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Shelton FR, Ishii H, Mella S, Chew D, Winterbottom J, Walijee H, Brown R, Chisholm EJ. Implementing a standardised discharge analgesia guideline to reduce paediatric post tonsillectomy pain. Int J Pediatr Otorhinolaryngol 2018; 111:54-58. [PMID: 29958614 DOI: 10.1016/j.ijporl.2018.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 05/12/2018] [Accepted: 05/17/2018] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Fenella R Shelton
- Department of Otolaryngology and Head and Neck Surgery, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK.
| | - Hirotaka Ishii
- Department of Otolaryngology and Head and Neck Surgery, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK
| | - Sophie Mella
- Department of Otolaryngology and Head and Neck Surgery, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK
| | - Dylan Chew
- Department of Otolaryngology and Head and Neck Surgery, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK
| | - Jemma Winterbottom
- Department of Otolaryngology and Head and Neck Surgery, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK
| | - Hussein Walijee
- Department of Otolaryngology and Head and Neck Surgery, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK
| | - Rachel Brown
- Department of Anaesthesia, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK
| | - Edward J Chisholm
- Department of Otolaryngology and Head and Neck Surgery, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK
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Abstract
At December 2014, this review has been withdrawn from the Cochrane Library. This review is out of date, although it is correct at the date of publication. The review may be misleading as new studies could alter the original conclusions. All previous versions of the review can be found in the ‘Other versions’ tab. We are seeking additional authors to support the updating of this review. For further information, please contact PaPaS Managing Editor, Anna Hobson [Contact Person]. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Joseph F Standing
- Pharmaceutical Biosciences, Uppsala Universitet, Division of Pharmacokinetics and Drug Therapy, Uppsala Universistet BMC Box 591, Uppsala, Sweden, 75124
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Bank PC, Swen JJ, Guchelaar HJ. Pharmacogenetic biomarkers for predicting drug response. Expert Rev Mol Diagn 2014; 14:723-35. [PMID: 24857685 DOI: 10.1586/14737159.2014.923759] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Drug response shows significant interpatient variability and evidence that genetics influences outcome of drug therapy has been known for more than five decades. However, the translation of this knowledge to clinical practice remains slow. Using examples from clinical practice six considerations about the implementation of pharmacogenetics (PGx) into routine care are discussed: the need for PGx biomarkers; the sources of genetic variability in drug response; the amount of variability explained by PGx; whether PGx test results are actionable; the level of evidence needed for implementation of PGx and the sources of information regarding interpretation of PGx data.
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Affiliation(s)
- Paul Christiaan Bank
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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Havel M, Sroka R, Englert E, Stelter K, Leunig A, Betz CS. Intraindividual comparison of 1,470 nm diode laser versus carbon dioxide laser for tonsillotomy: a prospective, randomized, double blind, controlled feasibility trial. Lasers Surg Med 2012; 44:558-63. [PMID: 22837058 DOI: 10.1002/lsm.22053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2012] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The need for reduction of post-tonsillectomy hemorrhage has led to promotion of tonsillotomy techniques for tonsil tissue reduction in obstructive tonsillar hypertrophy. This trial compares ablative tissue effects using 1,470 nm diode laser and carbon dioxide laser for tonsillotomy in an intraindividual design. METHODS 21 children aged 3-13 years (mean age 6.3 years) underwent laser tonsillotomy for obstructive tonsillar hypertrophy in this double blind, prospective, randomized, clinical feasibility trial. In each of the blinded patients, tonsillotomy was performed using fiber guided 1,470 nm diode laser (contact mode, 15 W power) on the one side and carbon dioxide laser (12 W power) on the other side. An independent, blinded physician documented clinical presentation and patients' symptoms preoperatively and on Days 1, 3, 7, 14, and 21 post-operatively using standardized questionnaire including VAS for each side separately. RESULTS The mean duration of operative treatment was 2.7 min using 1,470 nm laser and 4.9 min using carbon dioxide laser respectively. Intraoperative bleeding and the frequency of bipolar forceps use for intraoperative bleeding control was significantly less using 1,470 nm diode laser system. There was no difference in post-operative pain scores between the carbon dioxide laser treated and the 1,470 nm fiber guided diode laser treated side. No infections, hemorrhages or other complications occurred in the course of the 3 weeks post-operative period. CONCLUSIONS A fiber-guided 1,470 nm diode laser system offers an efficient and safe method for tonsillotomy as treatment of obstructive tonsillar hypertrophy. Compared to our standard practice (carbon dioxide laser), 1,470 nm laser application provides comparable tissue ablation effects with less intraoperative bleeding and shorter operation time.
