A Comparative Analysis - Postoperative Pain Management in Children Following Tonsillectomy & Adenoidectomy

Abstract

Tonsillectomy and Adenoidectomy are considered to be a common pediatric surgical procedure worldwide. Yet, pediatric populations often undergo moderate to severe pain after surgery procedures, making clinical and pediatric nursing practices an essential element in the aftercare treatment of these patients. As such, postoperative pain management of Tonsillectomy and Adenoidectomy in pediatric populations becomes an essential area of focus that needs to be investigated to address these concerns. Through a critical analysis of three articles, each from three major healthcare databases, PubMed, CINAHL, and Cochrane Medical Reviews, a better understanding emerges in finding the most effective way to reduce pain in pediatric population after tonsillectomy and adenoidectomy procedures.

Introduction

Tonsillectomy and Adenoidectomy are considered to be a common pediatric surgical procedure and is estimated to be performed 5,000,000 times each year on a global basis. Yet, postoperative pain management of Tonsillectomy and Adenoidectomy in pediatric populations has always been an essential area of focus in nursing as post-tonsillectomy morbidity (emesis, poor oral intake), constant results of prolonged duration of stay and moderate to severe pain intensity remains a significant clinical problem for the patient, family and physician (Steward, Grisel & Meinzen-derr, 2010). The final outcome of prolonged duration of stay for children in the postanesthesia care unit after surgery often translates into increased cost of care and as well as overcrowding, which would lead to further discomfort for the child and increase expenditures in nursing time and dollars (Smith, Newcomb, Sundberg & Shaffer, 2009). However, much debate still lingers on the most effective ways to manage postoperative tonsillectomy and adenoidectomy pain treatments. Despite such treatment discords, numerous studies have offered viable solutions and possible adjustments toward pain management of pediatric population after tonsillectomy and adenoidectomy. Through a critical analysis of three articles, each from three major healthcare databases, PubMed (MEDLINE), CINAHL, and Cochrane Medical Reviews, a better understanding emerges in finding the most effective way to reduce pain in pediatric population after tonsillectomy and adenoidectomy procedures.

While each article in their respective database held merit for their findings in postoperative pain management, they also have drawbacks that necessitated further investigation and research into the validity of the results. The three articles from the three databases, Cochrane Database of Systematic Reviews, PubMed (Medline) and CINAHl, are “Steroids for Improving Recovery Following Tonsillectomy in Children” by Steward, Grisel, and Meinzen-derr, “Relationship of Opioid Analgesic Protocols to Assessed Pain and Length of Stay in the Pediatric Postanesthesia Unit Following Tonsillectomy” by Smith, Newcomb, Sundberg and Shaffer and “A Randomized Clinical Trial of the Efficacy of Scheduled Dosing of Acetaminophen and Hydrocodone for the Management of Postoperative Pain in Children After Tonsillectomy” by Sutter et al, respectively.

The Cochrane Database of Systematic Reviews compiles extensive analyses of updated healthcare treatments and interventions, along with methodology and diagnostic tests. The research products put forth in the Cochrane Systematic Reviews is up to date and as well rigorously assessed, as each research analysis takes hundreds of hours and a whole team of people to produce. However, some of the major drawbacks are: lack of specific topics covered and the speed at which reviews are to be updated each year. When going through the database, it was found that the limited content and search capabilities of the site made researching for the topic of Postoperative Pain Management following Tonsillectomy and Adenoidectomy in Pediatric Population very difficult in obtaining compatible research articles. Moreover, since most full-text articles require paid subscription, access becomes further limited and is not accessible to the general public.

Steward et al. published the article, “Steroids for Improving recovery following tonsillectomy in children”, for the Cochrane Database of Systematic Reviews and found convincing evidence of effective pain management through a single dose of intraoperative, intravenous corticosteroid drug, dexamethasone, that would reduce postoperative emesis in children by half (2010). This review article took into consideration 19 studies of randomized, double-blind, placebo-controlled trials of single dose of intravenous, intraoperative corticosteroids published throughout multiple databases such as PubMed, TRIPdatabase, NHS Evidence- ENT and Audiology, Google in the review compilation. The results of compiling these 19 studies, 1756 participant ranging from nine months to 18 years of age, found that a statistically significant lower rate of emesis for patients who received the single dose dexamethasone treatment, at 21 percent, stands to benefit the pediatric population after having undergone a tonsillectomy or adenoidectomy procedure as opposed to the patients who received placebo effect of treatment (45 percent).

