provider education and standardized posttonsillectomy prescription protocols can safely decrease postoperative opioid prescribing. Further PDSA cycles are required to consider even fewer opioid prescription doses.

Postoperative pain course after paediatric tonsillectomy: A prospective observational study comparing one behavioural and one numerical pain assessment tool

INTRODUCTION

Paediatric tonsillectomy is often performed as outpatient surgery, although postoperative pain may be severe and protracted. This prospective observational study evaluated two paediatric pain assessment tools for use in telephone interviews with parents.

METHODS

ASA I-II children, ≥1 and < 13 years, undergoing outpatient tonsillectomy were recruited. Anaesthesia (propofol-remifentanil) and intraoperative analgesia were standardized. Sedating premedication was not given. Before discharge, a "smiley face" numerical pain assessment tool was introduced to parents. In telephone interviews on postoperative days 1, 3, 7 and 14, parents scored their childrens pain numerically (0-10) and on the behavioural Postoperative Pain Measure for Parents (PPMP, 0-15). Number of analgesic doses (paracetamol/ibuprofen) per 24 h was noted. Values are median (quartiles).

RESULTS

22 consecutive children were included, age 4 (3-6) years. Parents had administered analgesics to 100%, 95%, 80%, and 5% of children at the four interview times. Numerical pain scores were 3.5 (1-7) at hospital discharge, and 5.5 (3-7), 3 (2-6), 3.5 (0-6), and 0 (0-0) on postoperative days 1, 3, 7, and 14, respectively. In 12/22 children, pain declined to a value of 1 (0-2) on day 7. In 6/22 children pain initially declined, but surged to 5.5 (4-7) on day 7. Significant, protracted pain (9 (6-10) on day 7) was reported in 3/22 children. Behavioural (PPMP) scores were positively correlated to numerical pain scores (day 3: R² = 0.48, day 7: R² = 0.31, day 14: R² = 0.85). With increasing age, children systematically had lower behavioural pain scores for the same numerical pain score (0.61 per years age; p < 0.023).

CONCLUSION

In structured telephone interviews, parents effectively pain scored their children after outpatient tonsillectomy. Numerical and behavioural pain scores correlated well, however age-dependent. Pain courses varied considerably, and a majority of children had significant pain. Pain after paediatric tonsillectomy should be assessed and treatment individualised.

Post-Tonsillectomy Outcomes in Children With and Without Narcotics Prescriptions

OBJECTIVE

To examine differences in outcomes after tonsillectomy in children who received outpatient narcotics prescriptions compared to those who did not.

METHODS

The MarketScan database was analyzed for claims made for 14 days following tonsillectomy/adenotonsillectomy between 2008 and 2012 for privately insured children 1 to 17 years. Post-op bleeding, dehydration, emergency department (ED) visits, readmissions, and mean total costs for the 14 days after tonsillectomy were compared.

RESULTS

Of the 294 795 patients included, 60.9% received a narcotic prescription. Acetaminophen/hydrocodone bitartrate was received by 53.2% of the group receiving narcotic drugs, 42.5% received acetaminophen/codeine phosphate, 3.0% received acetaminophen/oxycodone hydrochloride, and 0.5% received oxycodone hydrochloride alone. Children who had been prescribed narcotics had significantly higher percentages of bleeding complications (2.7% vs 2.5%, P < .001), and ED visits (6.8% vs 6.6%, P < .001) within 14 days, but a lower percentage of readmissions (1.0% vs 1.5%, P < .001). No significant difference was observed between groups for dehydration. There were some age-related differences. The mean total health-care costs for 14 days post-op were the same in each group, except for the 4- to 6-year-olds, where the narcotic group had higher costs (US $7060 vs US $5840, P = .006).

CONCLUSION

In this large-scale study, we found small but statistically significant differences in outcomes related to use of narcotics. The only outcome that benefitted the narcotics group was a lower readmission rate.

Ibuprofen for Pain Control in Children: New Value for an Old Molecule

BACKGROUND

Acute pain is one of the major complaints reported in pediatric emergency departments and general wards. Recently, both the US Food and Drug Administration and European Medicine Agency emitted some warnings regarding the use of opioids, including codeine, in children.

OBJECTIVE

The aims of this study were summarizing the main pharmacological aspects of ibuprofen, discussing the current evidence about the use of ibuprofen in different and specific clinical settings, and providing a comparison with acetaminophen and/or codeine, according to available studies.