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Affiliation(s)
- Miriam Havel
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Munich, Marchioninistr. 15, 81377 Munich, Germany.
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Hosseini Jahromi SA, Hosseini Valami SM, Hatamian S. Comparison between effect of lidocaine, morphine and ketamine spray on post-tonsillectomy pain in children. Anesth Pain Med 2012; 2:17-21. [PMID: 24223328 PMCID: PMC3821106 DOI: 10.5812/aapm.4092] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 02/27/2012] [Accepted: 04/05/2012] [Indexed: 11/16/2022] Open
Abstract
Background An effective pain therapy to block or modify the physiological responses to stress has become an essential component of modern pediatric anesthesia and surgical practice. Objectives The goal of this study was to compare the analgesic effects of the spray forms of; lidocaine, morphine, ketamine, and normal saline on post-tonsillectomy pain scores in children. Patients and Methods A total of 120 children, American Society of Anesthesiologist (ASA) class I–II, scheduled for elective tonsillectomy were enrolled in this double-blind, clinical trial study. They were randomly divided into 4 groups, each receiving one of the following drugs at the end of operation; lidocaine spray (2 mg/kg); morphine spray (0.05 mg/kg); ketamine spray (0.5 mg/kg); or normal saline spray (8 puffs). For comparison of postoperative pain; the face, legs, activity, cry, consolability (FLACC) pain scale was evaluated during the first one hour of recovery period at 20 minutes intervals. The data was transferred to SPSS-10 software and analyzed statistically with the Scheffe test and Dunnett’s T3 test. P value less than 0.05 was considered significant. Results In the early postoperative period (time: 0) and at 20, 40 and 60 minutes of recovery time, FLACC scale scores in the control group were higher than in the three other groups. At 20 minutes, the FLACC scale score in the lidocaine group was lower than in the other groups. At 40 minutes, the statistical differences between FLACC scales of the lidocaine, morphine and ketamine groups were not significant (P > 0.05). Finally, at 60 minutes, the FLACC scale scores of the ketamine and morphine groups were lower than in the other groups. Conclusions The results of this study showed that lidocaine spray had the best pain controlling effect at 20 minutes in the recovery room, but after 40 minutes, ketamine and morphine sprays were more effective than the lidocaine spray.
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Affiliation(s)
| | - Seyedeh Masoumeh Hosseini Valami
- Department of Anesthesiology, Shahid Rajaee Hospital, Qazvin University of Medical Sciences, Qazvin, Iran
- Corresponding author: Seyedeh Masoumeh Hosseini Valami, Department of Anesthesiology, Shahid Rajaee Hospital, Qazvin University of Medical Sciences, Qazvin, Iran. Tel: +98-2813335800, Fax: +98-2813344812. E-mail:
| | - Sevak Hatamian
- Department of Anesthesiology, Hamadan University of Medical Sciences, Hamadan, Iran
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Standing JF, Savage I, Pritchard D, Waddington M. Cochrane Review: Diclofenac for acute pain in children. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Double-blind, randomised, controlled study of post-operative pain in children undergoing radiofrequency tonsillotomy versus laser tonsillotomy. The Journal of Laryngology & Otology 2010; 124:880-5. [PMID: 20380764 DOI: 10.1017/s0022215110000605] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In the last decade tonsillotomy has come into vogue again, whereas the number of tonsillectomies is decreasing rapidly. Currently, most tonsils are reduced by utilise electrosurgery, radiofrequency or carbon dioxide laser. However, it is not clear whether radiofrequency tonsillotomy is as effective as laser or other surgical techniques in respect of post-operative pain and haemorrhage. MATERIAL AND METHODS A prospective, randomised, double-blinded, controlled, clinical study was conducted in the otorhinolaryngology department of Ludwig Maximilians University, Munich, Germany. Twenty-six children with tonsillar hypertrophy were included. Exclusion criteria were: history of peritonsillar abscess, previous tonsil surgery, tonsillitis within two weeks, pain before surgery, psychiatric illness, asymmetrical tonsils, chronic analgesic usage, bleeding disorders and other surgical procedures during the same operation. Tonsillotomy was performed on one side with radiofrequency and on the other side with a carbon dioxide laser. All procedures were performed by a single surgeon, under general anaesthesia. A visual analogue scale was used to measure patients' pain on each side, administered by a 'blinded' nurse on the three post-operative mornings and evenings, within the hospital. RESULTS There was no difference in post-operative pain scores or haemorrhage, comparing laser versus radiofrequency tonsillotomy. Patient's overall reported pain was very modest compared with post-tonsillectomy pain. No haemorrhage or other adverse effects were observed.
