Postoperative analgesic and behavioral effects of intranasal fentanyl, intravenous morphine, and intramuscular morphine in pediatric patients undergoing bilateral myringotomy and placement of ventilating tubes.
BACKGROUND
Bilateral myringotomy and placement of ventilating tubes (BMT) is one of the most common pediatric surgical procedures in the United States. Many children who undergo BMT develop behavioral changes in the postanesthesia care unit (PACU) and require rescue pain medication. The incidence of these changes is lower in children receiving intraoperative opioids by the nasal, IM, or IV route compared with placebo. However, there are no data to indicate which route of administration is better. Our study was designed to compare the immediate postoperative analgesic and behavioral effects of 3 frequently used intraoperative techniques of postoperative pain control for patients undergoing BMT under general anesthesia.


METHODS
One hundred seventy-one ASA physical status I and II children scheduled for BMT were randomized into 1 of 3 groups: group 1-nasal fentanyl 2 μg/kg with IV and IM saline placebo; group 2-IV morphine 0.1 mg/kg with nasal and IM placebo; or group 3-IM morphine 0.1 mg/kg with nasal and IV placebo. All subjects received a standardized general anesthetic with sevoflurane, N(2)O, and O(2) and similar postoperative care. The primary end point of the study was the pain scores measured by the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale in the PACU.


RESULTS
There were no significant differences in peak FLACC pain among the 3 groups (mean [95% CI] 2.0 [1.2-2.8] for intranasal fentanyl, 2.7 [1.7-3.6] for IV morphine, and 2.9 [2.1-3.7] for IM morphine, respectively). There were no differences in the scores on the Pediatric Anesthesia Emergence Delirium (PAED) scale, incidence of postoperative emergence delirium (PAED score ≥ 12), emesis, perioperative hypoxemia, or need for airway intervention, and postoperative rescue analgesia. There were also no differences in the duration of PACU stay or parental satisfaction among the groups.


CONCLUSIONS
In this double-blind, double-dummy study, there was no difference in the efficacy of intranasal fentanyl, IM and IV morphine in controlling postoperative pain and emergence delirium in children undergoing BMT placement. The IM route is the simplest and avoids the potential for delays to establish vascular access for IV therapy and the risks of laryngospasm if intranasal drugs pass through the posterior nasopharynx and irritate the vocal cords.
Department of Anesthesiology & Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin, Suite 3300, Houston, TX, USA. hxkarlbe@texaschildrens.org
Helena K
HK
Hippard
Kalyani
K
Govindan
Ellen M
EM
Friedman
Marcelle
M
Sulek
Carla
C
Giannoni
Deidre
D
Larrier
Charles G
CG
Minard
Mehernoor F
MF
Watcha
D000281:Administration, Intranasal; D000367:Age Factors; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000762:Anesthesia Recovery Period; D015505:Chest Tubes; D002648:Child; D002652:Child Behavior / Q000187:drug effects*; D002675:Child, Preschool; D003693:Delirium / Q000209:etiology; D004311:Double-Blind Method; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007223:Infant; D018730:Infant Behavior / Q000187:drug effects; D007273:Injections, Intramuscular; D007275:Injections, Intravenous; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000295:instrumentation; D008297:Male; D009020:Morphine / Q000008:administration & dosage* / Q000009:adverse effects; D013506:Otologic Surgical Procedures / Q000009:adverse effects*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome; D014432:Tympanic Membrane / Q000601:surgery*
D000701:Analgesics, Opioid; D009020:Morphine; D005283:Fentanyl