A randomized clinical trial of the effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in children following tonsillectomy

Abstract

The purpose of this study was to determine whether around-the-clock (i.e. ATC) dosing of acetaminophen with codeine, with or without nurse coaching, compared to standard care with as needed (i.e. PRN) dosing: reduced children's reports of pain intensity with and without swallowing; increased pain relief, and increased analgesic consumption. Eighty children, 6-15 years, undergoing tonsillectomy were randomized to one of three treatment groups to receive acetaminophen with codeine (120 mg/12 mg/5 ml) for 3 days after surgery: PRN group (N = 28)-every 4 h PRN, with standard postoperative instructions, without nurse coaching; ATC group (N = 26)-every 4 h ATC, with standard postoperative instructions, without nurse coaching; and ATC+coaching group (N = 26)-every 4 h ATC, with standard postoperative instructions and nurse coaching. In all three groups, significant decreases were found over time in pain intensity scores at rest (P < 0.001) and with swallowing (P < 0.001). However, mean pain scores at rest and with swallowing were >3/10 until the fourth evening after tonsillectomy. Children in both ATC dosing groups received significantly greater amounts of acetaminophen and codeine than children in the PRN group (P < 0.003). No significant differences were found in the amount of analgesic administered between the ATC dosing groups with and without nurse coaching. No significant differences were found in the amount of nausea and vomiting among the three groups. Scheduled dosing of acetaminophen with codeine did not provide adequate pain relief for children following tonsillectomy. Nurse coaching does not increase parent's adherence with an ATC dosing schedule.

Children's pre-operative tonsillectomy pain education: Clinical outcomes

“…This suggests that acetaminophen with codeine would have provided suboptimal therapeutic analgesic management. In addition, the similarity between this study's pain ratings with another study [38] further suggests that for many children, acetaminophen with codeine was inadequate in treating their post-operative pain. Last, this study did not ask children if pain education fostered their use of self-initiated pain strategies or confidence in pursuing more aggressive analgesic management.…”

Perianesthesia Nurses’ Pain Management After Tonsillectomy and Adenoidectomy: Pediatric Patient Outcomes

“…15 Increased pain during swallowing may deter the patient from drinking and lead to dehydration. Nurse interventions to relieve pain after T&A must assure that children can drink before discharge home.…”

Oral morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial

“…16 Undertreatment is an important cause of inadequate postoperative analgesia. [17][18][19][20] Both ibuprofen 21,22 and oral morphine 22,23 have shown benefit in children with musculoskeletal injuries. Following deaths of children who received codeine postoperatively, 24,25 the United States Food and Drug Administration 26 and Health Canada 27 issued advisories.…”