Effect of an intravenous single dose of ketamine on postoperative pain in tonsillectomy patients

Perioperative opioids in high-risk children undergoing tonsillectomy - A single institution experience

BACKGROUND

Patients undergoing tonsillectomy/ adenotonsillectomy (T/AT) can experience substantial postoperative pain. The aims of this study are to assess perioperative pain management in high-risk children (children with severe obstructive sleep apnea and other complex medical comorbidities or age younger than 2 years) undergoing T/AT, and the impact on oxygen levels and pain during extended Post-Anesthesia Care Unit (PACU) admission.

METHODS

A retrospective case series study at a tertiary care children's hospital.

RESULTS

There were 278 children enrolled in the study. The Apnea-Hypopnea index and mean oxygen nadir on preoperative polysomnography were 31.3 ± 25.76/h and 79.5 ± 9.5 % respectively. Overall, 246 (89 %) patients received intraoperative opioids alone (n = 35, 13 %) or in combination with non-opioid analgesia (n = 209, 75 %). While the median dose of opioid-free medications (acetaminophen, ibuprofen) ranged from 93 to 100 % of standard maximal dosing by weight and age, the median dose of opioids was significantly lower and ranged from 54 to 63 % of standard maximal dosing by weight and age, with 43 % of the patients receiving less than half the recommended maximum dose. Oxygen desaturation was charted in 21 patients (8 %) during their PACU admission. Patients who received opioid-free analgesia were as likely to develop oxygen desaturations (n = 17 (81 %) vs. n = 228 (89.4 %), p = 0.27) and to receive rescue pain medication during their PACU stay as patients who received opioids intraoperatively (n = 18 (56 %) vs. n = 167 (68 %), p = 0.23).

CONCLUSIONS

Intraoperative pain management varies across high-risk pediatric tonsillectomies. Opioid-free analgesia was not associated with an increased need for pain medications during PACU admission, or with a decreased likelihood of oxygen desaturations compared to intra-operative opioid analgesia use.

A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy

Objectives

To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research.

Data Sources

PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley).

Methods

A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs.

Results

One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons.

Conclusion

Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.

Effects of an individualized analgesia protocol on the need for medical interventions after adenotonsillectomy in children: a randomized controlled trial

Background

It has been proposed that the dose of rescue opioids should be individually titrated to the severity of obstructive sleep apnea after adenotonsillectomy. However, a sleep study is not always available before adenotonsillectomy. This randomized, controlled and blinded trial evaluated a strategy of pain control individualized to the results of a fentanyl test, rather than the results of polysomnography, in children after adenotonsillectomy.

Methods

A total of 280 children (3–10 years old) undergoing elective adenotonsillectomy were randomized into an individualized protocol (IP) group or a conservative protocol (CP) group. All patients received a fentanyl test before extubation. Pain was assessed every 10 min in the recovery room, and rescue morphine was given when the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) score was > 6. In the IP group, the dose of rescue morphine was individualized to the results of the fentanyl test (10 μg/kg in the case of a positive result and 50 μg/kg in the case of a negative result). In the CP group, the dose was fixed (25 μg/kg). The primary outcome was the percentage of patients requiring at least one medical intervention. The secondary outcome was the median duration of CHEOPS scores > 6.

Results

Fewer patients in the IP group than in the CP group required medical interventions [11.9% (16/134) vs 22.3% (29/130), P = 0.025]. The median duration of CHEOPS scores > 6 was shorter in the IP group than in the CP group [20 (95% CI: 17 to 23) min vs 30 (95% CI: 28 to 32) min, P <  0.001].

Conclusions

Compared with a conservative dosing approach, this individualized protocol may improve analgesia without a significant increase in respiratory adverse events.

Trial registration

ClinicalTrials.gov NCT02990910, registered on 13/12/2016.

