Topical Ropivacaine in Prevention of Post-Tonsillectomy Pain in Adults

Tolska, Hanna Kaisa; Takala, Aino K.; Blomgren, Karin; Hamunen, Katri; Kontinen, Vesa K.

doi:10.1213/ane.0000000000002015

Cited by 9 publications

(14 citation statements)

References 19 publications

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“…Preemptive analgesia—an antinociceptive treatment that prevents the establishment of altered processing of afferent input—has been widely implemented into clinical practice, aiming to inhibit the development of hypersensitivity and hyperalgesia and to control postsurgical pain with minimum side‐effects . Early reports focused on the pre‐incisional injection of local anesthetics as preventive analgesic modality after tonsillectomy in pediatric patients . Nowadays, peritonsillar infiltration of other drugs has been investigated as alternatives to local anesthetics in the context of preemptive analgesia.…”

Section: Discussionsupporting

confidence: 80%

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta‐Analysis

et al. 2020

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Objectives The aim of this systematic review and meta‐analysis was to appraise clinical evidence of the impact of peritonsillar infiltration of tramadol, on postoperative pain control and the occurrence of adverse effects in children undergoing tonsillectomy. Methods A database search was conducted to identify randomized controlled trials (RCTs) pertinent to peritonsillar infiltration of tramadol compared to no treatment (placebo) or other analgesic regimens. The outcomes of interest were postoperative pain intensity, time to first analgesic demand, rescue analgesic consumption up to 24 hours after intervention, and the occurrence of adverse events. Results Twelve RCTs enrolling 972 pediatric patients were selected for qualitative analysis, among which eight were suitable for meta‐analysis. Tramadol infiltration induced a significant reduction of pain intensity up to 24 hours post‐tonsillectomy (mean difference [MD], −2.31; 95% confidence interval [CI], −3.49 to −1.12; P < 0.001; I2 = 97%) and time to first analgesic (MD 180.54; 95% CI, 56.91 to 304.18; P = 0.004; I2 = 99%), with no profound impact on postoperative nausea and vomiting (risk ratio [RR] 0.98; 95% CI, 0.73 to 1.32; P = 0.90; I2 = 0%) compared to the placebo group. The analgesic efficacy of tramadol infiltration was equivalent to the local or systematic use of ketamine or infiltration with local anesthetics. This effect was further enhanced when tramadol infiltration served as an adjunct to other analgesic interventions. No serious adverse events were reported. Conclusions In children undergoing tonsillectomy, peritonsillar infiltration of tramadol is associated with a postoperative analgesic benefit when compared to placebo, with negligible adverse events. Yet, no definite conclusion can be drawn due to the low quality, considerable heterogeneity, and paucity of the available data.

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Section: Discussionsupporting

confidence: 80%

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta‐Analysis

et al. 2020

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“…There were 24 studies identified, including 6 RCTs, 13 prospective observational studies, and 5 retrospective observational studies, that described mean or median consumption with either the standard deviation or the 75th percentile. 147,152,153,164-185 Opioid consumption was initially converted into morphine milligram equivalent (MME) units 186 ( Table 15 ), and individual procedures were compared. MME is a value assigned to compare the opioid dosage equivalency to another opioid.…”

Section: Key Action Statementsmentioning

confidence: 99%

“…Usage of multimodal analgesia in addition to opioids varied across included studies, and utilization of a multimodal strategy may result in significantly lower consumption. 147,152,166,169 The low-dose recommendation is zero opioids for all procedures, recognizing that use of a multimodal nonopioid analgesia strategy may obviate the need for opioids.…”

Section: Key Action Statementsmentioning

confidence: 99%

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Anne¹,

Mims

Tunkel

et al. 2021

Otolaryngol.--head neck surg.

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Objective Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. Purpose The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan. The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. Action Statements The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method. The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

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“…Tolska et al [23] found that bleeding requiring haemostasis under local anaesthesia was more common in the ropivacaine group (10/54 (18%)) than in the control group Only one study [26] and one meta-analysis [27] have been published since 2007 on the efficacy of lidocaine spray on postoperative pain after tonsillectomy. Jahromi et al [26] reported that lidocaine spray reduced pain scores for only 20 min after surgery when compared with saline or ketamine spray.…”

Section: Local Anaesthetic Infiltration and Topical Applicationmentioning

confidence: 99%

“…Tolska et al. [23] found that bleeding requiring haemostasis under local anaesthesia was more common in the ropivacaine group (10/54 (18%)) than in the control group (4/47 (8%)). One patient out of the 54 patients included in the ropivacaine group sustained postoperative bilateral pneumonia requiring 5 days of hospitalisation.…”

Section: Paracetamolmentioning

confidence: 99%

PROSPECT guideline for tonsillectomy: systematic review and procedure‐specific postoperative pain management recommendations

et al. 2020

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Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure-specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta-analysis guidelines with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol; non-steroidal anti-inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra-operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.

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Topical Ropivacaine in Prevention of Post-Tonsillectomy Pain in Adults

Abstract: Topical ropivacaine failed to reduce pain intensity during the first postoperative week. We observed no major adverse effects.

Cited by 9 publications

References 19 publications

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta‐Analysis

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta‐Analysis

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

PROSPECT guideline for tonsillectomy: systematic review and procedure‐specific postoperative pain management recommendations

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