Bupivacaine infiltration in children for postoperative analgesia after tonsillectomy
This randomised controlled study investigated whether the use of local anaesthetic infiltration would reduce the need for post-operative opioid compared to tramadol. Children were randomly allocated to receive either 3mg/kg of intravenous tramadol or infiltration of the tonsillar bed with 5mL of 0.25% bupivacaine. All children were operated on using the blunt dissection technique and they all received 30mg/kg paracetamol and 0.5mg/kg ketorolac. The primary outcome measure was the need for postoperative piritramide. The secondary outcomes were cumulative dose of piritramide, pain scores (Wong-Baker Faces Pain Rating Scale) and incidence of postoperative nausea/vomiting in the first 24 postoperative hours, time to discharge and adverse events.
57% of patients who received tramadol required piritramide in PACU compared to 81% in the bupivacaine group. The mean pain scores were greater in the bupivacaine group compared to the tramadol in the first 60 post-operative minutes, but were similar after an hour, reflecting the analgesia provided in PACU. The incidence of PONV was 61% in the tramadol group and 47% in the bupivacaine group.
Take home message
This study demonstrated that local anaesthetic infiltration for postoperative analgesia after tonsillectomy alone is not better than giving a higher-than-normal dose of tramadol alone. This study also demonstrated that there is a high incidence of post-operative nausea and vomiting if you do not administer anti-emetics. My standard practice would be to use a multimodal approach to my analgesia and administer 2 anti-emetics. This paper has not convinced me that adding local anaesthetic infiltration is advantageous.
Reviewed by: Dr Scott Ma