The Effect of Peritonsillar Infiltration of Ketamine and Dexamethasone for Postoperative Pain Relief in Children Following Adenotonsillectomy

Comparison of Peritonsillar Infiltration of Ketamine and Dexamethasone for Postoperative Pain Relief in Children Following Adenotonsillectomy

The immediate postoperative period after tonsillectomy, , is often difficult. These children frequently have severe pain but postoperative airway edema along with increased sensitivity to the respiratory-depressant effects of opioids may result in obstructive symptoms and hypoxemia. Opioid consumption may be reduced by non-steroidal anti-inflammatory drugs, but these drugs may be associated with increased bleeding after this operation.

Methods: One hundred sixty ASA I-II children 3-12 were randomized four groups of 40 each. Group P received a local peritonsillar infiltration of 2 ml saline, group D dexamethsone (0.2 mg/kg)) , group K ketamine (0.5 mg/kg) and group KD combination of ketamine0.5mg/kg dexamethasone 0.2mg/kg. All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy. Study drugs were marked only with a coded number label. A computer-generated table of numbers guided randomization. Modified Hannallah pain scale [observational pain scores (OPS)], nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at first, 15th, 30th and 60th min postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, vomiting and bleeding. All the children were premedicated with midazolam hydrochloride 0.3 mg/kg) and fentanyl 1micro g/kg intavenously. Anesthesia was induced with thiopental 5mg/kg and atracurium0.3mg/kg. Anesthesia was maintained with isoflurane 1.5% and nitrous oxide 30% in oxygen. The two surgeon used the same dissection and snare technique for all cases and hemostasis done with bipolar cutter. At the end of the surgery neuromuscular blockade was reversed by neostigmine 0.03 mg/kg) and atropine 0.01 mg/kg intravenously), anesthesia was discontinued and the tracheal tube removed in the operating room when patients were deep. After extubation the patients were taken to the postanesthesia care unit (PACU) where an nurse who were unaware of the study drug observed the patients. The pain scoring observer nurse in PACU was consistent. Time to awaken (from the end of anesthesia until the patients opened their eyes on command) and time to the first administration of postoperative analgesia were recorded. Pethidine in a titrated dose (total 1 mg/kg) was administered intravenously for rapid pain relief to patients with a OPS score > 4 or who were crying during two consecutive five minute observation periods until the child was comfortable. Postoperative pain during the first 24 h was assessed using a four-point scale: 0 no pain, 1 mild pain, 2 moderate pain, 3 severe pain by questioning their parents. In the ward the standardized postoperative analgesic technique was with acetaminophen supp (40 mg/kg followed by three doses of 20 mg/kg at 6-hour intervals to be given as needed for pain. Pethidine in a titrated dose (total 1 mg/kg) was administered intravenously for rapid pain relief to patients who had pain scale >3.Any supplementary analgesia , nausea and vomiting, bleeding, sleep disturbance and nightmares that the child might have had as surgery were assessed during a telephone follow up 24 h later.

Study Overview

• Status: Unknown
• Conditions: Tonsillectomy
• Intervention / Treatment: Drug: saline; Drug: Ketamine; Drug: Dexamethasone; Drug: ketamine-dexamethasone

• Study Type: Interventional
• Enrollment (Anticipated): 160
• Phase: Phase 2; Phase 1

Contacts and Locations

• Study Contact: Name: Marzieh Beigom khezri, assistant professor; Phone Number: +98 9123811009; Email: mkhezri@qums.ac.ir

Study Locations

• Iran, Islamic Republic of
  • Qazvin, Iran, Islamic Republic of, 34197/59811
    • Recruiting
    • Qazvin university of medical science
    • Contact: Marzieh Beigomb Khezri, assistant professor; Phone Number: +98 9123811009; Email: mkhezri@qums.ac.ir
    • Principal Investigator: Marzieh Beigom Khezri, assistant professor

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 3 years to 12 years (CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• children age 3-12 years ASAI,II

Exclusion Criteria:

• contraindication for usage of Ketamine, dexamethasone
• upper respiratory tract infection
• increase intracranial pressure( ICP)
• history of allergy ,seizure,psychiatric illness, , bleeding disorders
• chronic usage of analgesic ,antiemetic ,stroied drugs two weeks before surgery,
• history of peritonsillar abscess, , tonsillitis within two weeks, -

Study Plan

How is the study designed?

