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Topical ketamine and morphine for post-tonsillectomy pain

Published online by Cambridge University Press:  01 April 2008

Ö. Canbay ,
N. Çelebi ,
Ş. Uzun ,
A. Şahin ,
V. Çeliker  and
Ü. Aypar
Ö. Canbay*
Affiliation:
Hacettepe University, Faculty of Medicine, Department of Anaesthesiology, Sıhhıye, Ankara, Turkey
N. Çelebi
Affiliation:
Hacettepe University, Faculty of Medicine, Department of Anaesthesiology, Sıhhıye, Ankara, Turkey
Ş. Uzun
Affiliation:
Hacettepe University, Faculty of Medicine, Department of Anaesthesiology, Sıhhıye, Ankara, Turkey
A. Şahin
Affiliation:
Hacettepe University, Faculty of Medicine, Department of Anaesthesiology, Sıhhıye, Ankara, Turkey
V. Çeliker
Affiliation:
Hacettepe University, Faculty of Medicine, Department of Anaesthesiology, Sıhhıye, Ankara, Turkey
Ü. Aypar
Affiliation:
Hacettepe University, Faculty of Medicine, Department of Anaesthesiology, Sıhhıye, Ankara, Turkey
*
Correspondence to: Özgür Canbay, Department of Anaesthesiology, Faculty of Medicine, Hacettepe University, 06100 Sıhhıye, Ankara, Turkey. E-mail: ozgurcanbay@yahoo.com; Tel/fax: +90 312 3109600
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Summary

Background and objectives

Tonsillectomy is frequently associated with postoperative pain of considerable duration, which is usually accompanied by the substantial consumption of both opioid and non-opioid analgesics. Despite the use of different surgical and anaesthetic techniques in the search for safe and effective post-tonsillectomy pain relief, this problem remains a clinical dilemma. The aim of the current study was to evaluate the potential effects of topically administered ketamine and morphine by an oral rinse into the tonsillar fossae.

Methods

In all, 60 children, 15 for each group, aged between 3 and 12 yr scheduled for tonsillectomy were randomly assigned to one of four groups. Study drugs were administered to both tonsillar fossae for 5 min. Group K received 0.4 mL (20 mg) ketamine in 10 mL artificial saliva, Group KM received 0.4 mL (20 mg) ketamine + 5 mL (20 mg) 4‰ morphine aqueous solution in 5 mL artificial saliva, Group M received 5 mL (20 mg) 4‰ morphine aqueous solution in 5 mL artificial saliva, Group C received only 10 mL artificial saliva. Postoperative pain, nausea, vomiting, sedation and bleeding were evaluated.

Results

Pain scores were higher in the control group at arrival in the recovery ward (P < 0.05). Morphine and ketamine groups had longer effective analgesia time than the morphine + ketamine and control groups. The 24-h analgesic consumption was significantly higher in the control group.

Conclusion

Topical ketamine and morphine seems to be a safe and easy analgesic approach for decreasing adenotonsillectomy pain.

Keywords

TONSILLECTOMYPAIN ACUTE AND POSTOPERATIVEMORPHINEKETAMINE
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 25 , Issue 4 , April 2008 , pp. 287 - 292
Copyright
Copyright © European Society of Anaesthesiology 2008

