Effects of an individualized analgesia protocol on the need for medical interventions after adenotonsillectomy in children: a randomized controlled trial

Jian Guo, Peijun Zhuang, Kun Liu, Yuanyuan Wan, Xuan Wang, Jian Guo, Peijun Zhuang, Kun Liu, Yuanyuan Wan, Xuan Wang

Abstract

Background: It has been proposed that the dose of rescue opioids should be individually titrated to the severity of obstructive sleep apnea after adenotonsillectomy. However, a sleep study is not always available before adenotonsillectomy. This randomized, controlled and blinded trial evaluated a strategy of pain control individualized to the results of a fentanyl test, rather than the results of polysomnography, in children after adenotonsillectomy.

Methods: A total of 280 children (3-10 years old) undergoing elective adenotonsillectomy were randomized into an individualized protocol (IP) group or a conservative protocol (CP) group. All patients received a fentanyl test before extubation. Pain was assessed every 10 min in the recovery room, and rescue morphine was given when the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) score was > 6. In the IP group, the dose of rescue morphine was individualized to the results of the fentanyl test (10 μg/kg in the case of a positive result and 50 μg/kg in the case of a negative result). In the CP group, the dose was fixed (25 μg/kg). The primary outcome was the percentage of patients requiring at least one medical intervention. The secondary outcome was the median duration of CHEOPS scores > 6.

Results: Fewer patients in the IP group than in the CP group required medical interventions [11.9% (16/134) vs 22.3% (29/130), P = 0.025]. The median duration of CHEOPS scores > 6 was shorter in the IP group than in the CP group [20 (95% CI: 17 to 23) min vs 30 (95% CI: 28 to 32) min, P < 0.001].

Conclusions: Compared with a conservative dosing approach, this individualized protocol may improve analgesia without a significant increase in respiratory adverse events.

Trial registration: ClinicalTrials.gov NCT02990910 , registered on 13/12/2016.

Keywords: Adenotonsillectomy; Children; Individualized protocol; Medical interventions.

Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
CONSORT diagram. IP, individualized protocol; CP, conservative protocol
Fig. 2
Fig. 2
Survival curves of CHEOPS scores> 6. The probability of CHEOPS scores> 6 for all patients in the IP and CP groups, P < 0.001 (a). For the patients with positive results, P = 0.253 (b). For the patients with negative results, P < 0.001 (c). IP, individualized protocol; CP, conservative protocol; CHEOPS, Children’s Hospital of Eastern Ontario Pain Scale

References

    1. Brown KA. Outcome, risk, and error and the child with obstructive sleep apnea. Paediatr Anaesth. 2011;21(7):771–780. doi: 10.1111/j.1460-9592.2011.03597.x.
    1. Brown KA, Laferriere A, Lakheeram I, Moss IR. Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology. 2006;105(4):665–669. doi: 10.1097/00000542-200610000-00009.
    1. Raghavendran S, Bagry H, Detheux G, Zhang X, Brouillette RT, Brown KA. An anesthetic management protocol to decrease respiratory complications after Adenotonsillectomy in children with severe sleep apnea. Anesth Analg. 2010;110(4):1093–1101.
    1. Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, et al. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 Suppl):S1–15. doi: 10.1177/0194599811409837.
    1. Waters KA, McBrien F, Stewart P, Hinder M, Wharton S. Effects of OSA, inhalational anesthesia, and fentanyl on the airway and ventilation of children. J Applied Physiol (Bethesda, Md: 1985) 2002;92(5):1987–1994. doi: 10.1152/japplphysiol.00619.2001.
    1. Lerman J. Unraveling the mysteries of sleep-disordered breathing in children. Anesthesiology. 2006;105(4):645–647. doi: 10.1097/00000542-200610000-00004.
    1. Li YH, Wang X, Zhou ZJ, Zhuang PJ. Association between fentanyl test results and rescue morphine requirements in children after adenotonsillectomy. J Anesth. 2018;32(1):77–81. doi: 10.1007/s00540-017-2433-0.
    1. Tsui BCH, Wagner A, Cave D, Elliott C, El-Hakim H, Malherbe S. The incidence of laryngospasm with a "no touch" extubation technique after tonsillectomy and adenoidectomy. Anesth Analg. 2004;98(2):327–329. doi: 10.1213/01.ANE.0000097185.70171.89.
    1. Isaiah A, Pereira KD. Outcomes after adenotonsillectomy using a fixed anesthesia protocol in children with obstructive sleep apnea. Int J Pediatr Otorhi. 2015;79(5):638–643. doi: 10.1016/j.ijporl.2015.01.034.
    1. McMillan CO, Spahr-Schopfer IA, Sikich N, Hartley E, Lerman J. Premedication of children with oral midazolam. Can J Anaesth. 1992;39(6):545–550. doi: 10.1007/BF03008315.
    1. Roberts C, Al Sayegh R, Ellison PR, Sedeek K, Carr MM. How pediatric anesthesiologists manage children with OSA undergoing tonsillectomy. Ann Otol Rhinol Laryngol. 2020;129(1):55–62. doi: 10.1177/0003489419874371.
    1. Egan TD. Are opioids indispensable for general anaesthesia? Br J Anaesth. 2019;122(6):e127–e135. doi: 10.1016/j.bja.2019.02.018.
    1. Da Conceicao MJ, Da Conceicao DB, Leao CC. Effect of an intravenous single dose of ketamine on postoperative pain in tonsillectomy patients. Paaediatr Anesth. 2006;16:962–967. doi: 10.1111/j.1460-9592.2006.01893.x.
    1. Singleton MA, Rosen JI, Fisher DM. Plasma concentrations of fentanyl in infants, children and adults. Can J Anaesth. 1987;34(2):152–155. doi: 10.1007/BF03015333.
    1. Ginsberg B, Howell S, Glass PS, Margolis JO, Ross AK, Dear GL, et al. Pharmacokinetic model-driven infusion of fentanyl in children. Anesthesiology. 1996;85(6):1268–1275. doi: 10.1097/00000542-199612000-00007.
    1. Ansermino JM, Brooks P, Rosen D, Vandebeek CA, Reichert C. Spontaneous ventilation with remifentanil in children. Paediatr Anaesth. 2005;15(2):115–121. doi: 10.1111/j.1460-9592.2004.01397.x.

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