Apr 19 2005
When children have their tonsils removed, nonsteroidal anti-inflammatory drugs can be used for pain relief with no significant increase in bleeding and with less nausea and vomiting, according to a systematic review of current evidence.
NSAIDs include analgesics such as ibuprofen (Motrin) and naproxen (Aleve). Although these drugs are proven painkillers they also interfere with blood clotting, so there has been concern about excessive bleeding during or after surgery. Such problems are particularly risky for young tonsillectomy patients, because they have relatively small airways and low blood volume compared to adults.
Although doctors in the United Kingdom seem to be turning toward NSAIDs to reduce the stomach upset that frequently follows narcotic use, many in the United States prefer different surgical techniques that avoid discomfort and different drugs for the pain.
Dr. Mary Cardwell of North Manchester General Hospital in England led a team that reviewed 13 randomized controlled trials that compared NSAIDs with other painkillers or placebo after pediatric tonsillectomy. The studies included 955 children through age 16.
All of the trials analyzed whether severe bleeding that required additional surgery occurred more frequently when NSAIDS were used instead of other painkillers. However, such events are rare under any circumstances. “All the papers studied had insufficient numbers to be able to demonstrate any significant difference,” note the authors.
Seven trials involving 471 children looked at bleeding that could be controlled without a return to the operating room, and use of NSAIDs did not increase the frequency of these complications.
The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
Dr. Gretchen Siviter, a coauthor of the study and an anesthesiologist at England’s Royal Lancaster Infirmary, says use of nonsteroidals in the United Kingdom is “definitely an issue.”
“They’re proven to be good analgesics, but some doctors don’t give them because they’re worried about bleeding. I think the review might make people feel a bit easier about giving them.”
In the United States, many doctors seem to be taking a different approach. In fact, many patient advisories specifically say that NSAIDs should be avoided before and after surgery.
“Acetaminophen is used much more than nonsteroidals here in the States,” says Dr. Julie L. Wei of University of Kansas Medical Center. “We send everybody home with Tylenol combined with a narcotic like codeine for up to seven days.”
Dr. Todd G. Dray, chief of head and neck surgery at Kaiser Permanente’s Santa Clara Medical Center in California, agrees that American doctors are generally not looking toward NSAIDs to improve surgical recovery.
“My take on the issue is that the real ‘bang for the buck’ in decreasing post-op tonsillectomy pain is coming from improved surgical techniques,” he says. At least five new approaches make use of ultrasound, radiofrequency energy or lasers to break up and remove tissue, rather than conventional cutting or burning. Dray has relied exclusively on the new procedures for the past five years.
Both Wei and Dray also note that it is now common to give a steroid such as dexamethasone during surgery to minimize later nausea and vomiting.
Using these methods, says Dray, the need for narcotic painkillers decreases tremendously, and many patients can go home in less than three hours. He believes that rather than turning to NSAIDs, it’s preferable to rely on “medications and techniques that do not potentially increase post-op tonsillectomy bleeding.”