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References

1.Hamunen, K, Kontinen, V. Systematic review on analgesics given for pain following tonsillectomy in children. Pain 2005; 117: 40–50.CrossRefGoogle ScholarPubMed
2.Husband, AD, Davis, A. Pain after tonsillectomy. Clin Otolaryngol 1996; 21: 99–101.CrossRefGoogle ScholarPubMed
3.Jebeles, JA, Reilly, JS, Gutierrez, JF, Bradley, EL Jr, Kissin, I. Tonsillectomy and adenoidectomy pain reduction by local bupivacaine infiltration in children. Int J Pediatr Otorhinolaryngol 1993; 25: 149–154.Google Scholar
4.Fazi, L, Jantzen, EC, Rose, JB, Kurth, CD, Watcha, MF. A comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient. Anesth Analg 2001; 92: 56–61.CrossRefGoogle ScholarPubMed
5.Giannoni, C, White, S, Enneking, FK, Morey, T. Ropivacaine with or without clonidine improves pediatric tonsillectomy pain. Arch Otolaryngol Head Neck Surg 2001; 127: 1265–1270.CrossRefGoogle ScholarPubMed
6.Akural, EI, Koivunen, PT, Teppo, H, Alahuhta, SM, Löppönen, HJ. Post-tonsillectomy pain: a prospective, randomised and double-blinded study to compare an ultrasonically activated scalpel technique with the blunt dissection technique. Anaesthesia 2001; 56: 1045–1050.Google Scholar
7.Vasan, NR, Stevenson, S, Ward, M. Preincisional bupivacaine in posttonsillectomy pain relief: a randomized prospective study. Arch Otolaryngol Head Neck Surg 2002; 128: 145–149.Google Scholar
8.Molliex, S, Haond, P, Baylot, D et al. Effect of pre- vs. postoperative tonsillar infiltration with local anesthetics on postoperative pain after tonsillectomy. Acta Anaesthesiol Scand 1996; 40: 1210–1215.Google Scholar
9.Nordahl, SH, Albrektsen, G, Guttormsen, AB, Pedersen, IL, Breidablikk, HJ. Effect of bupivacaine on pain after tonsillectomy: a randomized clinical trial. Acta Otolaryngol 1999; 119: 369–376.Google Scholar
10.Naja, MZ, El-Rajab, M, Sidani, H, Kabalan, W, Ziade, MF, Al-Tannir, MA. Modified infiltration technique in tonsillectomy: expanded case report of 25 children. Int J Pediatr Otorhinolaryngol 2005; 69: 35–41.Google Scholar
11.Kountakis, SE. Effectiveness of perioperative bupivacaine infiltration in tonsillectomy patients. Am J Otolaryngol 2002; 23: 76–80.Google Scholar
12.Hall, DJ, Littlefield, PD, Birkmire-Peters, DP, Holtel, MR. Radiofrequency ablation versus electrocautery in tonsillectomy. Otolaryngol Head Neck Surg 2004; 130: 300–305.CrossRefGoogle ScholarPubMed
13.Hung, T, Moore-Gillon, V, Hern, J, Hinton, A, Patel, N. Topical bupivacaine in paediatric day-case tonsillectomy: a prospective randomized controlled trial. J Laryngol Otol 2002; 116: 33–36.Google Scholar
14.Wong, AK, Bissonnette, B, Braude, BM, Macdonald, RM, St-Louis, PJ, Fear, DW. Post-tonsillectomy with bupivacaine reduces immediate postoperative pain in children. Can J Anaesth 1995; 42: 770–774.CrossRefGoogle ScholarPubMed
15.El-Hakim, H, Nunez, DA, Saleh, HA, MacLeod, DM, Gardiner, Q. A randomised controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients. Clin Otolaryngol 2000; 25: 413–417.Google Scholar
16.Gunter, JB, Varughese, AM, Harrington, JF et al. Recovery and complications after tonsillectomy in children: a comparison of ketorolac and morphine. Anesth Analg 1995; 81: 1136–1141.Google ScholarPubMed