The efficacy of ketamine for postoperative pain control in adolescent patients undergoing spinal fusion surgery for idiopathic scoliosis

The use of ketamine in conjunction with morphine to reduce postoperative pain has been explored in several different surgery subtypes with conflicting results. Ketamine has shown promise to have both opioid sparing and analgesic effects in the postoperative setting. This study aimed to elucidate ketamine's ability to reduce morphine equivalent consumption and improve patient satisfaction after spinal fusion surgery for the correction of idiopathic scoliosis. This surgery is known to be associated with significant postoperative pain which impedes the ability to improve patient satisfaction, and may complicate the recovery timeline. Currently, the standard therapeutic regimen consists of patient-controlled analgesia morphine and the use of other opioids such as hydromorphone. A prospective, randomized double-blinded, placebo-controlled trial was performed to compare the standard morphine equivalent therapy alone against a standard therapy in conjunction with ketamine. Fifty adolescent patients were enrolled and randomized. Results yielded a significant reduction in postoperative morphine equivalent consumption (p = 0.042), adjusted postoperative pain scores (p < 0.001), and incidence of nausea and vomiting (p = 0.045). The application of ketamine as an analgesic in conjunction with the current standard of morphine equivalent therapy may serve as a superior pain control regimen for spinal surgeries in young population. This regimen enhancement may be generalizable to other surgery subtypes within similar populations. LEVEL OF EVIDENCE: Level I.

Effects of Low-dose Propofol or Ketamine on Coughing at Emergence from Anesthesia in Children Undergoing Tonsillectomy

Introduction Coughing is commonly observed during emergence from general anesthesia. In children, smooth emergence from anesthesia, especially after tonsillectomy, is crucial. In this study, we compared the effect of low-dose ketamine or propofol on emergence coughing in children undergoing tonsillectomy. Methods In this randomized clinical trial, 90 children undergoing tonsillectomy were randomly allocated into two groups: children in group A received 0.5-mg/kg propofol and children in group B received 0.5-mg/kg ketamine, at the end of anesthesia. The incidence and severity of cough, postoperative sedation, nausea, and vomiting, and pain score were recorded and compared. Results The incidence of no cough at emergence from anesthesia was 82.2% in the propofol group and 15.5% in the ketamine group (P = 0.00). Children in the ketamine group exhibited postoperative pain but were more sedated compared with those in the propofol group (P > 0.05). The incidence of postoperative nausea and vomiting was lower in the propofol group (P < 0.05). Conclusions At the end of general anesthesia with isoflurane in children undergoing tonsillectomy, 0.5-mg/kg propofol is more effective than 0.5-mg/kg ketamine in reducing cough response upon emergence from anesthesia, with a lower incidence of nausea and vomiting, as well as lower sedation in children.

[Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial]

OBJECTIVES

The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2mg.kg^-1) administered 30min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5mg.kg^-1) and saline placebo.

METHODS

One hundred children aged (7-12) years were randomly allocated in four groups (n=25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5mg.kg^-1 (Group K-IV), Nebulized Ketamine 1mg.kg^-1 (Group K-N1) or 2mg.kg^-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24h postoperative.

RESULTS

The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9±60.5min, 95% CI 375.9-425.87) and K-N2 (455.5±44.6min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5±86.1min, 95% CI 282.9-354.1) and Group C (68.3±21.9min, 95% CI 59.5-77.1; p<0.001), with a significant difference between K-N1 and K-N2 Groups (p<0.001). The total consumption of IV paracetamol in the first 24h postoperative was reduced in Group K-IV (672.6±272.8mg, 95% CI 559.9-785.2), Group K-N1 (715.6±103.2mg, 95% CI 590.4-840.8) and Group K-N2 (696.6±133.3mg, 95% CI 558.8-834.4) compared with Control Group (1153.8±312.4mg, 95% CI 1024.8-1282.8; p<0.001). With no difference between intravenous and Nebulized Ketamine Groups (p=0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p<0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects.

CONCLUSION

Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial

Objectives

The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg⁻¹) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg⁻¹) and saline placebo.

Methods

One hundred children aged (7–12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg⁻¹ (Group K-IV), Nebulized Ketamine 1 mg.kg⁻¹ (Group K-N1) or 2 mg.kg⁻¹ (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative.

