Perioperative Acetaminophen and Dexmedetomidine Eliminate Post-Operative Opioid Requirement following Pediatric Tonsillectomy.

Andrew G. Rudikoff,Janet Mora-Marquez,Carolyn V. Nguyen,Antonio Hernandez Conte,Robert L. Rettig,Franklin M. Banzali,Keira P. Mason,Qiaoling Chen,David D. Tieu,Marlene M. Nashed

doi:10.3390/jcm11030561

Abstract

Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.

Highlights

Tonsillectomy is one of the most common pediatric surgical procedures performed in the United States, with an estimated frequency of 289,000 per year [1]
There were no significant differences between the groups with regard to age, race and body mass index (BMI)
Our study is unique because itit follows follows the the opioid opioid intake intake of of these these children children through through all all three three phases phases of of care: care: because intraoperative, post-anesthesia care and at home

Summary

Introduction

Tonsillectomy is one of the most common pediatric surgical procedures performed in the United States, with an estimated frequency of 289,000 per year [1]. Pain control with opiates in the post-operative period (both immediate and following discharge home) is an important area of concern, balancing the analgesic needs with the risk of obstructive sleep apnea, hypopnea and respiratory depression [2]. Perioperative regimens of oral dextromethorphan and acetaminophen with intraoperative boluses of dexmedetomidine and ketamine have been successful in a small pilot study of how to eliminate opiates in these tonsillectomy patients [5]. By limiting the opioid-ordering capability and encouraging non-opioid alternative medications on electronic order sets, hospitals have decreased physician opiate orders for post-tonsillectomy children below seven years of age [6]. Multimodal approaches using dexmedetomidine, nonsteroidal analgesics and regional anesthesia have been shown to significantly decrease morphine requirements following pediatric tonsillectomy [11]

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