Furthermore, it was found that a dose of dexamethasone during tonsillectomy and adenoidectomy can prevent vomiting for one out of five children taking the drug, and allows participants to return to normal health and diet quicker and suffer less pain after surgery. Some of the limitations include, exclusionary methods bias, the global setting, and as well as the massive sample size of 1756 participants, makes the review’s credibility suffer as it becomes difficult to verify the consistency of the information and as well as any future follow-up capacities. The authors acknowledge these limitations in meta-analysis of combinability in pooling different surgical techniques, surgical procedures, anesthetic techniques, dexamethasone dosages and proposes using sensitivity analysis and as well as randomized trials of testing to make up for the possible variations.

PubMed, on the other hand, produces more than 23 million citations for biomedical literature from MEDLINE, life science journals, and online books. It is a free database that allows search content to be accessible via free and paid full-text articles. However, search results retrieve the same content as Ovid MEDLNE. Moreover, less oversight is dedicated towards appraising the article, and as such, much discretion is to be exercised when choosing a particular article for review.

Smith et al. published the article “Relationship of Opioid Analgesic Protocols to Assessed Pain and Length of Stay in the Pediatric Postanesthesia Unit Following Tonsillectomy” in PubMed (2009). The purpose of the study was to determine whether the use of opioid analgesic protocols in postoperative pain management after tonsillectomy and adenoidectomy in pediatric population have better outcomes in Post-anesthesia Care Units (PACU). The study had a sample size of 178 children between the ages of 7 to 12 who were confirmed not to already be prescribed for polypharmacy treatments for other conditions. The design of the study held 75 patients receiving analgesic protocol 1, which is morphine only administration in treatments and 103 receiving analgesic protocol 2, administration of fentanyl followed by morphine. No differences were found in the effectiveness of fentanyl and morphine for alleviating pain in children, even though morphine was started before the child’s perception of pain. As a result, there were no differences in stay between the two test groups, which proved that there is no documented efficacy in the preference of morphine over fentanyl in pain management after tonsillectomy or adenoidectomy. However, it was found that children who were given morphine on a routinely basis showed less nausea and vomiting. Limitations of this PubMed publication included verification of recorded information quality. Since most of the results of individual participant feedback were retrieved from retrospective chart review, any unrecoverable, unrecorded, or missing information of charts could alter the results of this study.

Finally, CINAHL is the database for nursing and allied health professionals to access health journal articles, evidence-based care sheets and quick lessons relevant to the nursing and allied health professional discipline. The database includes health content that MEDLINE does not and also has many benefits in searching evidence settings and easy to use CINAHL headings. However, some of the limitations include that the content and EPB limiters are fewer compared to MEDLINE and it is a subscription product, which restricts access to only affiliates and purchasers.

Sutters et al. published “A Randomized Clinical Trial of the Efficacy of Scheduled Dosing of Acetaminophen and Hydrocodone for the Management of Postoperative Pain in Children After Tonsillectomy” under the CINAHL database and found that scheduled dosing of acetaminophen and hydrocodone helps in pain management in early postoperative recovery of at-home outpatient population (2010). The study sample included 239 children aged 6 to 15 years old in a regional tertiary care center in California, with ethnicities ranging from White, African American, Hispanic and other races. The method design for the study administered 3 randomized treatment groups with hydrocodone and acetaminophen elixir, for the first 3 days with: 1.PRN Group- Standard care every 4 Hours without nurse coaching, 2. ATC Group- standard care without nurse coaching, 3. ATC Group – standard care with nurse coaching. The patients were observed and given medication under nurse supervision the first day, and were then sent home to be cared for by parents who either received or did not receive nurse coaching for the administration of drugs to the children. The study results indicated that children on a scheduled dosing procedure scored 3 on a 0-10 pain scale, which is lower than children who dosed without scheduled, on an as needed basis, scoring 4 on a 0-10 pain scale. However, this result was not clinically significant, as no difference was found in any of the demographic, parental, and surgical characteristics between the PRN and ATC groups, even though children on a scheduled drug administration basis scored lower in pain. The limitations of this study included unsupervised amount of analgesic dosing adjustment based on assessment of patient’s response and limited feedback design. Since pain intensity levels were only obtained twice a day, once in the morning and once in the evening, it was difficult to gage the level of pain that the pediatric population underwent and were able to report.