Results

The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9 ± 60.5 min, 95% CI 375.9–425.87) and K-N2 (455.5 ± 44.6 min, 95% CI 437.1–473.9) groups compared with Group K-IV (318.5 ± 86.1 min, 95% CI 282.9–354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5–77.1; p < 0.001), with a significant difference between K-N1 and K-N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K-IV (672.6 ± 272.8 mg, 95% CI 559.9–785.2), Group K-N1 (715.6 ± 103.2 mg, 95% CI 590.4–840.8) and Group K-N2 (696.6 ± 133.3 mg, 95% CI 558.8–834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8–1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects.

Conclusion

Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

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.

The effect of KETODEX on the incidence and severity of emergence agitation in children undergoing adenotonsillectomy using sevoflurane based-anesthesia

BACKGROUND

Postoperative emergency agitation (EA) is a common problem often observed in children undergoing general anesthesia. The purpose of this study was to evaluate whether a bolus of intraoperative low-dose ketamine followed by dexmedetomidine i.v. could reduce the incidence of EA in children undergoing adenotonsillectomy following sevoflurane-based anesthesia.

METHODS

A total of 92 children undergoing adenotonsillectomy, aged 3-7 years, were randomly allocated to receive either low-doseketamine 0.15 mg/kg followed by dexmedetomidine 0.3 μg/kg i.v. (KETODEX, n=45) or volume-matched normal saline (Control, n=47), about 10 min before the end of surgery. Anesthesia was induced and maintained with sevoflurane. Postoperative pain and EA were assessed with objective pain score (OPS) and the Pediatric Anesthesia Emergence Delirium scale (PAED), respectively. EA was defined as a PAED≥10 points. Recovery profile and postoperative complications were recorded.

RESULT

The incidence and severity of EA was lower in KETODEX group than controls (11% vs. 47%) and (2% vs. 13%), respectively (P<0.05). The frequency of fentanyl rescue was lower in KETODEX group than in controls (13.3 vs. 38.3%, P<0.05). Heart rate during extubation was significantly higher in the control group compared with children who received KETODEX (P<0.05). The incidence of postoperative pain was significantly less in the KETODEX group (15.5% vs. 63.8%, P<0.05). Times to interaction and extubation were significantly longer in the KETODEX group (P<0.05).

CONCLUSION

KETODEX reduces the incidence and severity of EA in children undergoing adenotonsillectomy following sevoflurane-based anesthesia and provided smooth extubation.

The analgesic effect of combined treatment with intranasal S-ketamine and intranasal midazolam compared with morphine patient-controlled analgesia in spinal surgery patients: a pilot study

Objectives

Ketamine is a well-known analgesic and dose-dependent anesthetic used in emergency and disaster medicine. Recently, a new formulation of S-ketamine, as an intranasal spray, was developed and tested in our institution in healthy volunteers. The authors investigated the effect of intranasal S-ketamine spray combined with midazolam intranasal spray in postoperative spinal surgery patients.

Materials and methods

In this prospective, computer-randomized, double-blinded noninferiority study in spinal surgery patients, the effects of intranasal S-ketamine and midazolam were compared with standard morphine patient-controlled analgesia (PCA). The primary end point was the numeric rating scale pain score 24 hours after surgery.

Results

Twenty-two patients finished this study, eleven in each group. There were similar numeric rating scale scores in the morphine PCA and the S-ketamine-PCA groups at 1, 2, 4, 24, 48, and 72 hours after surgery during rest as well as in motion. There were no differences in the satisfaction scores at any time between the groups. The number of bolus demands and deliveries was not significantly different.

Discussion

In our study, we found that an S-ketamine intranasal spray combined with intra-nasal midazolam was similar in effectiveness, satisfaction, number of demands/deliveries of S-ketamine and morphine, and number/severity of adverse events compared with standard intravenous PCA with morphine. S-ketamine can be regarded as an effective alternative for a traditional intravenous morphine PCA in the postoperative setting.

Clinical pharmacy intervention post tonsillectomy: a randomized control trial

BACKGROUND

Pain control in pediatric patients undergoing tonsillectomy remains a dilemma. Tramadol and ketamine are reported to be an effective analgesic.

