Pain after tonsillectomy: effectiveness of current guidelines?

BACKGROUND: Tonsillectomy is one of the most common major surgical procedures performed in children. In 2013, the use of codeine in children was severely restricted. French guidelines for treating tonsillectomy's postoperative pain at home have been reconsidered OBJECTIVE: The aim of our study was to measure effectiveness and safety of two schedules: acetaminophen + ibuprofen (A + I) and acetaminophen + tramadol (A + T) in children who underwent tonsillectomy. SETTING AND PATIENTS: We undertook a 1 year prospective and observational single-center study. All children who underwent tonsillectomy were eligible. The choice of the regimen, A + I group or A + T group, was left for the anesthesiologist in charge, done during the pre-anesthetic assessment. After hospital discharge, parents had to give systematically A + I or A + T, 4 times a day during 5 days and then acetaminophen alone for the next 5 days The primary endpoint was the home pain assessed using Parents' Postoperative Pain Measurement Short Form (PPPM-SF) scale. Secondary endpoints were the rate of further hospitalization and/or surgery due to tonsillectomy-related adverse events. RESULTS: Over the study period, 342 tonsillectomies were performed. The return rate of PPPM-SF scales was 58%. Two hundred patients were analyzed. The median age was 4 [3; 5.2] years and was lower in group A + I (4 [3; 5]; 5 [4; 7]; p < 0.0001). PPPM-SF scores were greater than or equal to 3 in both groups during the first 6 postoperative days. The mean decrease of PPPM-SF score over time was higher in group A + I than in group A + T (p = 0.007). Readmission rate was significantly higher in group A + T (A + I: 0; A + T: 7; p = 0.002) as the rate of reoperation for bleeding (A + I: 0; A + T: 3; p = 0.049). CONCLUSION: Home pain management after tonsillectomy should be improved. In clinical practice, A + I seems at least as effective as the combination A + T, without increasing readmission and/or additional surgery for bleeding.

Catecholamine-induced acute myocardial stunning after accidental intra-operative noradrenaline bolus.

We report a case of catecholamine-induced acute myocardial stunning that occurred in a six-year-old girl. This was triggered by an accidental noradrenaline injection during general anaesthesia for dental surgery. The clinical course was favourable, although cardiac enzymes and echocardiography were significantly altered. The child was discharged home on the second postoperative day, after complete clinical resolution. We emphasise the need to consider shortening the surgical procedure, and to closely monitor patients following a medication error involving vasopressors even in the absence of symptoms. We highlight the importance of a controlled process for storing, identifying, preparing, and handling medications. The identification of weaknesses in the overall process of drug prescription and administration is of utmost importance.

[Paediatric discharge score in ambulatory surgery]. / Score de sortie pédiatrique en chirurgie ambulatoire.

BACKGROUND: In adults, the Post-Anesthetic Discharge Scoring System (PADSS) was built to secure the discharge after outpatient surgery. We evaluate a pediatric adaptation: the Pediatric-PADSS (Ped-PADSS). STUDY DESIGN: Prospective cohort. METHODS: This was a prospective, observational, monocentric study for ambulatory patients. Ped-PADSS is built on 5 items each quoted 0, 1, or 2: hemodynamics, state of awakening, nausea/vomiting, pain and bleeding. A result ≥9/10 validated discharge if the anesthetist did not wish to review the patient, if the parents did not wish to revisit the anesthetist or if there was no hoarseness or dyspnea. The discharge was validated by the anesthetist and the surgeon. Ped-PADSS was made without the knowledge of the nursing team, one hour after return in service and repeated hourly. Addition of patient demographic data, the collection included the hours of leave by the anesthetist, surgeon and Ped-PADSS, the duration of hospital stay post procedure. RESULTS: On 150 patients, 148 patients were allowed to go out with the Ped-PADSS, one patient was released despite a Ped-PADSS<9. One patient was hospitalized for a surgical bleeding in agreement with the anesthetist, surgeon and the Ped-PADSS. Ninety-five percent of patients had a Ped-PADSS ≥9 after 2hours monitoring in the ambulatory unit. CONCLUSION: The majority of the children have met the criteria for discharge at the end of 2hours postoperative monitoring. The use of this score could reduce the hospitalization time in ambulatory unit.

[Ambulatory surgery in France: practical and medicolegal considerations]. / La chirurgie ambulatoire: organisation pratique et aspects médico-légaux, en France.

In France, ambulatory anaesthesia and surgery seem to be well codified. Many recommendations have been published by the Health Authority and the professional associations: they are summarized in this review. However, numerous practical problems persist: for example, two situations specific to paediatric practice are problematic parental comprehension and application of the information provided and poor access to strong analgesics outside the hospital. Despite this, the paediatric population is an ideal target for ambulatory care because of its usual good health and quicker recovery after minor injury as proven by the small percentage of failure and readmission.

[Systemic analgesia at home after pediatric day-case surgery]. / Analgésie systémique à domicile après chirurgie pédiatrique ambulatoire.

Currently, day-case surgery has a significant development. In pediatrics, a big part of interventions can be performed as a day-case surgery. However, postoperative pain, often wrongly regarded as minor, should not be underestimated or undertreated. The aim of this paper is to review the available systemic analgesics and to propose a way to use them in order to improve children's comfort and experiences in their own families.