17.Marret, E, Flahault, A, Samama, CM, Bonnet, F. Effects of postoperative, nonsteroidal, anti-inflammatory drugs on bleeding risk after tonsillectomy: meta-analysis of randomized, controlled trials. Anesthesiology 2003; 98: 1497–1502.Google ScholarPubMed
18.Moiniche, S, Romsing, J, Dahl, JB, Tramer, MR. Nonsteroidal antiinflammatory drugs and the risk of bleeding after tonsillectomy: a quantitative systematic review. Anesth Analg 2003; 96: 68–77.Google Scholar
19.Korpela, R, Korvenoja, P, Meretoja, OA. Morphine-sparing effect of acetaminophen in pediatric day-case surgery. Anesthesiology 1999; 91: 442–447.Google Scholar
20.Slatkin, NE, Rhiner, M. Topical ketamine in the treatment of mucositis pain. Pain Med 2003; 4: 298–303.CrossRefGoogle ScholarPubMed
21.Egeli, E, Harputluoglu, U, Oghan, F, Demiraran, Y, Guclu, E, Ozturk, O. Does topical lidocaine with adrenaline have an effect on morbidity in pediatric tonsillectomy? Int J Pediatr Otorhinolaryngol 2005; 69: 811–815.Google Scholar
22.Hannallah, RS, Broadman, LM, Belman, AB, Abramowitz, MD, Epstein, BS. Comparison of caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology 1987; 66: 832–834.Google Scholar
23.Fösel, T, Fötsch, S, Ebeling, O. Postoperative pain therapy after tonsillectomy in children. An observational study for 7 days. HNO 2005; 53: 722–726.Google Scholar
24.Grundmann, U, Wornle, C, Biedler, A, Kreuer, S, Wrobel, M, Wilhelm, W. The efficacy of the non-opioid analgesics parecoxib, paracetamol and metamizol for postoperative pain relief after lumbar microdiscectomy. Anesth Analg 2006; 103: 217–222.Google Scholar
25.Kotiniemi, LH, Ryhanen, PT, Valanne, J, Jokela, R, Mustonen, A, Poukkula, E. Postoperative symptoms at home following day-case surgery in children: a multicentre survey of 551 children. Anaesthesia 1997; 52: 963–969.Google Scholar
26.Romsing, J, Ostergaard, D, Drozdziewicz, D, Schultz, P, Ravn, G. Diclofenac or acetaminophen for analgesia in paediatric tonsillectomy outpatients. Acta Anaesthesiol Scand 2000; 44: 291–295.CrossRefGoogle ScholarPubMed
27.Anderson, BJ, Ralph, CJ, Stewart, AW, Barber, C, Holford, NH. The dose–effect relationship for morphine and vomiting after day-stay tonsillectomy in children. Anaesth Intensive Care 2000; 28: 155–160.Google Scholar
28.Mather, SJ, Peutrell, JM. Postoperative morphine requirements, nausea and vomiting following anaesthesia for tonsillectomy. Comparison of intravenous morphine and non-opioid analgesic techniques. Paediatr Anaesth 1995; 5: 185–188.Google Scholar
29.White, MC, Nolan, JA. An evaluation of pain and postoperative nausea and vomiting following the introduction of guidelines for tonsillectomy. Pediatric Anaesthesia 2005; 15: 683–688.Google Scholar
30.Naja, MZ, El-Rajab, M, Kabalan, W, Ziade, MF, Al-Tannir, MA. Pre-incisional infiltration for pediatric tonsillectomy: A randomized double-blind clinical trial. Int J Pediatr Otorhinolaryngol 2005; 69: 1333–1341.Google Scholar
31.Cerchietti, LC, Navigante, AH, Bonomi, MR et al. Effect of topical morphine for mucositis associated pain following concomitant chemoradiotherapy for head and neck carcinoma. Cancer 2002; 95: 2230–2236.Google Scholar
32.Cerchietti, LC, Navigantea, AH, Körte, MW et al. Potential utility of the peripheral analgesic properties of morphine in stomatitis-related pain: a pilot study. Pain 2003; 105: 265–273.Google Scholar