While the three articles differ much in the way that information is obtained, assessed, and evaluated, they each focus on different functions in the pain management process of after surgery tonsillectomy and adenoidectomy that may not be representative of the total pediatric population. While Sutter et al. focuses on pain management of around the clock nurse coaching in analgesic administration and the clinical practice approach, Smith, Newcomb, Sundberg, and Shaffer with Steward, Grisel, and Meizen-derr both focus on the actual drug use efficacy of pain management treatments. The level of pediatric participation from all three studies demonstrates that the estimations made in scalable result can only be a fraction of the representation of the total pediatric population. Steward, Grisel, and Meizen-derr’s review study incorporated 1756 children in pain management, one of the largest in participation magnitude conducted throughout the three studies being reviewed. However, this number is a result of excluding 43 studies of participants who failed to meet the specific criteria of allocation requirement (non-randomized), intravenous administration of steroids, limiting the experimental group to steroids only, and full completion of study and report of results. The generalized scope, and as well as the sheer magnitude of the study spanning across continents in the world makes individual application difficult in certain regions and localities.

On the other end of the spectrum, Smith, Newcomb, Sundberg, and Shaffer, along with Sutter et al., had a sample size comparatively similar, and similar drug administration of either fentanyl or morphine – both are considered to be safe and effective for children, but cannot be applied on a larger scale. Both studies had around 100 participants, but took only samples from one specific locality and picked out a handful of participants whose anatomy was specific to that locality. Such exclusionary selection in criteria in pediatric population designations make it difficult to be applied to a varied selection of population, but at the same time, can be useful in determining a well-practiced method of treatment for individual participants in the region. Furthermore, both confirmed the usage of fentanyl and morphine as normalized, preferred drugs of choice in pediatric pain management of after surgery tonsillectomy and adenoidectomy.

From these three articles, it was apparent that morphine and fentanyl were considered to be drugs of choice for pediatric pain management. However, it has also been proven that dexamethasone, a corticosteroid, is also very effective and may have less side-effect than morphine and fentanyl, which is found to induce nausea and vomiting in some patients (Smith et al., 2009). Furthermore, since morphine is found to be of similar potency with fentanyl, preference over any may be prejudiced by the element of cost than any other factor. However, further research should be conducted in potency of corticosteroid against either or both morphine and fentanyl to determine which of the drugs have the maximum amount of potency and can reduce pain more effectively in pediatric populations. Furthermore, the dosage amount and as well as level of care provided by nurses should also be taken into consideration when formulating a treatment plan for the pediatric population that have undergone tonsillectomy and adenoidectomy.

Hence, a multi-faceted, and complementary, approach towards systematic and standardized way of quantifying and treating pain for tonsillectomy and adenoidectomy is needed towards implementing a successful pain management system for after surgery pediatric population. As agreed upon by all the authors of the three articles, further research is warranted into studying drug preference, drug dosage, and oversight of nursing coaching and care as primary and foremost topics in pain management of pediatric population after tonsillectomy and adenoidectomy. As such, further research in dosage control and monitor, as well as continuing care in nursing supervision for scheduled administration of drug type and amount should be important next steps in the formulation of a viable and standardized way of administering care for pediatric populations that have performed tonsillectomy and adenoidectomy.

References

Smith, J., Newcomb, P., Sundberg, E., & Shaffer, P. (2009). Relationship of opioid analgesic protocolsto assessed pain and length of stay in the pediatric ostanesthesia unit following tonsillectomy. Journal of Perianesthesia Nursing. 24(2), 86-91.

Steward, D. L., Grisel, J., & Meinzen-derr, J. (2010). Steroids for improving recovery following tonsillectomyin children. Cochrane Database of Systematic Reviews, (8).

Sutters, K. A., Miaskowski, C., Holdridge-Zeuner, D., …Mahoney, K. (2010). A randomized clinicaltrial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy. Clinical Journal of Pain, 26(2), 95-103.