AIM OF THE STUDY

To evaluate the effect of peritonsillar infiltration of tramadol in combination with ketamine versus peritonsillar infiltration of tramadol posttonsillectomy.

SETTING

Specialty hospital in Jordan.

METHOD

Sixty children, aged 7-12 years, selected for tonsillectomy were enrolled in the study. We divided the patients into two groups 30 of each, Group I: received peritonsillar saline and peritonsillar infiltration of tramadol 2 mg/kg, Group II: received peritonsillar infiltration of ketamine 1.0 mg/kg added to peritonsillar tramadol 2 mg/kg.

MAIN OUTCOME MEASURE

Hemodynamic stability, pain scale, first request of analgesia, total analgesics consumption and post-operative nausea and vomiting (PONV) side effects were recorded 24 h after surgery.

RESULTS

The analysis of data showed that Group II had significantly lower face pain scale, longer time for first request of analgesia, and better hemodynamic stability than GI (p < 0.001). On the other hand the total analgesics requirements, time of surgery, and PONV showed no significant differences between the two groups.

CONCLUSION

Combined use of peritonsillar infiltration of ketamine 1.0 mg/kg with tramadol 2 mg/kg provided prolong analgesic effects, less pain with no side effect, and better hemodynamic stability compared with using tramadol alone in patients undergoing tonsillectomy.

Confronting the challenges of effective pain management in children following tonsillectomy

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

Ketamine peritonsillar infiltration during tonsillectomy in pediatric patients: An updated meta-analysis

OBJECTIVES

Peri-operative ketamine peritonsillar infiltration in children can reduce the incidence of postoperative nausea and vomiting (PONV), but its postoperative analgesic time is short. A previous meta-analysis in 2011 was inconclusive due to insufficient data. Consequently, we updated the meta-analysis to verify the role of ketamine peritonsillar infiltration for tonsillectomy in pediatric patients.

METHODS

Ten randomized controlled trials with a total of 522 cases were included. Pain intensity was measured by standard modified CHEOPS score.

RESULTS

The pain scores of ketamine group at 30 min and 60 min were significantly lower than placebo group after surgery [weighted mean difference (WMD) -1.20, 95% CI -2.20 to -0.19, P=0.02; WMD -1.71, 95% CI -2.12 to -0.22, P=0.02]. Analgesic requirement in ketamine group were less than placebo group [risk ratio (RR) 0.51, 95% CI 0.26-0.97; P=0.04]. Moreover, the incidence of PONV was lower in ketamine group. (RR 0.73, 95% CI 0.54-0.97; P=0.03). However, there were no differences between these two groups in operation time, anesthesia time, first analgesic time and pain score at 120 min.

CONCLUSIONS

Compared to placebo, ketamine peritonsillar infiltration can relieve postoperative pain within one hour but not at 120 min and reduces analgesic requirement and incidence of PONV. Moreover, there was no difference in the first analgesic time.

Efficacy of ketamine in improving pain after tonsillectomy in children: meta-analysis

BACKGROUND AND OBJECTIVES

The goal of this meta-analysis study was to perform a systematic review of the literature on the effects of ketamine on postoperative pain following tonsillectomy and adverse effects in children.

SUBJECTS AND METHODS

Two authors independently searched three databases (MEDLINE, SCOPUS, Cochrane) from their inception of article collection to February 2014. Studies that compared preoperative ketamine administration (ketamine groups) with no treatment (control group) or opioid administration (opioid group) where the outcomes of interest were postoperative pain intensity, rescue analgesic consumption, or adverse effects (sedation, nausea and vomiting, bad dream, worsening sleep pattern, and hallucination) 0-24 hours after leaving the operation room were included in the analysis.

RESULTS

The pain score reported by the physician during first 4 hours and need for analgesics during 24 hours postoperatively was significantly decreased in the ketamine group versus control group and was similar with the opioid group. In addition, there was no significant difference between ketamine and control groups for adverse effects during 24 hours postoperatively. In the subgroup analyses (systemic and local administration) regarding pain related measurements, peritonsillar infiltration of ketamine was more effective in reducing the postoperative pain severity and need for analgesics.