33.Likar, R, Koppert, W, Blatnig, H et al. Efficacy of peripheral morphine analgesia in inflamed, noninflamed and perineural tissue of dental surgery patients. J Pain Symptom Manage 2001; 21: 330–337.Google Scholar
34.Carlton, SM, Coggeshall, RE. Inflammation-induced changes in peripheral glutamate receptor populations. Brain Res 1999; 820: 63–70.Google Scholar
35.Carlton, SM, Zhou, S, Coggeshall, RE. Evidence for the interaction of glutamate and NK1 receptor in the periphery. Brain Res 1998; 790: 160–169.Google Scholar
36.Davidson, EM, Coggeshall, RE, Carlton, SM. Peripheral NMDA and non-NMDA glutamate receptors contribute to nociceptive behaviors in the rat formalin test. Neuroreport 1997; 8: 941–946.Google Scholar
37.Liu, XJ, White, TD, Sawynok, J. Intraplantar injection of glutamate evokes peripheral adenosine release in the rat hind paw: involvement of peripheral ionotropic glutamate receptors and capsaicin-sensitive sensory afferents. J Neurochem 2002; 80: 562–570.Google Scholar
38.Oatway, M, Reid, A, Sawynok, J. Peripheral antihyperalgesic and analgesic actions of ketamine and amitriptyline in a model of mild thermal injury in the rat. Anesth Analg 2003; 97: 168–173.Google Scholar
39.Warncke, T, Jorum, E, Stubhaug, A. Local treatment with the N-methyl-d-aspartate receptor antagonist ketamine, inhibit development of secondary hyperalgesia in man by a peripheral action. Neurosci Lett 1997; 227: 1–4.Google Scholar
40.Pedersen, JL, Galle, TS, Kehlet, H. Peripheral analgesic effects of ketamine in acute inflammatory pain. Anesthesiology 1998; 89: 58–66.Google Scholar
41.Gottrup, H, Bach, FW, Arendt-Nielsen, L, Jensen, TS. Peripheral lidocaine but not ketamine inhibits capsaicin-induced hyperalgesia in humans. Br J Anaesth 2000; 85: 520–528.Google Scholar
42.Crowley, KL, Flores, JA, Hughes, CN et al. Clinical application of ketamine in the treatment of neuropathic pain. Int J Pharm Compound 1998; 2: 122–127.Google Scholar
43.Quan, D, Wellish, M, Gilden, DH. Topical ketamine treatment of postherpetic neuralgia. Neurology 2003; 60: 1391–1392.Google Scholar
44.Ushida, T, Tani, T, Kanbara, T, Zinchuk, V, Kawasaki, M, Yamamoto, H. Analgesic effects of ketamine ointment in patients with complex regional pain syndrome type I. Reg Anesth Pain Med 2002; 27: 524–528.Google Scholar
45.Azevedo, V, Lauretti, G, Pereira, NL, Reis, MP. Transdermal ketamine as an adjuvant for postoperative analgesia after abdominal gynecological surgery using lidocaine epidural blockade. Anesth Analg 2000; 91: 1479–1482.Google Scholar
46.Poyhia, R, Vainio, A. Topically administered ketamine reduces capsaicin-evoked mechanical hyperalgesia. Clin J Pain 2006; 22: 32–36.Google Scholar
47.Richebe, P, Rivat, C, Rivalan, B, Maurette, P, Simonnet, G. Low doses ketamine: antihyperalgesic drug, non-analgesic. Ann Fr Anesth Reanim 2005; 24: 1349–1359.Google Scholar
48.Smith, DJ, Perrotti, JM, Mansell, AL, Monroe, PJ. Ketamine analgesia is not related to an opiate action in the periaqueductal gray region of the rat brain. Pain 1985; 21: 253–265.Google Scholar
49.Finck, AD, Ngai, SH. Opiate receptor mediation of ketamine analgesia. Anesthesiology 1982; 56: 291–297.Google Scholar
50.Smith, DJ, Westfall, DP, Adams, JD. Assessment of the potential agonistic and antagonistic properties of ketamine at opiate receptors in the guinea-pig ileum. Neuropharmacology 1982; 21: 605–611.Google Scholar