Control of Pain After Tonsillectomy in Children

Abstract

Clinicians should understand effective methods of analgesia after tonsillectomy in children, and know the potential consequences of each option. Caution should be employed when using opioids, particularly in young children with severe OSAS. Although large studies of NSAID use have shown effective pain management without an increase in posttonsillectomy bleeding frequency, the potential for more severe bleeding events has been debated. Cold dissection techniques lead to less pain, but hot techniques remain popular, with less intraoperative blood loss and shorter operative time. Partial (intracapsular) tonsillectomy seems to reduce pain as well.

Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients

“…In a review on control of pain after tonsillectomy, regular assessment of a child's pain, potentially done with behavioral pain scales, was mentioned as a means of quantifying the pain level . Even if pain is recognized though, parents may not give prescribed analgesics at the recommended dosages.…”

“…2,8 In a review on control of pain after tonsillectomy, regular assessment of a child's pain, potentially done with behavioral pain scales, was mentioned as a means of quantifying the pain level. 12 Even if pain is recognized though, parents may not give prescribed analgesics at the recommended dosages. In their feasibility study evaluating scheduled dosing of acetaminophen plus hydrocodone after T&A in 47 children ages 3 to 5 years, Sutters et al 13 noted that the number of missed doses was significantly higher on the third postoperative day when compared to the first day after surgery.…”

The Use of Codeine and Tramadol in the Pediatric Population—What is the Verdict Now?

“…Historically, nonsteroidal anti-inflammatory drugs like ibuprofen have been considered suboptimal for relieving pain because of concerns about increasing bleeding after adenotonsillectomy (D'Souza, Schmidt, Xie, Adelman, & Nardone, 2015;Pfaff, Hsu, & Chennupati, 2016). However, recent literature refuted this fear, and more otolaryngologists now recommend using ibuprofen as an initial regimen to relieve pain in patients who do not have a history of opioid use (Tan & Tunkel, 2017). If ibuprofen is chosen as an analgesic option, the clinician needs to ensure that the patient is well hydrated, because recent literature has documented acute kidney injury related to nonsteroidal anti-inflammatory drug use in children (especially younger than 5 years) who are dehydrated or at risk of dehydration (de Martino, Chiarugi, Boner, Montini, & de Angelis, 2017;Misurac et al, 2013).…”

“…In otherwise hydrated patients, clinicians may recommend alternating acetaminophen with ibuprofen for analgesia (Liu & Ulualp, 2015), because acetaminophen alone may not be adequate in providing pain relief in this population (Tan & Tunkel, 2017). The child's caregivers need to be counseled on how to alternate acetaminophen and ibuprofen, because the literature has documented medication errors from this combination due to misunderstanding dosing directions (Eluri et al, 2017;Yue, Jiang, Sun, & Wu, 2014).…”

“…Oxycodone is mainly metabolized by UGT2B7 and morphine by CYP3A4 (Lauder & Emmott, 2014;Smith, 2011). Nonetheless, extra caution is warranted when using these opioids in patients with history of obstructive sleep apnea or severe lung disease because they have compromised airways at baseline, and respiratory depression remains a known adverse effect (Tan & Tunkel, 2017). Other options to relieve pain documented in the literature include a short course of steroids (Aveline, Le Hetet, Le Roux, & Bonnet, 2015) and sucralfate (Mliura et al, 2009); however, the evidence supporting their use is limited, and their use should be reserved for refractory cases.…”