PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations
Study Type & Method: This is a systematic review on the management of pain after tonsillectomy in adults and children. It was reviewed by the procedure-specific postoperative pain management (PROSPECT) working group, a collaboration of surgeons and anaesthetists that formulate procedure-specific pain management recommendations after operations.
They used the PROSPECT methodology to perform a literature search on randomised controlled trials on pain management and tonsillectomies. They excluded mixed surgical procedures and procedures other than adenoidectomy or tonsillectomy. They divided studies into adult, paediatric or mixed groups (where they were unable to determine the ages within the groups) and performed a qualitative assessment of the data with no meta-analysis looking at pain intensity scores on either visual analogue scale or numerical rating score as the primary outcome. The level of evidence was graded, recommendations were drafted by the authors and sent to the PROSPECT working group for review. A consensus was achieved within the group on the recommendations for best practice analgesia in tonsillectomy patients.
- All patients should have a basic analgesic regimen including paracetamol and NSAIDs administered either pre- or intra-operatively and continued post-operatively.
- A single dose of IV dexamethasone is recommended intra-operatively for analgesic and antiemetic effects.
- In patients with contra-indications to the basic analgesic regimen, preoperative gabapentinoids, dexmedetomidine and/or intra-operative ketamine (in children only) are recommended as alternative analgesic medications.
- Analgesic adjuncts, such as intra-operative or post-operative acupuncture and post-operative honey are also recommended.
- Opioids should be reserved as rescue analgesics in the post-operative period.
The study addresses an important topic which is applicable to a large population of paediatric patients in multiple hospital settings.
In its favour, it provides evidence-based guidance on a basic analgesic regimen with recommendations for evidence-based adjuncts if there were contraindications to the basic analgesic regimen. There were also a good number of studies included (226).
Limitations included heterogeneity between studies with variable doses, routes of administration of drugs, time points of pain recording and absence of properly designed control groups in some studies. Most studies were also of small size so may have overestimated the effect of analgesia. Also, some drugs e.g., paracetamol only had weak evidence for its efficacy (Grade D) when compared to NSAIDS and dexamethasone (both Grade A) but it was still included in the basic analgesic regimen after review by the working group.
This was a thorough review, which attempts to introduce guidelines on the use of basic analgesic regimens for tonsillectomy based on the evidence available.
Reviewed by Dr Patrick Rubie