Evaluation of multimodal approach for minimizing post-tonsillectomy morbidity in pediatric patients a prospective randomized study

ABSTRACT

Tonsillectomy is a very common paediatric day-cast procedure that is associated with significant postoperative pain. Pain control continues to be a challenge for adenotonsillectomy patients. To study the effect of combination of pre-emptive analgesia with acetaminophen, pre-induction dose of dexamethasone and intra-operative infiltration olbupivacain on post-tonsillectomy pain and morbidity in young children. A prospective, randomized study, done over a total of 100 children, aged 3 to 12 years, undergoing tonsillectomy or adenotonsillectomy operation, in KFSH, Buraidah in KSA. Patients were randomly divided into two groups. Group 1, received acetaminophen 35mg/kg supp. Or 15mg/kg orally, and IV 0.5mg/kg of dexamethasone in the ward just before sending to OR and local infiltration of 2mL of bupivacain 0.5% in each tonsil bed after the completion of surgery but before the patient's recovery from anaesthesia. Group 2 was placebo. Both groups received standard anaesthetic technique by the same anaesthetist and were operated using the same cold tonsil dissection technique by the one ENT surgeon. Modified objective pain score [OPS] was chosen as the primary end-point of the study. Time to first analgesic dose, total dose of analgesia in the first 24 hours, time to 100mL of oral intake and incidence of vomiting were registered as secondary end-points, as well as the length of hospital stay. The average modified objective pain score was significantly lower in the study group at all measurement timings. Dose of analgesia given in the first 24 hours was lower and time to first analgesic dose was longer in the study group. Also time to 100mL of oral intake was shorter in the study group. The incidence of late vomiting was significantly more frequent in the placebo group. Seven patients in the placebo group and none in the study group had a delayed discharge from the hospital [more than a 24-h stay] because of poor oral intake, this was statistically significant. The additive effect of the multimodal approach has dramatically minimized post-tonsillectomy pain and vomiting as well as improved postoperative oral intake and consequently reduced the period of hospital stay in pediatric patients undergoing tonsillectomy operation