Levobupivacaine Alone Versus Levobupivacaine Plus Magnesium Infiltration for Post-Tonsillectomy Analgesia

The efficacy of magnesium sulphate in preventing laryngospasm in paediatric patients undergoing general anaesthesia: A systematic review and meta-analysis of randomised control trials

BACKGROUND

Laryngospasm is sustained closure of the airways and can be a life-threatening condition. Magnesium sulphate is postulated to reduce the incidence of laryngospasm if administered peri-operatively. This systematic review and meta-analysis was performed to assess the efficacy of magnesium sulphate in preventing peri-operative laryngospasm in paediatric patients undergoing non-cardiac surgery.

METHODS

Four databases and a trial registry were searched. Inclusion criteria were paediatric patients undergoing general anaesthesia. Exclusion criteria were patients who underwent cardiopulmonary bypass during surgery. The intervention of interest was the peri-operative administration of magnesium sulphate. The intervention was compared to either a placebo or other pharmacological agent. The primary outcome was the incidence of laryngospasm. A meta-analysis of all studies was performed. Sub-group analysis was subsequently performed.

RESULTS

A total of 953 patients from 13 trials were included in this study. Nine RCTs administered magnesium intravenously and 4 RCTs administered magnesium locally. Laryngospasm rates were 6% lower in the magnesium group (OR 0.48 [95% CI 0.25-0.96], p = 0.04) compared to control in the pooled data. Subgroup analysis showed laryngospasm rates were lower by 12.5% (Odds Ratio 0.26 [CI 0.09-0.76], p = 0.01) in the local magnesium group. Subgroup analysis of studies that only administered intravenous magnesium did not show a statistically significant difference in the incidence of laryngospasm (OR 0.73 [95% CI 0.33-1.63], p = 0.44).

CONCLUSIONS

This review shows a potential role for magnesium in the prevention of laryngospasm in paediatric patients undergoing general anaesthesia. There is a correlation between local administration of magnesium and reduction in laryngospasm rates. Further studies are required to assess the efficacy of intravenous magnesium in prevention of laryngospasm.

REGISTRATION

Prospective Register of Systematic Reviews (PROSPERO); PROSPERO ID CRD42022307868 (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022307868).

Efficacy of Levobupivacaine Versus Levobupivacaine Plus Dexmedetomidine Infiltration for Post-Tonsillectomy Analgesia: A Randomized Controlled Trial

Background. The study evaluated the analgesic effects of levobupivacaine infiltration in the tonsil bed, and a combination of levobupivacaine and dexmedetomidine in patients undergoing tonsillectomy. Methods. Ninety children (ages 3 to 7 years) who were scheduled for a tonsillectomy were allocated randomly into two groups. (L Group): peritonsillar infiltration with 0.25% levobupivacaine (2 ml + 0.5 ml saline 0.9% per tonsil). (LD Group): levobupivacaine 0.25% (2 ml) plus dexmedetomidine 1 μg/kg diluted in 1 ml saline 0.9% (0.5 ml in each tonsil), and administered by peritonsillar infiltration (2.5 ml per tonsil) following intubation 3–5 minutes before operation. To avoid bias, infiltrate a total volume of 2.5 ml in each tonsil. The first analgesic request time was the primary outcome, with postoperative pain score, total analgesic consumption, total oral intake, sedation, and side effects as secondary outcomes. Results. The first rescue analgesia time in the LD group was longer (644.31 ± 112.89 min) than in the L group (551.51 ± 146.16 min, $P$ -value <0.001). The number of patients who required >1 analgesic dose in the L group (n = 13) was higher than in the LD group (n = 5). The LD group consumes a lower total dose of IV paracetamol in the first 24 hours postoperatively (321.89 ± 93.25 mg) than the L group (394.89 ± 183.71 mg, $P<0.00$ -value < 0.050). On the first day postoperatively, patients in the LD group had a higher total oral intake ( $P<0.001$ ). Except for a slight increase in laryngospasm in the L group, there were no side effects. Conclusions. The Children’s peritonsillar infiltration of levobupivacaine and dexmedetomidine improved postoperative pain after adenotonsillectomy. The topically applied levobupivacaine and dexmedetomidine were concomitant with no systemic effects, greater total oral intake on the first day postoperative, and higher family satisfaction.

