British Journal of Anaesthesia 2019: e397-e411
Tolska K, Hamunen K, Takala A and Kontinen VK.
Aim of Study
To analyse effectiveness of systemic medications used for post-tonsillectomy pain in adult and adolescent patients.
Design and Location
Systematic review with meta-analysis
Incidence or intensity of pain
Use of rescue analgesics and adverse effects
Data were analysed by calculating the mean difference with the corresponding 95% confidence intervals (CI). Statistical heterogeneity was analysed with a x2 test and I2 was calculated.
The authors retrieved 2219 citations from an electronic database search and an additional 14 citations from reference lists of reviews. After excluding duplicates and articles that did not fulfil the inclusion criteria, full-text articles of 81 studies were assessed for eligibility, based on the title and abstract. Of these, 29 studies representing 1816 patients met the inclusion criteria, of which 13 were suitable for pooled meta-analysis.
The main finding quoted by the authors is the scarcity of data and short duration of follow up in these studies. During first week pain intensity in both study and placebo groups ranged from 4-8. By the end of week 1, pain intensity had decreased to less than 4/10 in most study groups but remained >4/10 in most placebo groups.
Paracetamol, NSAIDs, Dexamethasone, gabapentenoids and dextromethorphan have beneficial effects for post tonsillectomy pain on the day of operation. However none provide adequate analgesia when used alone. More research is required to further evaluate the best combination of the above analgesics.
Stated Limitations from the Study
The quality of the data is based on the availability of well conducted studies. Only studies published in English were reviewed. Mixed studies including children were excluded. Studies were clinically heterogeneous with a wide variation in the timings of study medication, use of rescue and additional analgesics. 12 out of 29 studies did not describe a primary outcome.
Discussion from Journal Club Meeting (? Change of Practice)
Use of high dose aspirin as an analgesic for post tonsillectomy, and whether there was an increased risk of post-tonsillectomy haemorrhage. The study has reported no increased risk, however the consensus was that anaesthetists would be uncomfortable prescribing 600mg aspirin regularly or PRN post tonsillectomy.
Current practices of TTOs (prescribed by the ENT team) – usually paracetamol, NSAID and codeine. Would paracetamol, NSAID and gabapentinoid be a better combination? No conclusion reached.
High dose dexamethasone use, and its benefits in tonsillectomy, currently 3.3-6.6mg is used in KH.
Summary by Dr J Haugh. Journal Club Meeting 12 September 2019.