Good Practice in Postoperative and Procedural Pain Management ...

RecommendationsA combination of individually titrated intraoperative opioids,dexamethasone, and regularly administered perioperativemild analgesics (NSAIDS and/or paracetamol) isrecommended for management of tonsillectomy pain:Grade A (12,13).Topical application or injection of local anesthetic in thetonsillar fossa improves early pain scores following tonsillectomy:Grade A (14,15).Tramadol can produce similar analgesia to morphine orpethidine: Grade B (16–18).Peritonsillar injection of tramadol has no advantage oversystemic administration: Grade B (19,20).Intraoperative intravenous ketamine does not providesignificant postoperative advantage compared with opioid:Grade B (16,17,21,22).Implementation of standardised protocols including intraoperativeopioid ± anti-emetic, perioperative NSAID(diclofenac or ibuprofen), and paracetamol is associatedwith acceptable pain relief and low rates of PONV:Grade C (23,24).EvidenceSignificant levels of pain, behavioral disturbance, sleepdisruption, and altered activity can persist for 5–8 daysfollowing tonsillectomy (25–28). Regular administrationof paracetamol and NSAID is necessary for severaldays postoperatively, and adequate parentaleducation about pain assessment and medication use isrequired.Opioids: Intraoperative opioids are given during tonsillectomyand may be required in the postoperativeperiod (12). Morphine is the prototype opioid, butthere has been some interest in the use of tramadol followingtonsillectomy.Tramadol produces similar analgesia and side effectsto morphine (29) and pethidine (16). Tramadol1mgÆkg )1 was equianalgesic with IV paracetamol15 mgÆkg )1 in one study (30). One study reported lessnausea with tramadol than morphine (18). In patientswith sleep apnea tramadol was associated with fewerepisodes of oxygen desaturation at one time pointpostoperatively (1–2 h, no difference at earlier or latertime points to 6 h) (29). Comparison of intravenousand peritonsillar injection of tramadol 2 mgÆkg )1reported minor improvements with peritonsillar injection(19), but effects are likely to be related to systemicabsorption. Tramadol 1 mgÆkg )1 (IV), 2 mgÆkg )1 (IM),or 3 mgÆkg )1 by peri-tonsillar injection reduced painscores when compared with placebo (20,31). Of particularconcern, children in these placebo groups receivedno intra-operative analgesia. However, tramadol wasless effective than ketoprofen (higher pain scores andhigher postoperative PCA fentanyl) and did not differfrom placebo in one study (32).NSAIDS improve analgesia when compared withplacebo (10/11 studies) and provide similar analgesiato opioids (7/8 studies) and paracetamol (3/3 studies)(33). A systematic review found that heterogeneity ofthe data precluded meta-analysis, and many studiescomparing two active treatments were not sensitiveenough to show a difference (12). Subsequent studieshave reported similar analgesia with ketorolac andfentanyl (34), no improvement with addition of rofecoxibto opioid and paracetamol (35), and no differencein pain scores but increased rescue analgesicrequirements with IV paracetamol compared withpethidine (36). Ketoprofen improved analgesia in thefirst 6 h postoperatively in comparison with tramadolor placebo (32).Paracetamol is more effective given orally prior tosurgery than rectally after induction of anesthesia, itreduces opioid requirements and PONV (37–39).Local anesthesia: Two recent meta-analyses reportedstatistically significant reductions in postoperative painscores with local anesthetic techniques for up to 48 h,but the effect size decreased after the first 4–6 h(14,15). Topical application and infiltration wereequally effective (14), and no difference was foundbetween LA infiltration before or after removal of thetonsils (15). Postoperative analgesic requirements werereduced (15), but there was no significant difference inadverse events (14) or PONV (15). In additional studies,bupivacaine infiltration and topical levobupivacaineswabs improved pain scores but did not alterPONV (40,41). Others reported no benefit with peritonsillarLA infiltration (42) and similar analgesiawhen topical 2% viscous lignocane was compared withrectal diclofenac (43).Ketamine (IV) improves analgesia when comparedwith placebo (21,44,45) but provides no advantagewhen compared with equianalgesic opioid (17,46) andmay increase side effects (22). Addition of ketamine0.25 mgÆkg )1 to morphine 0.1 mgÆkg )1 did not significantlyimprove analgesia (47). Topical application onswabs (ketamine 20 mg in children aged 3–12 years)(48) or peritonsillar infiltration reduced very earlypain scores and opioid requirements (49), effects mayrelate to systemic absorption. The combination of ketamine0.5 mgÆkg )1 IV and topical bupivacaine infiltrationresulted in minor reductions in pain scoresª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 35