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Abstract
BACKGROUND Diclofenac is commonly used for acute pain in children, but is not licensed for this indication in all age groups. OBJECTIVES 1) Assess the efficacy of diclofenac for acute pain in children. 2) Assess the safety of diclofenac for short-term use in children. 3) Identify gaps in the evidence to direct future research. SEARCH STRATEGY Seventeen databases indexing clinical trial reports were searched in February 2005 (with an update search as part of this first review in May 2008). A hand search of Paediatric Anaesthesia was undertaken and summaries obtained of adverse reaction reports from the UK Yellow Card Scheme and World Health Organization (WHO) Monitoring Centre. The reference lists of included studies were also searched. SELECTION CRITERIA Any published report, in any language, involving the administration of diclofenac to a patient aged 18 years or younger for acute pain and detailing either monitoring of efficacy or safety. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted the data. Authors were contacted where necessary. Review Manager version 5 was used for analysis. MAIN RESULTS 1) EFFICACY: randomised controlled trials (RCTs) comparing diclofenac with placebo/any other treatment by using pain scores (assessed or reported), or need for rescue analgesia.2) SAFETY: any type of study seeking adverse events (regardless of cause). An adverse event was defined as any reported adverse or untoward happening to a patient being treated with diclofenac for acute pain.Seven publications on diclofenac efficacy and 79 on safety (74 studies plus five case reports) were included in the final analysis. Compared with placebo/no treatment, diclofenac significantly reduced need for post-operative rescue analgesia (relative risk [RR] 0.6; number needed to treat to benefit [NNT] 3.6; 95% confidence interval [CI] 2.5 to 6.3).Compared with any other non-NSAID, patients receiving diclofenac suffered less nausea or vomiting, or both (RR 0.6; NNT 7.7 [5.3 to 14.3]). There appeared to be no increase in bleeding requiring surgical intervention in patients receiving diclofenac in the peri-operative period. Serious diclofenac adverse reactions occurred in fewer than 0.24% of children treated for acute pain. The types of serious adverse reactions were similar to those reported in adults. AUTHORS' CONCLUSIONS Diclofenac is an effective analgesic for perioperative acute pain in children. It causes similar types of serious adverse reactions in children as in adults, but these are rare. More research on optimum dosing and safety in asthmatic children is required.
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Affiliation(s)
- Joseph F Standing
- Pharmaceutical Biosciences, Uppsala Universitet, Division of Pharmacokinetics and Drug Therapy, Uppsala Universistet BMC Box 591, Uppsala, Sweden, 75124
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Voronov P, Przybylo HJ, Jagannathan N. Apnea in a child after oral codeine: a genetic variant - an ultra-rapid metabolizer. Paediatr Anaesth 2007; 17:684-7. [PMID: 17564651 DOI: 10.1111/j.1460-9592.2006.02182.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Polina Voronov
- Department of Anesthesiology, Children's Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Wilson ME, Helgadóttir HL. Patterns of Pain and Analgesic Use in 3- to 7-Year-Old Children After Tonsillectomy. Pain Manag Nurs 2006; 7:159-66. [PMID: 17145490 DOI: 10.1016/j.pmn.2006.09.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Tonsillectomy is a common surgical procedure usually associated with moderate to severe pain. Although self-report is the gold standard for pain assessment, researchers have not studied young children at home with self-report measures. The purpose of this study was to describe the patterns of self-reported pain intensity and analgesic administration in 3- to 7-year-old children undergoing tonsillectomy during the operative day in the hospital and the first 2 postoperative days at home in Iceland. As part of a larger study, 68 children undergoing tonsillectomy were taught to use the Wong-Baker FACES Pain Rating Scale. Pain intensity scores and data about administration of analgesics were collected from children, the medical record, and the parents over a 3-day period. Children received primarily acetaminophen or acetaminophen with codeine in the hospital. At home, 99% of doses administered were acetaminophen only. Most doses were administered rectally. Forty percent of children received 24-hour therapeutic doses in the hospital. Only 10% received a 24-hour therapeutic dose at home despite significant pain scores of 4 or 5 persisting through the second postoperative day. Younger children were less likely to receive acetaminophen with codeine. In the hospital, children with pain intensity scores of 4 or 5 received prescribed morphine only 13% of the time. Children experienced clinically significant pain through the second postoperative day and will probably require a change in protocol to provide more aggressive pain management earlier. This study extends to younger children the research evidence that current pain protocols are inadequate.
