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Obstructive sleep apnoea syndrome and analgesia after tonsillectomy
- Tamsin L Gregory, A Richard Gande (26 March 2008)
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The proof is in the tasting
- Andrew J Davidson, Pablo Ingelmo (29 February 2008)
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Do we have the right dose? Comparing apples and oranges!
- Faye M Evans, Santhanam Suresh, MD, Children's Memorial Hospital, Chicago (20 February 2008)
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Tamsin L Gregory , A Richard Gande
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We read with interest the paper by Capici et al comparing the duration of analgesia following intravenous or rectal acetaminophen after adenotonsillectomy in children.(1) The authors concluded that rectal acetaminophen 40 mg kg -1 provided analgesia of longer duration compared with an equivalent dose of i.v. acetaminophen. All children received fentanyl 1-2 mcg kg –1. We believe that in comparing the baseline characteristics of the two groups of patients the authors overlooked an important aspect of preoperative evaluation. In an increasing proportion of children undergoing tonsillectomy and adenoidectomy, the main indication for surgery is obstructive sleep apnoea syndrome (OSAS), (2) which results in recurrent episodes of hypoxaemia. Recurrent hypoxaemia in children is associated with increased analgesic sensitivity to opiates and reduced opioid requirement for analgesia following adenotonsillectomy,(3,4) as commonly observed by anaesthetists who regularly anaesthetise this group of patients. OSAS was not amongst the exclusion criteria in the study by Capici et al, nor do the authors indicate whether any of the patients in either treatment group have OSAS. If either of the groups contained a disproportionate number of patients with OSAS, the mean duration of action of fentanyl administered intra-operatively could be prolonged. This could alter the postoperative analgesic requirements in either group, and therefore we believe that the results of the study should be interpreted with caution. References 1. Capici F, Ingelmo PM, Davidson A, et al. Randomized controlled trial of duration of analgesia following intravenous or rectal acetaminophen after adentonsillectomy in children. BJA 2008; 100:251-5 2. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990; 99:187-191 3. Brown KA, Laferriere A, Moss IR. Recurrent Hypoxemia in Young Children with Obstructive Sleep Apnea Is Associated with Reduced Opioid Requirement for Analgesia. Anesthesiology 2004; 100:806 –10 4. Brown KA, Laferriere A, Lakheeram I, Moss IR. Recurrent Hypoxemia in Children Is Associated with Increased Analgesic Sensitivity to Opiates. Anesthesiology 2006; 105:665-669 Conflict of Interest:None declared |
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Andrew J Davidson, Clinical Associate Professor Department of Pharmacology, University of Melbourne, Pablo Ingelmo
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Thank you for your interest in our paper. We agree that the pharmacokinetics, and in particular the pharmacodynamics of analgesics in children are complex; there being a poorly understood relationship between blood levels and clinical analgesia. As such it is unfortunate that we could not add to this area with blood levels. Given our poor understanding of the basic pharmacology we would suggest that it is of great importance to conduct clinical trials demonstrating and comparing clinical effectiveness of new analgesic therapies. Our study simply demonstrated longer acceptable analgesia with the larger rectal dose. Although pharmacokinetic data are certainly useful, it is cinical trials such as this which provide greater evidence to guide clinical practice. Conflict of Interest:None declared |
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Faye M Evans, Pediatric Anesthesiologist Emory University, Children's Healthcare of Atlanta, Georgia, Santhanam Suresh, MD, Children's Memorial Hospital, Chicago
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We read with interest this article in your journal comparing intravenous acetaminophen to rectal acetaminophen in children undergoing adeno-tonsillectomy. Although the rescue medication was required at a much later time frame in the rectal acetaminophen group, as indicated in the Kaplan- Mier curve, we were unclear if the dose that was administered intravenously was equianalgesic. This data would have been more profound and may have a better impact on practice if it had been combined with phamacokinetic data. The global comfort scale may not be a predictor of postoperative pain control either since it is subjective. Further rigorous data is needed to support this data interpretation. Conflict of Interest:Santhanam Suresh, MD Cadence Pharmaceuticals, Funded research |
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