CONCLUSION

Preoperative administration of ketamine systemically or locally could provide pain relief without side-effects in children undergoing tonsillectomy. However, considering the insufficient evaluation of efficacy of ketamine according to the administration methods and high heterogeneity in some parameters, further clinical trials with robust research methodology should be conducted to confirm the results of this study.

Treatment effects of dexmedetomidine and ketamine on postoperative analgesia after cleft palate repair

Primary cleft palate repair may result in significant pain in the immediate postoperative period, which can lead to vigorous crying resulting in wound dehiscence and pulmonary complications. Effective pain control with opioids is the mainstay but administration on the floor has to be countered with the complications associated with their use, chiefly respiratory depression and sedation. We retrospectively examined the efficacies of intraoperative administration of intravenous (IV) dexmedetomidine (DEX) and ketamine (KET) to prevent early postoperative pain in children undergoing primary cleft palate repair and compared the results against relevant literature. The Texas Children's Hospital anesthesia database was queried to identify children undergoing a palatal surgery from December 2011 to December 2012. Inclusion criteria permitted completed primary palatal surgery without major complications and intraoperative administration of DEX or KET. The control group (CTRL) received no additional drug. A comprehensive literature review was performed. A total of 71 pediatric patients underwent palatal surgery during the study period with 46 patients qualifying for analysis. Although results were not significant, consistent trends were observed with regards to lower opioid requirements during the first 24 hours for both medications compared with the CTRL. KET also had shorter time to discharge. The literature review resulted in several studies supporting decreased postoperative pain end points for both DEX and KET. In our sample, DEX and KET reduced postoperative opioid requirements. KET seems to have the added benefit of a shorter hospital stay. These finding are supported in the literature. With further investigation, the addition of these drugs may serve to provide improved pain relief without over sedation in patients undergoing cleft palate repair.

Developmental neurotoxicity of ketamine in pediatric clinical use

Ketamine is widely used as an anesthetic, analgesic, and sedative in pediatric clinical practice and it is also listed as an illicit drug by most countries. Recent in vivo and in vitro animal studies have confirmed that ketamine can induce neuronal cell death in the immature brain, resulting from widespread neuronal apoptosis. These effects can disturb normal development further altering the structure and functions of the brain. Our recent studies further indicate that ketamine can alter neurogenesis from neural stem progenitor cells in the developing brain. Taken together, these findings identify a novel complication associated with ketamine use in premature infants, term newborns, and pregnant women. Recent data on the developmental neurotoxicity of ketamine are reviewed with proposed future directions for evaluating the safety of ketamine in these patient populations.

Comparison of peritonsillar infiltration effects of ketamine and tramadol on post tonsillectomy pain: a double-blinded randomized placebo-controlled clinical trial

Aim

To assess the effect of peritonsillar infiltration of ketamine and tramadol on post tonsillectomy pain and compare the side effects.

Methods

The double-blind randomized clinical trial was performed on 126 patients aged 5-12 years who had been scheduled for elective tonsillectomy. The patients were randomly divided into 3 groups to receive either ketamine, tramadol, or placebo. They had American Society of Anesthesiologists physical status class I and II. All patients underwent the same method of anesthesia and surgical procedure. The three groups did not differ according to their age, sex, and duration of anesthesia and surgery. Post operative pain was evaluated using CHEOPS score. Other parameters such as the time to the first request for analgesic, hemodynamic elements, sedation score, nausea, vomiting, and hallucination were also assessed during 12 hours after surgery.

Results

Tramadol group had significantly lower pain scores (P = 0.005), significantly longer time to the first request for analgesic (P = 0.001), significantly shorter time to the beginning of liquid regimen (P = 0.001), and lower hemodynamic parameters such as blood pressure (P = 0.001) and heart rate (P = 0.001) than other two groups. Ketamine group had significantly greater presence of hallucinations and negative behavior than tramadol and placebo groups. The groups did not differ significantly in the presence of nausea and vomiting.

Conclusion

Preoperative peritonsillar infiltration of tramadol can decrease post-tonsillectomy pain, analgesic consumption, and the time to recovery without significant side effects.