Critical review on the efficacy and safety of levobupivacaine peritonsillar infiltration

Levobupivacaine is a long-acting local anesthetic that is both safe and non-toxic. However, few researchers have examined the efficacy and safety of peritonsillar injections of levobupivacaine for postoperative pain relief. The goal of this study was to assess current randomized controlled trials that employed this strategy. A literature review was conducted using databases such as DELPHIS, PUBMED, COCHRANE, and SCOPUS. A total of fifteen randomized controlled trials were found and thoroughly reviewed. There were no fatalities reported. One study reported a case of nausea and vomiting. In most of the studies, levobupivacaine with magnesium, epinephrine, dexamethasone hydrochloride, tramadol, or levobupivacaine alone were compared to a placebo. Four trials employed different combinations of levobupivacaine and other medicines to recruit adults. Most of the studies had a modest sample size. As a result, larger research with more representative populations should be conducted. Despite certain flaws in the trial design, our findings suggest that levobupivacaine is safe and effective at reducing postoperative pain.

Efficacy of dexmedetomidine for perioperative morbidities in pediatric tonsillectomy: A metaanalysis

OBJECTIVES

This study aimed to assess the effects of perioperative dexmedetomidine as an adjuvant to tonsillectomy compared with opioid or sham in children.

DATA SOURCE

Five databases (PubMed, SCOPUS, Embase, Web of Science, and Cochrane Central Register of Controlled Trials) were searched from inception of article collections to April 2017.

REVIEW METHODS

Prospective, randomized controlled studies that compared outcomes between children who underwent tonsillectomy plus dexmedetomidine administration (intervention) and children who underwent tonsillectomy with placebo or opioid (control) were systemically and independently reviewed by two researchers. The outcomes of interest were emergence agitation, postoperative pain intensity, rescue analgesic consumption, and other morbidities (nausea and vomiting and agitation).

RESULTS

Fifteen studies with n = 1,552 met the inclusion criteria. Postoperative pain scores and the need for analgesics in the postanesthesia care unit (PACU) were significantly decreased in the dexmedetomidine group versus the control group. The incidence and degree of agitation and desaturation incidence in the PACU also were significantly lower in the dexmedetomidine group than in the control group. Additionally, there was no significant difference in the duration of staying PACU between both groups. In subgroup analyses by administration method (bolus injection or continuous injection), dexmedetomidine was shown to be effective at reducing postoperative morbidities regardless of administration method.

CONCLUSION

Perioperative administration of dexmedetomidine can provide pain and agitation relief without side effects in children undergoing adenotonsillectomy. Considering the high heterogeneity of results within some parameters; however, further clinical trials with robust research methodology should be conducted to confirm the results of this study. Laryngoscope, 128:E184-E193, 2018.

Efficacy of Adjuvant Magnesium for Posttonsillectomy Morbidity in Children: A Meta-analysis

Objectives The perioperative administration of magnesium is known to reduce postoperative morbidities in adults, such as pain, agitation, and laryngospasm. The objective is to assess the effects of perioperative magnesium as the adjuvant to tonsillectomy as compared with tonsillectomy in children. Data Source Five databases (PubMed, SCOPUS, Embase, Web of Science, Cochrane). Method Two authors independently searched databases up to January 2017. We compared perioperative magnesium administration (magnesium groups) with no administration of magnesium (control group). The following outcomes were measured: postoperative pain intensity, analgesics administration, or other morbidities (laryngospasm, agitation, postoperative bleeding) in the postoperative 24 hours. Additionally, to evaluate the discrepancy of effects according to different administration routes, subgroup analyses regarding effects according to systemic or local administration of magnesium were performed. Results Nine prospective randomized controlled studies (n = 615) that evaluated the effect of magnesium in children having undergone tonsillectomy met inclusion criteria. Compared with control group, the time for first analgesic requirement was significantly delayed in magnesium groups (standardized mean difference = 0.75; 95% CI, 0.20-1.31; P = .0079). Laryngospasm (log odds ratio = -1.09; 95% CI,-2.11 to -0.07; P = .0362) and agitation score (standardized mean difference = -0.67; 95% CI, -0.97 to -0.36; P < .0001) in the recovery room also significantly decreased in magnesium groups. In subgroup analyses regarding pain and laryngospasm-related measurements, local administration of magnesium was shown to be more effective at reducing postoperative morbidities. Conclusions Perioperative magnesium regardless of route may offer pain, agitation, and laryngospasm relief without adverse effects in pediatric tonsillectomy. Based on the high heterogeneity of results within some parameters, further studies need to be performed to affirm these results.

