EFFECT OF LOCALLY APPLIED BUPIVACAINE FOLLOWING TONSILLECTOMY IN CHILDREN WHO RECEIVED INTRAVENOUS PENTAZOCINE AND PARACETAMOL

Abstract

BACKGROUND: Tonsillectomy causes moderate pain postoperatively and this is a major
morbidity associated with the procedure. The pain affects the patient’s feeding, discharge from
the hospital, ability to return to school and reduces satisfaction with the surgical treatment.
Multimodal approach to pain management is the current trend of achieving better postoperative
analgesia and minimise the undesirable effects of pain medications. Local anaesthetics combined
with systemic opioids can greatly improve analgesia with reduction in opioid consumption, thus
reducing the opioid associated side effects. A local anaesthetic (LA) agent such as bupivacaine
has found its use in the institution of local and regional anaesthesia or analgesia for surgical
procedures as it has a long duration of action.

OBJECTIVES: This study was designed to determine the effectiveness of locally applied
bupivacaine in reducing pain in children following tonsillectomy.

PATIENTS AND METHODS: Following the approval from University of Ibadan/University
College Hospital (UI/UCH) Ethics Committee and the National Postgraduate Medical College of
Nigeria (NPMCN) approval, informed consent was obtained from the parents of each patient.
Fifty two patients aged 1-8 years of the American Society of Anesthesiologists (ASA) physical
status I or II requiring adenotonsillectomy or tonsillectomy under general anaesthesia were
studied. The patients were randomized into two groups. Study group A, had their tonsillar fossae
packed with swabs soaked in bupivacaine at 2mg/kg diluted up to 10ml while group B, which is
the control group had their fossae packed with tonsillar swabs soaked in 10ml of normal saline.
All patients received intravenous pentazocine at 0.5mg/kg and paracetamol at 15mg/kg at
induction.
All patients had their non-invasive arterial blood pressure, oxygen saturation, ECG, end tidal
carbon dioxide and temperature monitored perioperatively. The primary outcome was the time
for the first request for analgesic. Post-operative pain was assessed using Ouchers faces scale for
8 hours.

RESULTS: The two groups were comparable with respect to their demographic characteristics,
duration of surgery and doses of pentazocine and paracetamol used intraoperatively. The time to
first analgesic request was prolonged significantly in the bupivacaine group compared to the
placebo group, with mean (±SD) time duration of 295.77 ± 169.88 minutes and 27.15 ± 17.13
minutes respectively within the study period of 8 hours (p = 0.00). There were seven (27%)
patients in the bupivacaine group that required rescue analgesic (pentazocine) compared to
twenty two (85%) patients in the placebo group that received rescue analgesic (p=0.00).

The haemodynamic parameters of the patients were comparable at the preoperative and
intraoperative period. However, there was some variability in the immediate postoperative
period. The mean pulse (beats/minute), the mean systolic blood pressure (mmHg) and mean
diastolic blood pressure (mmHg) in the bupivacaine group were; 111.23±54.0, 102.23±15.50 and
60.33±11.70 compared with the placebo group of 125.53±43.0, 122.56±54.0 and 61.67±12.72
(p= 0.04, 0.04 and 0.06) respectively which was statistically significant for both mean pulse rate
and systolic blood pressure. This was in contrast to the diastolic blood pressure for the two
groups of 60.33±11.70 and 61.67±12.72mmHg for the bupivacaine and placebo respectively, (p
= 0.06) which was not statistically significant. There were no recorded episodes of
haemodynamic instability.
The level of pain relief satisfaction in the bupivacaine group was much higher (96.2%) when
compared with the placebo group (23.1%), (p=0.00).

There were no episodes of seizure or coma in the two groups. However; one patient in the
bupivacaine group developed laryngospasm immediately after extubation. This occurred as the
patient was being extubated during a light plane of anaesthesia.

CONCLUSION: The application of swabs soaked in bupivacaine on tonsillar fossae after
adenotonsillectomy is a safe and effective method of pain relief in children.