Registration No: IRCT201103255764N2

Evaluation of a low dose ketamine in post tonsillectomy pain relief: a randomized trial comparing intravenous and subcutaneous ketamine in pediatrics

BACKGROUND

Pain control in children is still a therapeutic dilemma. Preschool patients are affected from undesirable effects of postoperative pain more than adults. Tonsillectomy is associated with a high incidence of postoperative pain, not only complicating the recovery, but also delaying patients discharge.

OBJECTIVES

Despite employing different surgical and anesthetic strategies in post-tonsillectomy pain relief, this is still a clinical problem. The study was designed to evaluate the efficacy of a low dose ketamine in post tonsillectomy pain relief.

PATIENTS AND METHODS

Our prospective randomized double blinded study enrolled 75 pediatric patients (3-10 years old) who were scheduled for a tonsillectomy procedure. Patients were randomly assigned to one of three groups receiving; intravenous (IV) ketamine 0.5mg/kg, subcutaneous (SC) ketamine 0.5 mg/kg and placebo at the end of the operation. Post-operative pain score was assessed using modified CHEOPS.

RESULTS

In our study we did not find any significant difference among the three groups regarding sex, age, and weight, duration of operation, hemodynamic stability, and nausea and vomiting. However, in ketamine groups, pain score and analgesic consumption were significantly lower (P < 0.00). The efficacy of the both ketamine groups was similar.

CONCLUSIONS

The study demonstrated that the both subcutaneous and intravenous injections of ketamine, at the end of the operation, were safe and effective for post-tonsillectomy pain control. Ketamine reduced postoperative analgesic medications consumption without increasing the risk of complications.

Comparison of ketamine and fentanyl for postoperative pain relief in children following adenotonsillectomy

Adenotonsillectomy has a high incidence of postoperative pain. Therefore, the purpose of this study was to evaluate the effectiveness and safety of either ketamine or fentanyl for postoperative pain relief in children following adenotonsillectomy. Sixty children aged 3-12 years, scheduled for adenotonsillectomy, were enrolled in this randomized, double-blind study. Patients were divided into two groups of 30 cases and received intravenous ketamine (0.5 mg kg(-1)) or fentanyl (1 microg kg(-1)). Modified Hannallah pain scale or Observational Pain Scores (OPS), nausea, vomiting, bleeding, rescue analgesia, sedation and post-anesthesia recovery scores were recorded both at first and 15th minute postoperatively. Moreover, patients receiving ketamine (group 1) or fentanyl (group 2) had comparable OPS and sedation score both on arrival and at 15th minute in the recovery room (p > 0.05). Although rescue analgesics were similarly required in both groups (p > 0.05), the time to reach rescue analgesia was shorter in group 1 (p = 0.001). Only one patient in fentanyl group had nausea and vomiting in the first 15 min that needed antiemetic in the recovery room. In conclusion, intravenous fentanyl (1 microg kg(-1)) compared with intravenous ketamine (0.5 mg kg(-1)) might provide extended time to first analgesic in children undergoing adenotonsillectomy. Interestingly, fentanyl and ketamine did not differ in post-operative vomiting.

Ketamine for perioperative pain management in children: a meta-analysis of published studies

INTRODUCTION

Balanced analgesia, using both opioid and nonopioids agents, has become the standard care for postoperative pain management. Ketamine, a compound with analgesic and antihyperalgesic properties, has been shown to decrease postoperative pain and opioid requirements in adults. The goal of the present meta-analysis was to investigate postoperative analgesic properties of ketamine in pediatric patients.

MATERIAL AND METHODS

A comprehensive literature search was conducted to identify clinical trials that used ketamine as a perioperative analgesic compound in children and infants. Outcomes measured were postoperative analgesic consumption, pain intensity and duration of sensory block (when ketamine was used by caudal route) during the postoperative care unit (PACU) stay and the early postoperative period (6-24 h after leaving the operative room). The data from each trial were combined to calculate the pooled odds ratios or standard mean differences and their 95% confidence intervals.

