Analgesia after tonsillectomy with controlled intravenous morphine – overdue or exaggerated?

Gostian, Magdalena; Loeser, Johannes; Bentley, Tanya; Wolber, Philipp; Schwarz, David; Balk, Matthias; Gostian, Antoniu-Oreste

doi:10.1016/j.bjorl.2021.08.002

Acessibilidade / Reportar erro

Brasil

Brazilian Journal of Otorhinolaryngology

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original article • Braz. j. otorhinolaryngol. 89 (1) • Jan-Feb 2023 • https://doi.org/10.1016/j.bjorl.2021.08.002 copy

Analgesia after tonsillectomy with controlled intravenous morphine – overdue or exaggerated?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To assess the value of a morphine Patient Controlled Intravenous Analgesia (PCIA) after Tonsillectomies (TE).

Methods:

30 adult patients were treated with oral analgesics (protocol group) and compared to 30 patients treated with a morphine PCIA for the first 3 Postoperative Days (PODs) after TE. Average and maximum pain severities (Numeric Rating Scale – NRS: 0–10) on PODs 1–3, analgesic score, quality of life, patient satisfaction and side effects were defined as outcome measures.

Results:

Average pain severities of the protocol and the PCIA group were of similar magnitude (NRS) (POD1: 4.48 vs. 4.71 [p = 0.68], POD2: 4.75 vs. 4.22 [p = 0.32] and POD3: 4.44 vs. 4.25 [p = 0.71]). Maximum pain intensities on POD1 (p = 0.92), POD2 (p = 0.51) and POD3 (p = 0.36) were also comparable between both groups. Patients with a PCIA consumed significantly more opioids (p = 0.001) without significant more side-effects.

Conclusion:

The PCIA did not provide a superior pain control compared to oral analgesics. In view of the considerable effort and the high opioid consumption, it cannot be recommended as a standardized application for pain control after TE.

Keywords
Tonsillectomy; Postoperative pain; Patient reported outcome; Quality of life; Patient satisfaction

Highlights

Postoperative pain intensities following tonsillectomy regularly reach high levels.

So far there is no effective evidence-based treatment concept.

Strong opioids for pain treatment have not been evaluated yet.

Patient Controlled Intravenous Analgesia is effective in multiple disciplines.

After tonsillectomy opioids are not a necessary and effective therapeutic option.

Parameter	Protocol group (n = 30)	PCIA group (n = 30)	Statistical comparison
Female gender (n/%)	19/63.3	18/60.0	χ²(1) =0.07, p = 0.79
Age (years)	25.3 ± 5.1 (18–36)	24.9 ± 7.0 (18–45)	t₍₅₈₎ =0.27, p = 0.79
Height (cm)	172.8 ± 7.2	175.6 ± 11.4	t_(48,74) = −1.15, p = 0.26
Weight (kg)	76.8 ± 17.3	77.4 ± 14.3	t₍₅₈₎ = −0.16, p = 0.86
ASA physical status	I: 20/66.7	I: 24/82.8	χ²(1) = 2.01,
(I/II/III) (n/%)	II: 10/33.3	II: 5/17.2	p = 0.16
Duration of inpatient stay	4.7 ± 1.6 (3–9)	4.4 ± 1.3 (3–11)	t₍₅₈₎ = 0.71, p = 0.48
Cutting/Suture time (min)	37.7 ± 11.7 (12–57)	38.9 ± 13.6 (10–63)	t₍₅₈₎ = −0.37, p = 0.72
Piritramide in the recovery room (mg)	2.3 ± 3.0 (0–8.5)	1.8 ± 4.3 (0–20)	t₍₅₈₎ = 0.57, p = 0.57
Fentanyl intraoperatively (mg)	0.38 ± 0.10 (0.2–0.5)	0.41 ± 0.15 (0.25–1)	t₍₅₈₎ = −0.92, p = 0.36
Antibiotics administered postoperatively (n/%)	3/10.0	7/23.3	χ²(1) = 1.92, p = 0.17

NRS 1-3	NRS > 3 at rest and I or NRS > 5 on ambulation		NRS > 5 at rest
Basic medication	Level 1	Level 2	Rescue Medication
Metamizole 750 mg p.o. 1-1-1-1	Tramadol retard 100 mg p.o. 1-0-1	Morphine retard 20 mg p.o. 1-0-1	Morphine immediate release 10 mg p.o. (max. 6x daily)
+
Ibuprofen 600 mg p.o. 1-1-1 + Pantoprazole 40 mg p.o. 1-0-0
Gastric tube / dysphagia:	Gastric tube / dysphagia:	Gastric tube / dysphagia:	Gastric tube / dysphagia:
Ibuprofen 600 mg mortars or Juice 4% 1-1-1	Tramadol 20 gtt/50 mg IV 1-1-1-1	Morphine 2% 16 gtt / 20 mg retard Granulate 1-0-1	Morphine 2% 4-8 gtt (max. 6x daily)
Metamizole 30 gtt p.o. 1750 mg lV 1-1-1-1

Side effect	Protocol group (n = 30)	PCIA group (n = 30)	Statistical comparison
Persistent nausea (n/%)	20/66.7	19/63.3	p = 0.79
Degree of persistent nausea	2.30 ± 1.39	3.15 ± 2.03	t₍₃₇₎ = 1.54, p = 0.13
Vomiting (n/%)	7/23.3	10/33.3	p = 0.39
Degree of vomitting	2.26 ± 1.42	1.97 ± 1.67	t₍₁₅₎ = 0.38, p = 0.71
Obstipation (n/%)	13/43.3	22/73.3	p = 0.02
Degree of obstipation	1.55 ± 1.07	2.44 ± 2.15	t₍₃₂₎ = 1.39, p = 0.17
Fatigue (n/%)	28/93.3	28/93.3	p > 0.999
Degree of fatigue	4.25 ± 1.98	4.23 ± 2.23	t₍₄₄₎ = 0.032, p = 0.98
Concentration disorders (n/%)	14/46.7	21/70.0	p = 0.07
Degree of concentration disorders	2.76 ± 1.85	2.54 ± 1.76	t₍₃₃₎ = 0.36, p = 0.72
Sleep disturbance (n/%)	29/96.7	26/86.7	p = 0.16
Degree of sleep disturbance	2.53 ± 1.77	2.89 ± 1.82	t₍₅₃₎ = −0.76, p = 0.45
Vertigo (n/%)	18/60.0	17/56.7	p = 0.79
Degree of vertigo	2.11 ± 1.53	2.70 ± 2.12	t₍₃₃₎ = −0.95, p = 0.35

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] * Corresponding author. E-mail: magdalenaf@gmx.de (M. Gostian).