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Published on: November 6, 2019
Comparative Effectiveness of Analgesia for Early Pain Management After Pediatric Tonsillectomy: A Systematic Review
Xialin Deng1,2, Shishun Zhao2, Wenlai Guo3
1From the Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China.
Insights
Effective pain management after pediatric tonsillectomy involves local anesthetic infiltration (bupivacaine, levobupivacaine) for older children and dexamethasone for younger children. These options provide superior pain relief and reduce complications.
Area of Science:
- Pediatric Anesthesiology
- Pain Management
- Pharmacology
Background:
- Effective pain relief after pediatric tonsillectomy is critical but lacks a clear consensus on optimal analgesics.
- This study addresses the need for evidence-based recommendations for post-tonsillectomy pain management in children.
Purpose of the Study:
- To conduct a systematic review and network meta-analysis to identify the most effective analgesics for pain management following pediatric tonsillectomy.
- To compare the efficacy and safety of various analgesic interventions, including local anesthetics, opioids, and glucocorticoids.
Main Methods:
- Systematic review and random-effects network meta-analysis of 82 randomized controlled trials involving 6110 pediatric patients undergoing tonsillectomy.
- Searched major databases (PubMed, Embase, Cochrane, Web of Science) up to June 30, 2023.
- Primary outcomes: pain scores and postoperative complications; secondary outcomes: need for rescue analgesia, functional evaluation, sedation scores.
Main Results:
- Local anesthetic infiltration (bupivacaine, ropivacaine, lidocaine, levobupivacaine), morphine, and dexamethasone demonstrated significant pain relief.
- Dexamethasone was more effective than bupivacaine in reducing postoperative complications.
- Levobupivacaine and morphine showed superiority in reducing the need for rescue analgesia compared to certain other agents.
Conclusions:
- Local bupivacaine or levobupivacaine infiltration is recommended for older children, while dexamethasone injection is suggested for younger children for early post-tonsillectomy analgesia.
- Individual patient condition and clinical context should guide the selection of the optimal analgesic strategy.
Background:
Timely and effective analgesia after tonsillectomy in children is crucial, but there is currently no consensus on the optimal analgesics. This analysis aimed to identify the most effective for this surgery.
Methods:
We conducted a systematic review and network meta-analysis (random-effects model) of randomized controlled trials comparing analgesics for pediatric tonsillectomy. We searched relevant studies in PubMed, Embase, Cochrane Library, and Web of Science databases from database inception until June 30, 2023. Children (≤18 years old) who underwent tonsillectomy with or without adenoidectomy were eligible for inclusion. Primary outcomes encompassed pain score and postoperative complications; secondary outcomes included postoperative supplementary analgesia, functional evaluation, and sedation score.
Results:
In total 82 randomized controlled trials involving 6110 patients were included, forming the primary network that comprised comparative data for 16 different interventions (including placebo) across 6 types of analgesics. The integrated analysis revealed that nonsteroidal anti-inflammatory drugs except ketoprofen had no significant effects in relieving postoperative pain (mean difference [MD], -2.96; 95% confidence interval [CI], -5.59 to -0.32; P = .10). Local anesthetic infiltration (bupivacaine: MD, -2.76; 95% CI, -3.88 to -1.64, P = .01; ropivacaine: MD, -2.49; 95% CI, -4.25 to -0.73, P = .02; lidocaine: MD, -1.86; 95% CI,-3.52 to -0.2, P = .02; levobupivacaine: MD, -1.06; 95% CI, -2.00 to -0.12, P = .01), analgesics (morphine: MD, -2.07; 95% CI, -3.14 to -1.00; P = .02), and glucocorticoids (dexamethasone: MD, -0.45; 95% CI, -0.73 to -0.16; P = .01) were effective in relieving pain after pediatric tonsillectomy. In reducing incidence of postoperative complications, dexamethasone was superior to bupivacaine (relative risk [RR], 0.60; 95% CI, 0.43-0.83; P = .02). Regarding the number of patients needing rescue analgesic, levobupivacaine was superior to lidocaine (RR, 0.51; 95% CI, 0.32-0.81; P = .01). In rescue analgesia requirement, morphine outperformed lidocaine (RR, 0.44; 95% CI, 0.25-0.75; P = .01) and ropivacaine (RR, 0.54; 95% CI, 0.32-0.91; P = .01) in efficacy but not different from bupivacaine ( P = .10) and levobupivacaine ( P = .12).
Conclusions:
Based on these results, we would recommend local bupivacaine infiltration or local levobupivacaine infiltration for older children and dexamethasone injection for younger children for early analgesia after tonsillectomy. However, clinicians should choose the optimal analgesic based on the individual child's condition and clinical situation.
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