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Affiliation(s)
- Margaret E Wilson
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska 68198-5330, USA.
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Arya AK, Donne A, Nigam A. Double-blind randomized controlled study of coblation tonsillotomy versus coblation tonsillectomy on postoperative pain in children. Clin Otolaryngol 2005; 30:226-9. [PMID: 16111417 DOI: 10.1111/j.1365-2273.2005.00970.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to establish if children experienced any difference in pain, between coblation tonsillectomy and coblation tonsillotomy. DESIGN A double-blind randomized controlled trial was performed. SETTING District general hospital department of Otolaryngology. PARTICIPANTS Eighteen children listed for tonsillectomy were recruited into the study. Each was randomly assigned either tonsillotomy or tonsillectomy in the right tonsil. The contralateral tonsil was removed by the other method. In the first 24-h period (while in hospital) the children were interviewed at 2, 5, 10 and 24 h to quantify the pain they perceived in right and left sides. There was a four point visual analogue scoring system for monitoring pain. The power of the study was 80%. In this study the patients were their own controls. MAIN OUTCOME MEASURES Visual analogue pain scores were plotted against time and the area under the curves was calculated (AUC). RESULTS The AUC mean difference was 0.47. A t-test for the difference gives a P-value of 0.85 and a 95% confidence interval for difference is -0.79 to 5.73, which clearly contains zero. Using AUC as a combined pain score there is no statistically significant difference between tonsillotomy and tonsillectomy (power value of 80%). CONCLUSIONS There is no demonstrable statistical difference between techniques when measuring pain experienced by children in the 24-h postoperative period.
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Affiliation(s)
- A K Arya
- Department of Otolaryngology, Head and Neck Surgery, Blackpool Victoria Hospital, UK.
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Idvall E, Holm C, Runeson I. Pain experiences and non-pharmacological strategies for pain management after tonsillectomy: a qualitative interview study of children and parents. J Child Health Care 2005; 9:196-207. [PMID: 16076895 DOI: 10.1177/1367493505054417] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tonsillectomy is one of the most common paediatric surgical procedures. This study aimed to investigate children's experience of pain and the nonpharmacological strategies that they used to manage pain after tonsillectomy. A further aim was to investigate parental views on these same phenomena. Six children (aged seven to 18 years) and their parents (four mothers and two fathers) were interviewed separately on the day after tonsillectomy. The data were analysed using a qualitative approach. Pain experiences were divided into the categories of physiological pain and psychological pain. Children rated their 'worst pain' during the past 24 hours between 6 and 10 (visual analogue scale, 0-10). The non-pharmacological strategies used most frequently to manage pain were thermal regulation (physical method) and distraction (cognitive-behavioural method) according to the framework used. Specific non-pharmacological strategies for pain management relative to different surgical procedures need to be considered.
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Affiliation(s)
- Ewa Idvall
- Department of Medicine and Care, Division of Nursing Sciences, Linköping University and Division of Research, County Council Kalmar, Sweden.
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Abstract
The purpose of this study was to examine the relationships among temperament, self-reported pain, parent's report of children's pain behavior and pain intensity, amount of pain medication received, and parents' attitudes toward use of analgesics in 3- to 7-year-old children undergoing tonsillectomy. Sixty-eight child/parent dyads participated in the study. Correlations were found between some temperamental factors and child's self-reported pain intensity in the hospital and at home as well as parents' report of pain behavior at home. There was a significant positive relationship between the child's self-reported pain intensity and analgesic administration in the hospital and at home.
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Arya A, Donne AJ, Nigam A. Double-blind randomized controlled study of coblation tonsillotomy versus coblation tonsillectomy on postoperative pain. ACTA ACUST UNITED AC 2004; 28:503-6. [PMID: 14616666 DOI: 10.1046/j.1365-2273.2003.00750.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This double-blind randomized controlled trial of coblation tonsillotomy versus coblation tonsillectomy uses visual analogue scoring to compare the pain experienced in the 24h postoperative period. No statistically significant difference in pain is demonstrated in the group of 14 patients studied. Tonsillectomy is recommended over tonsillotomy.
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Affiliation(s)
- A Arya
- SHO in Otolaryngology at Blackpool Victoria Hospital, Lancashire, UK
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