Impact of a revised postoperative care plan on pain and recovery trajectory following pediatric tonsillectomy.

Study Type:  Prospective observational cohort study (a follow-on from a previous cohort study from the same institution).

Methods:  A previous cohort study of tonsillectomy at Perth Children’s Hospital demonstrated moderate to severe pain postoperatively, with pain lasting a median of 6 days (range 0-23 days) and nausea and vomiting post discharge affecting 8% of patients on day one postoperatively.  This new study was a follow-on prospective cohort study where all patients <18 years of age undergoing tonsillectomy at the PCH during two separate two-week study periods in 2016 and 2017 were identified postoperatively.  Patients were excluded if: they were having additional procedures (other than adenoidectomy, grommets and CIT), they were ASA 3-5, they had a language barrier likely to impede data collection, department of child services were involved in their care, or PICU was planned postoperatively.

Intraoperative analgesia was administered at the preference of the treating anaesthetist.  Postoperative and discharge analgesia were standardized across patients as paracetamol 6th hourly and ibuprofen 8th hourly for 7 days postoperatively.  Oxycodone 0.1mg/kg/dose (max 5mg) 6th hourly prn was dispensed, with lower doses on a case-by case basis for co-morbidities such as moderate OSA, craniofacial abnormalities. All three medications were dispensed to the patient on discharge.

Nursing and pharmacy staff received educational sessions covering the expected recovery trajectory and key information to provide to parents.  Specific information was communicated orally to parents, as well as via a written information sheet about the importance of regular analgesia.  The discharge education package included a medication diary.

89 patients were recruited.  Data was collected on pain scores, rates of nausea and vomiting, medication use and unplanned re-presentation rates, by telephone within 3 days of surgery and every 2-3 days thereafter and continued until the child was pain free without analgesia and had returned to normal activities (median 13 days, range 0-24 days).  The primary aim of the study was to re-evaluate the severity and duration of post-tonsillectomy pain after changing the discharge pathway.

Findings:  Of the 89 patients recruited, 20 were lost to follow-up.  Moderate-severe pain lasted a median of 5 days (range 0-12 days).  However, by post-op day 5, only 37 (53%) of parents continued to administer regular analgesia. 29 (42%) had pain scores ≥ 4/10 beyond post-op day 7. Despite this, those who strictly adhered to the dosing schedule of regular simple analgesia on postoperative days 1-3 did not report a statistically significant difference in pain scores compared to those who did not.

On 227/955 (23.8%) of the study days, parents rated their child’s worst pain as ‘severe’ and on 78 (8.2%) study days, across 33 (47.8%) patients, parents did not use an opioid analgesia despite reporting that their child’s pain was ‘severe’.

Median number of oxycodone doses used was 5 (0-22).  Only 28 (46%) had disposed of left-over oxycodone within a month of surgery.  24 (35%) experienced nausea or vomiting post discharge.  Median time to return to normal activities was 6 (0-14) days.

32 (46%) patients made a total of 45 visits to the GP (27) or ED (18) during the follow-up period. 39% of these presentations occurred between postop day 5 and 7, of which 44% were due to pain.

Take Home Message / Commentary

Despite implementing teaching sessions for nursing staff on provision of information at discharge, discharging patients with all three medications to take home, as well as written information and a medication diary, it remains difficult to achieve compliance in home administration of analgesics, despite parental reports of high pain scores.

Limitations of the study include using parent-proxy pain scores and the possibility of parental recall bias.  There may have been bias in parental reporting of ‘return to normal’ activities.  It may have been useful to ask parents to explain gaps in their provision of regular analgesia (e.g., child refusal, too busy, lack of understanding).

Tonsillectomy is a commonly performed procedure in paediatric patients.  Further work to understand how we can assist parents to assess and provide analgesia to their children is warranted.  Perhaps a mobile phone app with a prompt system for delivery of regular analgesia could be considered.

Reviewed by Dr Nicole Anderson