STUDY DESIGN AND METHODS

Studies evaluating ibuprofen for the management of acute pain in children were extracted from the PubMed and MEDLINE database within the period ranging from 1985 through 2017. After discussing safety of ibuprofen and its concomitant use with acetaminophen, the specific indications for the clinical practice were considered.

RESULTS

Ibuprofen resulted to be more effective than acetaminophen, and comparable to the combination acetaminophen-codeine, for the control of acute pain related to musculoskeletal pain. Moreover, similar results have been reported also in the management of toothache and inflammatory diseases of the oral cavity and pharynx. Ibuprofen resulted to be useful as a first approach to episodic headache. Finally, the role of ibuprofen in the management of postoperative pain and, particularly, after tonsillectomy and/or adenoidectomy has been reconsidered recently.

CONCLUSIONS

Ibuprofen resulted to be the most studied nonsteroidal anti-inflammatory drug in the management of acute pain in children; in general, it showed a good safety profile and provided evidence of effectiveness, despite some differences according to the specific clinical context.

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

Background: Adenotonsillectomy remains one of the most frequently performed surgical procedures in children. Despite improvements in anaesthetic and surgical techniques, severe pain is reported in as many as 25–50% of children. Pain assessment and knowledge of drug pharmacodynamics and pharmacokinetics in the paediatric patient, is a prerequisite for optimal care. Much has been written on perioperative pain management following tonsillectomy. However, no consensus has been reached on what the ideal analgesic regimen should be. This audit is a review of current practice at Chris Hani Baragwanath Academic Hospital. It aims to identify problems and develop possible solutions to improve anaesthetic practice. Methods: A prospective, contextual, descriptive study design using a data collection sheet was used on paediatric patients presenting for tonsillectomy. Results: Eighty-five patients aged three to 12 years of age, with ASA grading I or II, were enrolled in the study. The choice of anaesthetic was variable with a combination of simple analgesics, opioids and adjuvants. This affected postoperative pain scores. Snare dissection and monopolar cautery haemostasis, was the standard surgical technique. Surgical seniority influenced the duration of tonsillectomy, with an effect on postoperative pain scores. Conclusions: Audits are necessary to evaluate what resources are needed to optimise care. The occurrence of pain after tonsillectomy continues to be poorly managed. Appropriate premedication and fasting of clear fluids for no more than two hours, needs to be introduced. Where possible surgical technique should involve bipolar cautery and be limited to less than 45 minutes. A preemptive, multimodal, opioid-sparing anaesthetic should be routinely practised.

Implementing a standardised discharge analgesia guideline to reduce paediatric post tonsillectomy pain

OBJECTIVES

To reduce readmission for pain control post-paediatric tonsillectomy.

INTRODUCTION

Paediatric tonsillectomy is a common procedure in the UK. Uncontrolled pain at home is a common reason for re-admission and therefore adequate analgesic control following paediatric tonsillectomy is vital for a smooth post-operative recovery. Analgesic regimens at a district general hospital in England were audited and a standardised protocol was subsequently implemented.

METHODS

A retrospective audit from September 2014 to August 2015 was completed. Discharge analgesic regimens and readmission rates post-tonsillectomy for recurrent tonsillitis in 2-17 year-old children were studied in a large general hospital in the United Kingdom. A standardised weight-based algorithm was used to dose scheduled regular paracetamol for 2 weeks. Second cycle prospective audit ran from December 2015 to November 2016.

RESULTS

In cycle 1, 151 children (mean age, 7.9 years) underwent tonsillectomy for tonsillitis, 25 (16.6%) of whom were readmitted. 12 (7.9%) experienced postoperative haemorrhage, 13 (8.6%) required pain control, and one (1.2%) had infection. The discharging analgesic regimen varied widely and often included purchase of over-the-counter ibuprofen and paracetamol. In cycle 2, 118 children (mean age, 8.8 years) underwent tonsillectomy, 17 (14.4%) were readmitted; 12 (10.2%) had post-operative haemorrhage, 0 needed pain control, 5 (4.2%) had other problems. There was a significant reduction in readmission for pain control (p = 0.0027) from 7.3% to 0% in the study. There was no significant change in overall readmission rate (16.6%-14.4%) or postoperative haemorrhage rate (8.9% overall).

DISCUSSION

Analgesia prescription post tonsillectomy varies widely and over the counter prescriptions of ibuprofen and paracetamol is based on age rather than weight with patients receiving inadequate analgesic doses. A readily available standardised postoperative analgesic protocol can significantly reduce readmission rates for pain control following paediatric tonsillectomy.

Update of the Scientific Opinion on opium alkaloids in poppy seeds

Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.