Postoperative pain after tonsillectomy – the value of standardized analgesic treatment protocols

Abstract

Objective

To alleviate pain after tonsillectomy (TE) with escalating gradual treatment protocols in a prospective trial.

Materials & Methods

Following TE, 83 consecutive adult patients were treated with two different four-staged escalating analgesic protocols. Metamizole served as basic medication in protocol 1 (PT1; n = 44), whereas with protocol 2 (PT2; n = 39) ibuprofen was applied as baseline analgesic. Both protocols were escalated according to the patient´s needs to metamizole and ibuprofen vice versa and additional weak to strong opioids. The primary efficacy endpoint was defined as the minimum and maximum pain as well as pain on ambulation (NRS, 0–10). Secondary endpoints comprised analgesic score, patient satisfaction and treatment-related side-effects.

Results

Both patient groups exhibited similar demographic characteristics (PT1: Ø 28.8 years; 64% ♀ and PT2: Ø 26.6 years; 56% ♀). Maximum pain (6.7 ± 1.9 vs. 7.6 ± 1.6, t₍₈₁₎ = −2.254, p = 0.027) and pain on ambulation (5.0 ± 1.8 vs. 5.8 ± 1.8, t₍₈₁₎ = -2.114, p = 0.038) were significantly higher with PT2. 68.2% of patients with PT1 needed an escalation of analgesic treatment compared to 100% with PT2 (p < 0.001). The opioid consumption was also significantly higher with PT2 (43.2% vs. 71.8%, p < 0.001). There were no significant differences regarding functional impairments, side-effects and patient satisfaction (7.0 ± 2.0 vs. 7.4 ± 2.4, t₍₇₉₎ = −0.897, p = 0.373).

Conclusion

Both treatment protocols yielded in a high degree of patient satisfaction but dissatisfactory pain relief following TE. Metamizole can be recommended as a basic medication allowing for improved pain relief. Reported pain intensities were independent of the amount of opioid intake. Further research is mandatory to standardize and improve analgesic treatment after TE.

Introduction

Despite major progress in pain assessment and management, acute postoperative pain therapy in general seems to be still insufficient [1]. Especially severe pain is often underestimated and there is a striking situation of shortage and undersupply [2], [3], [4], [5]. This can be particularly applied to so-called “minor”-surgeries. One classic example is the tonsillectomy (TE), which is ranked among the 25 most painful surgical procedures and is considered to be even more painful than a gastrectomy or thoracotomy [6]. Its severe postoperative pain intensity has been demonstrated in numerous studies [6], [7], [8], [9], [10]. Nonetheless, in spite of numerous trials, a standardized postoperative analgesic management with satisfactory pain control could not be established so far [11]. Since pain after TE is such an important and unsolved issue, several countries, such as the United States, Sweden and France have worked for establishing guidelines with the aim of better pain control [12], [13], [14]. Again, it has been stated that up to now there is neither an ideal pain concept nor an optimal scheme for dosage of analgesics [12]. Although expired since April 2014, the recommended pain-treatment referrals in Germany are documented in the S3 guidelines on the treatment of acute perioperative and posttraumatic pain (AWMF guidelines 041/001) [1]. Adequate pain management is known to be of outmost importance for a quick convalescence and reduces postoperative morbidity and mortality [13,14]. Furthermore it prevents long-term impairments such as chronic pain [15], [16], [17], improves quality of life and shortens treatment time [18]. In case of TE inadequate pain management can be related to increased postoperative bleeding rates [19,20]. To improve this issue, guidelines and standardization in form of specific and standardized analgesic concepts are needed [14,21]. Since the standard practice in pain therapy is performed in accordance with the guidelines of the World Health Organization (WHO step-by-step plan), we developed two different graduated analgesic approaches consisting of non-opioid basic medication and the option of adding additional medication, e.g. morphine, for higher persistent pain intensities. Another objective of the alteration of treatment protocols was the possible reduction of metamizole consumption due to its much discussed potentially life-threatening side-effects. Therefore, metamizole was replaced as first line basic medication in protocol 1 (PT1) by ibuprofen in protocol 2 (PT2). Both treatment protocols were evaluated with respect to pain relief in relation to analgesic score, functional impairments, treatment-related side-effects and patient satisfaction.