‘Desire for more analgesic treatment’: pain and patient-reported outcome after paediatric tonsillectomy and appendectomy

Study Type: Cohort study analysing pain and pain-related adverse outcomes in children 24 hours after tonsillectomy or appendectomy.

Method: Data was obtained from the PAIN OUT infant registry, which prospectively consents for, enrols and records pain-related outcomes in children over 4 years old in the post-operative period. Exclusion criteria were parent refusal, cognitive impairment, communication problems for the patient/parents and discharge before data collection. All data was collected from a standardised questionnaire on the first day postoperatively and patient records.

The primary endpoint was the answer to the question “Would you have liked to have received more pain treatment?”. Other outcomes included pain composite scores (mean of pain at rest, worst pain and movement pain) and interference composite scores (pain when coughing, waking up with pain and other adverse events). They further analysed patients in groups that had received no non-opioid, one, two or three non-opioid analgesics before emergence from anaesthesia. The research group included data from the registry for 898 patients from 12 European hospitals between 2015 and 2019.

Findings: They found 22.7% of children wanted more pain treatment on day 1 after surgery with no significant differences between tonsillectomies and appendectomies. Pain composite scores and interference composite scores were also significantly higher in patients wanting more pain treatment on day 1 after surgery. In the tonsillectomy group, there was a significant decrease in the desire for more pain treatment at 24 hours with increasing number of non-opioid analgesics given before emergence. Children not receiving any non-opioid analgesic before emergence had a greater risk (OR 3.5) of desiring more pain treatment in the first day after surgery.

Commentary: The study addresses a relevant clinical question of experience of post-operative pain, which is applicable to paediatric populations in multiple settings. However, I was uncertain of the added benefit of including both tonsillectomies and appendectomies in the study and comparing outcomes between the two groups. The study was designed to analyse clinically relevant endpoints and meet patient-centred outcomes and perception of care.

It highlighted a heterogeneous approach to pain management in several hospitals with no standardised use of non-opioid analgesics. Considering the benefit of using non-opioid analgesics in this study, an argument for using a standardised non-opioid analgesic regimen could be made.

There are some limitations of the study. It only assessed outcomes on day 1, so adverse outcomes beyond this time were not analysed. It did not differentiate between the severity of disease e.g., chronic tonsilitis and severe acute tonsilitis, peri-tonsillar abscess or patient baseline characteristics e.g., anxiety and baseline perceptions or expectations of pain. Overall, this was an interesting study, attempting to look at clinically relevant endpoints for tonsillectomies and appendectomies but did suffer from some design flaws.

Reviewed by Dr Patrick Rubie