Perioperative Intravenous Acetaminophen in Pediatric Tonsillectomies

Abstract

This study investigated the effect of perioperative intravenous (IV) acetaminophen on opioid requirements in pediatric patients undergoing tonsillectomy at a single center. This retrospective chart review included patients who were less than 18 years old and underwent an outpatient tonsillectomy procedure. Patients who received non-Food and Drug Administration (FDA)-approved dosing of IV acetaminophen, without documented weights, and on chronic pain medications at the time of the procedure were excluded. The primary outcome was opioid requirements postoperatively prior to discharge measured as morphine equivalents per kilogram. Descriptive statistics were used to compare differences between groups. A multivariate analysis was performed, accounting for differences between groups in baseline and procedural characteristics. In total, 157 patients were included in this study, of whom 55 had received IV acetaminophen and 102 had not. The average IV acetaminophen dose for was 14.5 mg/kg for patients weighing less than 50 kg (n = 22); the remaining patients received the maximum 1 g dose. Patients who received IV acetaminophen were less likely to be administered postoperative opiates as compared with those did not (45.5% vs 63.7%, odds ratio = 0.48, = .036). There was a trend toward a decrease in total amount of opiates administered with IV acetaminophen (0 vs 0.033 µg/kg, = .61). After adjusting for age and documented pain assessment, IV acetaminophen administration remained a significant factor for postoperative opiate administration. Perioperative administration of IV acetaminophen was associated with less frequent administration of symptom-directed opiates in pediatric tonsillectomies. This finding indicates that the agent may have an opioid-sparing effect in this patient population.

Association of Intravenous Acetaminophen Administration With the Duration of Intravenous Opioid Use Among Hospitalized Pediatric Patients

“…The reduction in IV opioid duration in the group that received IV acetaminophen prior to IV opioid medications confirms several small pediatric and larger adult trials that reported a reduction in opioid utilization when opioids were preceded by IV acetaminophen. 13 , 14 , 16 , 18 , 20 , 22 , 36 , 37 Prior pediatric trials of IV acetaminophen primarily focused on specific postoperative patient populations, such as spinal fusions and tonsillectomies, with only 1 trial focusing on nonoperative patients, a cohort of sickle cell patients. 13 , 14 , 15 , 17 Our inclusion of both operative and nonoperative pediatric inpatients adds to the generalizability of the results.…”

“… 10 , 11 , 12 Intravenous (IV) acetaminophen has been a common analgesic initiated prior to opioids in multimodal pain regimens with the purpose of reducing subsequent opioid requirements. 13 , 14 , 15 , 16 However, assessments of the association between IV acetaminophen and opioid use in multimodal pain regimens have had conflicting results. 13 , 14 , 15 , 17 , 18 , 19 , 20 , 21 In particular, randomized studies that compare treatment that initiates pain control with IV acetaminophen and supplements with opioids vs therapy initiated with opioids have been small with conflicting results.…”

“… 13 , 14 , 15 , 16 However, assessments of the association between IV acetaminophen and opioid use in multimodal pain regimens have had conflicting results. 13 , 14 , 15 , 17 , 18 , 19 , 20 , 21 In particular, randomized studies that compare treatment that initiates pain control with IV acetaminophen and supplements with opioids vs therapy initiated with opioids have been small with conflicting results. 13 , 18 , 19 , 22 The aim of this analysis was to determine if the initiation of IV acetaminophen prior to IV opioids would result in a reduction in the total hospital duration of IV opioid use compared with IV opioid medications administered without IV acetaminophen in both operative and nonoperative pediatric inpatients in a national database.…”

Does Intravenous Acetaminophen Reduce Opioid Requirement in Pediatric Emergency Department Patients With Acute Sickle Cell Crises?

“…Alternative and adjunctive therapies to opioids have been recently investigated; however, the study results have been mixed. Most of the studies illustrating significant pain control with IV acetaminophen have been done in populations with acute pain due to fractures, renal colic, or postoperative pain 14,16–18,22–26 . A recent study by Blok et al 20 comparing IV acetaminophen to morphine in adults with acute pain in the ED failed to demonstrate an opioid‐sparing effect but showed that a small number of patients used less opioids in the following 24 hours after discharge.…”

A Quality Improvement Initiative to Decrease Inappropriate Intravenous Acetaminophen Use at an Academic Medical Center

“…In a separate study, patients who received 1 dose of IV APAP for tonsillectomy were less likely to receive postoperative opioids than those who did not; however, overall opioid consumption was similar between the groups (0 vs 0.033 μg/kg, P = .61). 18 The incorporation of IV APAP into surgical protocols as "fast-track" programs has become increasingly popular to provide adjuvant pain relief and promote early discharge. 19 , 20 These fast-track cardiac protocols have demonstrated decreased opioid consumption, adequate analgesia, decreased side effects, and early extubation.…”