RESULTS

Thirty-five randomized, blinded controlled studies were retrieved from the literature. Systemic ketamine was effective in decreasing PACU pain intensity and analgesic requirement but failed to influence early (6-24 h) pain intensity and analgesic requirement. Ketamine administered locally during tonsillectomy, decreased PACU and early (6-24 h) pain intensity and PACU analgesic requirements. Used as an adjuvant for caudal analgesia, ketamine increased the duration of sensory block and PACU analgesic requirement without impacting PACU pain intensity. Ketamine failed to exhibit a postoperative opioid-sparing effect.

CONCLUSIONS

This meta-analysis found that administration of ketamine was associated with decreased PACU postoperative pain intensity and nonopioid analgesic requirement. However, ketamine failed to exhibit a postoperative opioid-sparing effect.

A systematic review of faces scales for the self-report of pain intensity in children

CONTEXT

Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference.

OBJECTIVES

To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility.

METHODS

Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori.

RESULTS

From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS.

CONCLUSIONS

For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.

Effects of perioperative intravenous low dose of ketamine on postoperative analgesia in children

BACKGROUND AND OBJECTIVE

Low dose of ketamine reduces postoperative pain and opioid consumption in adult studies. However, there are only a few data with controversial results in the paediatric population. The aim of this randomized controlled trial was to evaluate the use of low doses of intravenous ketamine on postoperative pain in children after surgery on the lower part of the body.

METHODS

Thirty-seven children with ASA 1 or 2 from 6 to 60 months of age, undergoing scheduled surgery, were prospectively enrolled in a double blind sequential trial using a triangular test, with analysis every 10 patients treated. The children were randomly assigned to intravenously receive saline or 0.15 mg kg(-1) ketamine before surgery, followed by a continuous infusion of 1.4 microg kg(-1) min(-1) over 24 h. After sevoflurane induction and tracheal intubation, a caudal anaesthesia was performed in all children (1 ml kg(-1) of bupivacaine 0.25% with epinephrine). The postoperative analgesic technique was standardized with intravenous paracetamol 15 mg kg(-1) 6 h(-1), rectal morniflumate (20 mg kg(-1) 12 h(-1)) and intravenous nalbuphine infusion 1.2 mg kg(-1) 24 h(-1) for 24 h. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, additional bolus of nalbuphine (if CHEOPS >7) and side effects were recorded from eye opening every 2 h over 24 h. The primary endpoint was the CHEOPS area under the curve.

RESULTS

There was no difference in terms of additional bolus of nalbuphine as well as CHEOPS score area under the curve between groups, that is, 76 +/- 10 in the ketamine group versus 74 +/- 7 in the control group. No psychomimetic side effects were noted.

CONCLUSION

The study failed to show any evidence of benefit of ketamine to improve analgesia in children when given in addition to a multimodal analgesic therapy with paracetamol, a NSAID and an opiate.

Role of N-methyl-D-aspartate receptor antagonists in postoperative pain management

PURPOSE OF REVIEW

In recent years, hundreds of studies have examined the clinical efficacy of N-methyl-D-aspartate (NMDA) receptor antagonists such as ketamine and dextromethorphan as an adjunct to routine postoperative pain management. The purpose of this review is to describe the detail of the study that successfully demonstrated the efficacy of NMDA receptor antagonists.

RECENT FINDINGS

The effect of perioperative ketamine infusion, dextromethorphan, and memantine on postoperative opioid-induced analgesia and prevention of long-term persistent pain is described.

SUMMARY

The co-administration of ketamine and morphine as a mixture is not recommended for postoperative pain relief. As an adjunct in multimodal analgesia, low-dose ketamine infusion and the administration of dextromethorphan may be able to improve postoperative pain status. Memantine exhibits the greatest potency among NMDA receptor antagonists. In future, research should consider the perioperative infusion of ketamine followed by long-term administration of memantine for the prevention of persistent pain.

Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies

BACKGROUND

Emergence agitation (EA) in children is increased after sevoflurane anaesthesia. The efficacy of prophylactic treatment is controversial. The aim of this study was to provide a meta-analysis of the studies of the pharmacological prevention of EA in children.