Design Details

• Primary Purpose: PREVENTION
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: QUADRUPLE

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
PLACEBO_COMPARATOR: saline; One hundred sixtyAmerican Society of Anesthesiologists (ASA) I-II children 3-12 were randomized four groups of 40 each. Group P received a local peritonsillar infiltration of 2 ml saline, group D dexamethsone (0.2 mg/kg)) , group K ketamine (0.5 mg/kg) and group KD combination of ketamine0.5mg/kg-dexamethasone 0.2mg/kg. All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy( all four groups).	Drug: saline; local peritonsillar infiltration of 2 ml saline,
ACTIVE_COMPARATOR: ketamine; One hundred sixtyAmerican Society of Anesthesiologists (ASA) I-II children 3-12 were randomized four groups of 40 each. Group P received a local peritonsillar infiltration of 2 ml saline, group D dexamethsone (0.2 mg/kg)) , group K ketamine (0.5 mg/kg) and group KD combination of ketamine0.5mg/kg-dexamethasone 0.2mg/kg. All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy( all four groups).	Drug: Ketamine; local peritonsillar infiltration of ketamine (0.5 mg/kg)
ACTIVE_COMPARATOR: dexamethasone; One hundred sixtyAmerican Society of Anesthesiologists (ASA) I-II children 3-12 were randomized four groups of 40 each. Group P received a local peritonsillar infiltration of 2 ml saline, group D dexamethsone (0.2 mg/kg)) , group K ketamine (0.5 mg/kg) and group KD combination of ketamine0.5mg/kg-dexamethasone 0.2mg/kg. All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy( all four groups).	Drug: Dexamethasone; local peritonsillar infiltration dexamethasone (0.2 mg/kg))
ACTIVE_COMPARATOR: dexamethasone-ketamine; One hundred sixtyAmerican Society of Anesthesiologists (ASA) I-II children 3-12 were randomized four groups of 40 each. Group P received a local peritonsillar infiltration of 2 ml saline, group D dexamethsone (0.2 mg/kg)) , group K ketamine (0.5 mg/kg) and group KD combination of ketamine0.5mg/kg-dexamethasone 0.2mg/kg. All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy( all four groups).	Drug: ketamine-dexamethasone; local peritonsillar infiltration combination of ketamine0.5mg/kg-dexamethason 0.2mg/kg

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
pain will be assessed by [observational pain scores (OPS)]	5 minutes After extubation when the patients were taken to the postanesthesia care unit (PACU)
pain will be assessed by [observational pain scores (OPS)]	15th min postoperatively (15 minutes After extubation when the patients were taken to the postanesthesia care unit (PACU))
pain will be assessed by [observational pain scores (OPS)]	30th min postoperatively (30 minutes After extubation when the patients were taken to the postanesthesia care unit (PACU))
pain will be assessed by [observational pain scores (OPS)]	60thmin postoperatively (60 minutes After extubation when the patients were taken to the postanesthesia care unit (PACU))
time to first demand of analgesia	during 60min postoperatively (during 60 minutes After extubation when the patients were taken to the postanesthesia care unit (PACU))
postoperative analgesic consumption	during 24 h postoperative (in the ward)

Secondary Outcome Measures

Outcome Measure	Time Frame
nausea, vomiting will be assessed by questioning their parents.	during 60th min after extubation at postanesthesia care unit
bleeding will be assessed by questioning their parents	during 24 h postoperative (in the ward)
family satisfaction will be assessed by questioning their parents.	during 24 h postoperative (in the ward).
nausea, vomiting will be assessed by questioning their parents.	during 24 h postoperative (in the ward)

Collaborators and Investigators

• Sponsor: Qazvin University Of Medical Sciences

Study record dates

Study Major Dates

• Study Start: July 1, 2010
• Primary Completion (ANTICIPATED): November 1, 2013
• Study Completion (ANTICIPATED): December 1, 2013

Study Registration Dates

• First Submitted: September 1, 2010
• First Submitted That Met QC Criteria: September 9, 2010
• First Posted (ESTIMATE): September 10, 2010

Study Record Updates

• Last Update Posted (ESTIMATE): May 7, 2013
• Last Update Submitted That Met QC Criteria: May 6, 2013
• Last Verified: May 1, 2013

More Information

Terms related to this study

• Keywords: pain; postoperative pain; tonsillectomy; peritonsillar infiltration
• Additional Relevant MeSH Terms: Pathologic Processes; Postoperative Complications; Pain; Neurologic Manifestations; Pain, Postoperative; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Central Nervous System Depressants; Autonomic Agents; Peripheral Nervous System Agents; Enzyme Inhibitors; Analgesics; Sensory System Agents; Anesthetics, Dissociative; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; Excitatory Amino Acid Antagonists; Excitatory Amino Acid Agents; Anti-Inflammatory Agents; Antineoplastic Agents; Antiemetics; Gastrointestinal Agents; Glucocorticoids; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Antineoplastic Agents, Hormonal; Protease Inhibitors; Ketamine; Dexamethasone; Dexamethasone acetate; BB 1101
• Other Study ID Numbers: ACTRN12610000658011