Magnesium sulfate in pediatric anesthesia: the Super Adjuvant

Magnesium is an essential chemical element in all organisms, intervening in most cellular enzymatic reactions; thus, its importance in homeostasis and as a therapeutic tool in highly challenging patients such as pediatrics. The primary purpose of this paper was to review the role of magnesium sulfate as an adjuvant drug in pediatric anesthesia. This compound already has the scientific backing in certain aspects such as analgesia or muscle relaxation, but only theoretical or empirical backing in others such as organ protection or inflammation, where it seems to be promising. The multitude of potential applications in pediatric anesthesia, its high safety, and low cost make magnesium sulfate could be considered a Super Adjuvant.

Magnesium sulfate for postoperative complications in children undergoing tonsillectomies: a systematic review and meta-analysis

OBJECTIVE

Previous systematical reviews showed that systemic magnesium decreased postoperative pain and reduced morphine use without any reported serious adverse effects in adults. However, studies in children yielded different results. So we conducted a systematic review to evaluate the impact of magnesium sulfate on postoperative complications in children undergoing tonsillectomies.

METHODS

The PubMed, EMbase via OVID, CENTRAL, and WHO ICTRP were searched to identify randomized controlled trials that addressed the effect of magnesium for postoperative pain, agitation, and complications in children undergoing tonsillectomies. Two reviewers screened titles and abstracts for eligibility and assessed the quality of the included studies. The meta-analysis was performed using RevMan 5.3.

RESULTS

Ten randomized controlled trials involving 665 participates published between 2003 and 2015 were included. Eight studies showed no different effect on pain scores between MgSO₄ and control groups. Two studies showed significant lower emergence agitation incidence in MgSO₄ group (pooled OR = 0.18, 95% CI 0.07 to 0.48, P = 0.0006). Five studies showed rescue analgesia was reduced in MgSO₄ group (RR = 0.53, 95% CI 0.31 to 0.91, P = 0.02). Laryngospasm was founded lower in MgSO₄ group (OR = 0.36, 95% CI 0.13 to 0.96, P = 0.04). Postoperative nausea and vomiting was found no difference between two groups (OR = 1.23, 95% CI 0.70 to 2.18, P = 0.47).

CONCLUSION

Unlike the studies in adults, this review shows there is no statistically significant effect of perioperative use of magnesium in the postoperative pain control in children undergoing tonsillectomies. But it seems has benefits in reducing rescue analgesia, emergence agitation incidence, and laryngospasm.

Adjuncts to local anaesthetics in tonsillectomy: a systematic review and meta-analysis

The infiltration of local anaesthetic agents has been shown to reduce post-tonsillectomy pain. A number of recent studies have shown that the addition of agents such as clonidine and dexamethasone improve the efficacy of nerve blocks and spinal anaesthesia. The aim of this review was to determine whether additives to local anaesthetic agents improve post-tonsillectomy outcomes. Four major databases were systematically searched for all relevant studies published up to August 2016. All study designs with a control group receiving local anaesthetic infiltration and an intervention receiving the same infiltration with an added agent were included in this review. These studies were then assessed for level of evidence and risk of bias. The data were then analysed both qualitatively and where appropriate by meta-analysis. We reviewed 11 randomised controlled trial (RCTs) that included 854 patients. Due to inconsistencies in the methods used to report outcomes, both quantitative and qualitative comparisons were required to analyse the extracted data. Overall, we found that dexamethasone, magnesium, pethidine and tramadol reduce post-operative pain and analgesia use, with dexamethasone in particular significantly reducing post-operative nausea and vomiting and magnesium infiltration significantly reducing the incidence of laryngospasm. This systematic review of RCTs provides strong evidence that the use of dexamethasone and magnesium as additives to local anaesthetics reduces post-tonsillectomy pain and analgesia requirement. There is limited evidence that pethidine and tramadol have a similar effect on pain and analgesia requirement. The studies in this pooled analysis are sufficiently strong to make a level one recommendation that the addition of magnesium to local anaesthetics reduces the incidence of laryngospasm, a potentially lethal post-operative complication. Review level of evidence: 1.