METHODS

A comprehensive literature search was conducted to identify clinical trials that focused on the prevention of EA in children anaesthetized with sevoflurane, desflurane, or both. The data from each trial were combined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% confidence interval. I(2) statistics were used to assess statistics heterogeneity and the funnel plot and the Begg-Mazumdar test to assess bias.

RESULTS

Thirty-seven articles were found which included a total of 1695 patients in the intervention groups and 1477 in the control ones. Midazolam and 5HT(3) inhibitors were not found to have a protective effect against EA [OR=0.88 (0.44, 1.76); OR=0.39 (0.12, 1.31), respectively], whereas propofol [OR=0.21 (0.16, 0.28)], ketamine [OR=0.28 (0.13, 0.60)], alpha(2)-adrenoceptors [OR=0.23 (0.17, 0.33)], fentanyl [OR=0.31 (0.18, 0.56)], and peroperative analgesia [OR=0.15 (0.07, 0.34)] were all found to have a preventive effect. Subgroup analysis according to the peroperative analgesia given does not affect the results.

CONCLUSIONS

This meta-analysis found that propofol, ketamine, fentanyl, and preoperative analgesia had a prophylactic effect in preventing EA. The analgesic properties of these drugs do not seem to have a role in this effect.

The effect of preoperative fasting on postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy

OBJECTIVE

The aim of this prospective randomized study was to examine whether active counseling and more liberal oral fluid intake decrease postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy.

METHODS

Families, whose child was admitted for ambulatory tonsillectomy or adenotonsillectomy, were randomly assigned to the study groups (n=116; 58 families in each group). The intervention group received the fasting instructions with face-to-face counseling for the child's active preoperative nutrition, and the control group the fasting instructions according to the hospital's standard procedure. The level of postoperative pain and nausea was scored in the postanesthesia care unit (PACU) during the first postoperative hour, as well as at 2, 4, 8 and 24h postoperatively. The first scoring in PACU was performed by the attending nurse with a 0-10 scale. The rest of the estimations were made independently and simultaneously by the children using a VAS scale, and by the parents using a 0-10 scale.

RESULTS

The children in the control group were in more pain in the PACU than the children in the intervention group, and the difference between the groups was statistically significant (p=0.0002). All pain scores, according to the children and the parents, increased after the surgery. In both groups the highest score values were found at home 8h after surgery, and no significant difference was found between the study groups. On the first postoperative morning, the children in the control group were in pain (p=0.047). The children did not have significant nausea in the PACU, but the nausea increased postoperatively. Four hours after surgery the children were most nauseous according to all estimations (60%, n=116). More than half of the children vomited and most vomited clotted blood. Nausea and vomiting decreased during the evening of the surgery, but six children vomited the next morning, four of them vomited blood. The incidence and intensity of postoperative nausea and vomiting between the intervention and control groups were not statistically significant. However, preoperative nutritional counseling and more liberal per oral fluid intake appeared to have a positive effect on the children's well-being and helped them to better tolerate postoperative nausea and vomiting.

CONCLUSIONS

The preoperative counseling about active preoperative nutrition significantly reduces the child's pain during the first posttonsillectomy hours and might prepare the child to better tolerate the stress of potential postoperative nausea and vomiting.

Long-term use of an intravenous ketamine infusion in a child with significant burns

We report the use of an intravenous ketamine infusion for 37 days in a 9-year-old child with 42% body surface area burns. Ketamine was administered both in the intensive care unit and the surgical ward and provided high quality analgesia as an opioid adjunct. Throughout the long duration of administration, the child did not develop tolerance or experience psychomimetic side effects and weaning of the ketamine infusion was achieved rapidly, without evidence of withdrawal. This case demonstrates the safe and effective use of long-term intravenous ketamine in a child with significant burns on a surgical ward. We have focused the discussion on the issues of tolerance and weaning of long-term ketamine infusions in children.

Perioperative uses of low-dose ketamine for pain management

The purpose of this article is to explore the most current literature regarding perioperative pain management uses of low-dose ketamine. Research has demonstrated significant reductions in postoperative pain scores as well as opioid consumption with low-dose ketamine administration without side effects associated with its induction doses. The availability of S(+)-ketamine with double the analgesic potency of ketamine will create even more reason for its use.