Oral morphine for pain management in paediatric patients after tonsillectomy and adenotonsillectomy.

The withdrawal of codeine for use in children following tonsillectomy enforced a change in our practice of providing regular paracetamol and ibuprofen, with codeine for breakthrough pain relief. Our objectives were to; examine the effectiveness of paracetamol and ibuprofen; examine the effectiveness of the addition of rescue (PRN) morphine to regular paracetamol and ibuprofen. A 2 cycle prospective audit was conducted on our unit. Telephone consultations were conducted with parents of 74 children undergoing tonsillectomy and adenotonsillectomy. Cycle 1 (C1, without morphine) contained 24 consecutive patients and cycle 2 (C2, with morphine) contained 50 consecutive patients. Postoperative health service contact and outcome was recorded: worst pain scores on days 4 and 7 were obtained using validated pain assessment tools scoring 0-10. Cycle 2 results underwent subgroup analysis by method of surgery i.e. coblation (C2C) and cold steel dissection (C2D) groups. More than half of parents felt simple analgesia was not effective enough in both cycles, this number was significantly higher in both 2nd cycle groups (C1=54%, C2C=74%, p=0.003, C2D=84%, p=0.0001). Mean worst pain reported at day 4 was similar for all groups, but the morphine groups reported higher pain at day 7 (C1 1.6, C2C 3.59, p=0.017, C2D 3.90, p=0.002). Antibiotic prescribing for children contacting a GP after surgery was significantly lower in the morphine groups (C1 24%, C2C 7%, p=0.0014, C2D 5%, p=0.0002). There was no difference in measured outcomes between the 2nd cycle groups. This service evaluation found that postoperative morphine on an as-required basis, in addition to regular paracetamol and ibuprofen, did not significantly alter initial pain profile, worst pain scores or rate of health service contact when compared to regular paracetamol and ibuprofen alone. The majority of children in this study felt additional analgesia required. Children in the morphine groups experienced significantly less pharmacological intervention when contacting the GP after surgery.

Oremule B ，Johnson M ，Sanderson L ，Lutz J ，Dodd J ，Hans P ... -  《-》

Analgesia following adenotonsillar surgery in children: is Oramorph required in addition to paracetamol and ibuprofen?

Recent advice against codeine use in children prompted our unit to prescribe Oramorph as required, in addition to regular paracetamol and ibuprofen, as post-(adeno)tonsillectomy analgesia. This study investigated whether Oramorph was in fact required. Following (adeno)tonsillectomy, parents were telephoned and asked whether they used Oramorph. Of 56 children studied, 41 (73.2%) were given Oramorph. In the 15 (26.8%) that were not, this was because parents felt it was not required in 14 children, and in 1 case, it was due to worries about side effects. Overall, 14 carers (25.0%) expressed concerns about Oramorph use, mostly over possible side effects. When regular paracetamol and ibuprofen are used post-(adeno)tonsillectomy, nearly three quarters of children require Oramorph as well. Prescribing Oramorph as required, in addition to regular paracetamol and ibuprofen, is appropriate following adenotonsillar surgery.

Wei Chern Gan R ，Kamani T ，Daniel M 《-》

Comparison of Oral Loading Dose to Intravenous Acetaminophen in Children for Analgesia After Tonsillectomy and Adenoidectomy: A Randomized Clinical Trial.

Acetaminophen is a frequently used adjunct analgesic in pediatric patients undergoing tonsillectomy and adenoidectomy. We compared opioid administration following preoperative intravenous (IV) or oral acetaminophen in addition to a standard multimodal regimen to test the hypothesis that 1 loading dose approach would provide superior opioid sparing effects among pediatric surgical patients undergoing tonsillectomy and adenoidectomy. This single-center, double-blind, double-dummy prospective randomized study was conducted in patients ages 3 to 15 years undergoing tonsillectomy and adenoidectomy with or without myringotomy and tube placement between September 2017 and July 2019. Subjects received 1 dose of either oral acetaminophen 30 mg/kg with IV placebo (oral group) or IV acetaminophen 15 mg/kg with oral placebo (IV group). Acetaminophen plasma levels were measured at 2 timepoints to evaluate safety and determine plasma levels attained by each dosing regimen. Intraoperative opioid administration and postoperative analgesia were standardized. Standardized postoperative multimodal analgesia included opioid if needed to control pain assessed by standardized validated pediatric pain scales. The primary outcome measure was total opioid administration in the first 24 hours after surgery. Continuous data were not normally distributed and were analyzed using the Wilcoxon rank sum test and the Hodges-Lehman estimator of the median difference. Clinical significance was defined as a 100 µg/kg IV morphine equivalents per day difference. Sixty-six subjects were randomized into and completed the study (29 women, 37 men; age 5.9 ± 3.0 years; percentile weight for age 49.5 ± 30.2; no differences between groups). There was no opioid dose difference between oral (median 147.6; interquartile range [IQR], 119.6-193.0 µg/kg) and IV groups (median 125.4; IQR, 102.8-150.9 µg/kg; median difference 21.3; 95% confidence interval [CI] -2.5 to 44.2 µg/kg IV morphine equivalents; P = .13). No acetaminophen levels exceeded the predefined safety threshold (40 mg/L). No difference was found in the percentage of patients with severe pain: 50.0% oral group, 47.2% IV group; relative risk of severe pain in IV 0.94; 95% CI, 0.57-1.6; P = .82. Postoperative plasma acetaminophen levels were higher in oral (22; IQR, 16-28 mg/L) than IV (20; IQR, 17-22 mg/L) group (median difference 7.0; 4.0-8.0 mg/L; P = .0001). Opioid-sparing effects did not differ following an oral or standard IV acetaminophen loading dose with no identified acetaminophen toxicity in pediatric patients undergoing tonsillectomy and adenoidectomy who received standardized multimodal postoperative analgesia. An oral loading dose may provide more consistent serum acetaminophen levels at lower cost compared to a standard IV dose.

Lammers CR ，Schwinghammer AJ ，Hall B ，Kriss RS ，Aizenberg DA ，Funamura JL ，Senders CW ，Nittur V ，Applegate RL 2nd ... -  《-》

Double-blind, placebo-controlled analgesic study of ibuprofen or rofecoxib in combination with paracetamol for tonsillectomy in children.

Pickering AE ，Bridge HS ，Nolan J ，Stoddart PA ... -  《BRITISH JOURNAL OF ANAESTHESIA》

The effectiveness of clonidine as an analgesic in paediatric adenotonsillectomy.

Reimer EJ ，Dunn GS ，Montgomery CJ ，Sanderson PM ，Scheepers LD ，Merrick PM ... -  《Canadian Journal of Anesthesia-Journal canadien d anesthesie》