An evaluation of pain and postoperative nausea and vomiting following the introduction of guidelines for tonsillectomy.
BACKGROUND
Tonsillectomy and adenotonsillectomy have a high incidence of postoperative pain, and postoperative nausea and vomiting (PONV). Pain is traditionally controlled with morphine but this increases the risk of PONV and may cause respiratory depression. Antiemetics reduce PONV but their routine use has been questioned on safety grounds.


METHODS
After determining the current anesthetic management of elective tonsillectomy and adenotonsillectomy patients in our hospital, guidelines were developed to avoid the routine use of morphine and antiemetics. The effect on pain and PONV was then evaluated over a 3 month period. Postoperative pain was scored using the Oucher visual analog scale and nausea scored using a five point scale.


RESULTS
We analysed 34 cases to determine our current practice and 37 cases to evaluate the effect of introducing guidelines. Postguidelines, the median Oucher pain score at 4 h was 10, and at 8, 12, 16 h was zero. Despite receiving no antiemetics, only two children vomited (5%) after introduction of guidelines.


CONCLUSIONS
Guidelines which use a combination of paracetamol, nonsteroidal anti-inflammatory drugs and fentanyl, provide excellent analgesia with minimal PONV after elective tonsillectomy and adenotonsillectomy. As a result the routine use of morphine and antiemetics can be avoided.
White
Michelle C
MC
Department of Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK.
Nolan
Judith A
JA
D000082:Acetaminophen / Q000627:therapeutic use; D000233:Adenoidectomy; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000768:Anesthesia, General; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D000932:Antiemetics / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D017558:Elective Surgical Procedures; D005260:Female; D005283:Fentanyl / Q000627:therapeutic use; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009020:Morphine / Q000627:therapeutic use; D017063:Outcome Assessment, Health Care; D010147:Pain Measurement; D010149:Postoperative Pain / Q000145:classification / Q000517:prevention & control*; D020250:Postoperative Nausea and Vomiting / Q000145:classification / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D013997:Time Factors; D014068:Tonsillectomy
D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D000932:Antiemetics; D000082:Acetaminophen; D009020:Morphine; D005283:Fentanyl