Double-Blind Randomized Placebo-Controlled Trial of Single-Dose Intravenous Acetaminophen for Pain Associated With Adenotonsillectomy in Pediatric Patients With Sleep-Disordered Breathing

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.

Pharmacologic management of post-tonsillectomy pain in children

Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.

Intraoperative Single-Dose Intravenous Acetaminophen for Postoperative Analgesia After Skin Laser Irradiation Surgery in Paediatric Patients: A Small Prospective Study

Objective

Acetaminophen is an analgesic that shows efficacy in postoperative pain relief in children. Many drugs such as opioids, non-steroidal anti-inflammatory drugs, and/or acetaminophen have been used in paediatric skin laser irradiation surgery for postoperative pain relief. However, acetaminophen has some advantages over opioids, and opioids are being used less often. We aimed to demonstrate the effectiveness of intravenous (IV) acetaminophen during surgery for postoperative pain in paediatric skin laser irradiation.

Methods

The present study is a small, prospective, double-blinded, randomized controlled trial. Paediatric patients (1-12 years old with an American Society of Anesthesiologists physical Status I and II), scheduled for skin laser irradiation for a nevus or haemangioma between October 2014 and April 2016 were randomized into the acetaminophen (n=9) and placebo (saline, n=8) groups. The observational face scale (FS) and the Behavioural Observational Pain Scale (BOPS) scores were recorded on emergence from anaesthesia, and 1, 2, and 4 hr post-surgery.

Results

Patient characteristics were not significantly different except with regard to the irradiation area and surgery time. The observational FS and BOPS scores of the acetaminophen group were lower than those of the placebo group; median (minimum-maximum) at each recording time: 1 (0-2) - 0 (0-2) - 0 (0-1) - 0 (0-2) vs. 2 (0-4) - 0 (0-2) - 0 (0-2) - 0 (0-1) and 1 (0-3) - 1 (0-3) - 1 (0-2) - 0 (0-1) vs. 2 (0-4) - 3 (0-5) - 1 (0-4) - 0 (0-3), p=0.07 and p=0.003, respectively. No differences in post-surgical analgesic use or adverse events were observed.

Conclusion

In this study, we showed that the IV acetaminophen group had lower observational FS and BOPS scores in the early postoperative period; however, further studies including a large number of patients are required to confirm our findings.

Impact of coblation versus electrocautery on acute post-operative outcomes in pediatric tonsillectomy

Objective

Based on previous studies in the pediatric population, it remains unclear whether there is a difference in postoperative pain between two widely used tonsillectomy techniques: coblation and bovie electrocautery. This large prospective study investigates whether postoperative pain scores differ between these two surgical techniques for tonsillectomy.

Methods

Prospective, non‐randomized study of children aged 2–8 enrolled in a randomized controlled trial of single‐dose intravenous acetaminophen for pain associated with adenotonsillectomy. Included procedures occurred between October 2012 and June 2015 at a tertiary referral center. Only patients whose operations exclusively used coblation or electrocautery and who required postoperative admission for extended observation were included. Follow‐up period was the length of inpatient stay. Patients and nurses who recorded the pain scores were blinded to the tonsillectomy technique.

Results

A total of 183 patients were included: 117 coblation cases and 66 electrocautery cases. Pain scores in the surgical recovery unit and pain scores after admission to the floor unit were not significantly different between coblation and electrocautery, either before or after adjustment for patient age, body mass index, intravenous acetaminophen use, and surgeon. There was also no difference in length of stay, readmission rate, or post‐tonsillectomy hemorrhage.

Conclusions

Coblation and electrocautery tonsillectomy are associated with similar post‐operative pain scores in the recovery and inpatient units in the pediatric population. As coblation is costlier, the results of this study may affect which tool is used by otolaryngologists from a cost–benefit perspective.

Level of evidence

III