literature reviews
Pediatric Pain Management for Tonsillectomy: An End of Year Literature Review
By Franklin Chiao, MD
Assistant Professor of Anesthesiology
Komansky Children’s Center
New York Presbyterian Medical Center-Weill Cornell Medical College
FRC9026@med.cornell.edu
Twitter: TheDOCFrancois
Tonsillectomy, one of the most common pediatric surgeries, challenges physicians with respect to pain management. Given the well-known risk of codeine use after tonsillectomy, researchers were determined to see the impact of morphine and NSAID use after tonsillectomy. There was also a case report illustrating a risk of tramadol use for tonsillectomy.
The risk of desaturation, apnea and increased morbidity after tonsillectomy may not be limited to codeine as events have occurred with tramadol and morphine. An anesthesia team in France reported critical desaturation events with Tramadol in a patient who was a CYP2D6 ultrarapid metabolizer. This 5 year old with obstructive sleep apnea was discharged after an uneventful stay of 6 hours in the post anesthesia care unit. 8 hours later, he received 1mg/kg of oral tramadol. The next morning he was found comatose by his parents and brought to the hospital where he had a Glasgow coma scale of 8. On room air arterial blood gas, pH was 7.06, CO2 was 94mmhg, O2 60mmhg. The patient recovered in the pediatric intensive care unit after three 500mcg doses of naloxone. Subsequently, the FDA issued a safety watch for tramadol use in pediatrics. Perhaps, there should be more thought about guidelines for the use of tramadol after tonsillectomy.
Investigators in Canada found that morphine caused a significant number of desaturation events after tonsillectomy surgery. They randomized 91 patients with sleep apnea aged 1 to 10 to post-operative acetaminophen with morphine or acetaminophen with ibuprofen. It was not surprising that there were more desaturation events with an opioid, but there were 11.2 more on average per hour with morphine compared to 1.8 fewer events per hour with ibuprofen. Given that pain scores and hemorrhage rates were similar in both groups, perhaps alternatives to morphine would be beneficial.
Pain management for tonsillectomy is challenging particularly because of airway obstruction and respiratory events. While the intensive care unit setting is able to prevent and reduce the risk of morbid events, it is not practical or economic to send every child there. These two publications highlight the risk of opioids besides codeine. Researchers and clinicians are hopeful that these studies and future research will help guide us towards a more comfortable standard of practice.
References
- Orliaguet G1 et al. “A case of respiratory depression in a child with ultrarapid CYP2D6 metabolism after tramadol.” Pediatrics. 2015 Mar; 135:753-5
- Kelly LE et al. “Morphine or ibuprofen for post-tonsillectomy analgesia: A randomized trial.” Pediatrics. 2015 Feb; 135:307. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm463499.htm
