Skip to main content
SpringerLink
Log in

Comparison of topical ropivacaine with and without ketamine on post-surgical pain in children undergoing tonsillectomy: a randomized controlled double-blind study

  • Original Article
  • Published:
Journal of Anesthesia Aims and scope Submit manuscript

Abstract

Purpose

Tonsillectomy in pediatric patients may cause severe postoperative pain. Topical local anesthetics are an easy and safe way to control post-tonsillectomy pain, but there is no benefit during the early postoperative stage. Topical ketamine shows a good effect on early stage postoperative pain. We compared the effect of topical ropivacaine with and without ketamine on post-tonsillectomy pain.

Methods

Patients aged 3–7 years undergoing tonsillectomy were selected to participate in the study. Our study was performed in a randomized, placebo-controlled, double-blind manner. Patients were randomly assigned to one of two groups using computer-generated random numbers. The researchers who assessed the pain score, the caregivers, and the patient were blinded to group assignment. One group received topical ropivacaine with saline (RS group) and the other group received topical ropivacaine with 20 mg ketamine (RK group) on the tonsillar bed. Pain scores using the modified Children’s Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 15 min and 30 min, and at 1, 2, 4, 8, 16 and 24 h were recorded. Rescue analgesic requirement and complications were also recorded.

Results

A total of 66 patients were randomly assigned to the RS group (n = 33) and the RK group (n = 33). The mCHEOPS scores were significantly lower in the RK group at 15 min (P = 0.046). The mCHEOPS scores of the two groups decreased with time, but there was no intergroup interaction. The RS group received more analgesics until 1 h after surgery and the RK group received more analgesics during 1–24 h after surgery. There were no differences in adverse outcomes.

Conclusions

Topical ropivacaine with ketamine can reduce immediate postoperative pain and analgesic requirement better than ropivacaine alone.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Subramanyam R, Varughese A, Willging JP, Sadhasivam S. Future of pediatric tonsillectomy and perioperative outcomes. Int J Pediatr Otorhinolaryngol. 2013;77:194–9.

    Article  PubMed  Google Scholar 

  2. Stewart DW, Ragg PG, Sheppard S, Chalkiadis GA. The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair. Paediatr Anaesth. 2012;22:136–43.

    Article  PubMed  Google Scholar 

  3. Kendrick D, Gibbin K. An audit of the complications of paediatric tonsillectomy, adenoidectomy and adenotonsillectomy. Clin Otolaryngol Allied Sci. 1993;18:115–7.

    Article  CAS  PubMed  Google Scholar 

  4. Vlok R, Melhuish TM, Chong C, Ryan T, White LD. Adjuncts to local anaesthetics in tonsillectomy: a systematic review and meta-analysis. J Anesth. 2017. doi:10.1007/s00540-017-2310-x

    PubMed  Google Scholar 

  5. Grainger J, Saravanappa N. Local anaesthetic for post-tonsillectomy pain: a systematic review and meta-analysis. Clin Otolaryngol. 2008;33:411–9.

    Article  CAS  PubMed  Google Scholar 

  6. Haksever M, Ozmen S, Akduman D, Solmaz F. Topical bupivacaine compared to bupivacaine infiltration for post-tonsillectomy pain relief in children: a prospective randomized controlled clinical study. Eur Arch Otorhinolaryngol. 2014;271:2555–9.

    Article  PubMed  Google Scholar 

  7. Bean-Lijewski JD. Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial. Anesth Analg. 1997;84:1232–8.

    Article  CAS  PubMed  Google Scholar 

  8. Alsarraf R, Sie KC. Brain stem stroke associated with bupivacaine injection for adenotonsillectomy. Otolaryngol Head Neck Surg. 2000;122:572–3.

    Article  CAS  PubMed  Google Scholar 

  9. Oghan F, Harputluoglu U, Guclu E, Kocaman B, Ozturk O. Does topical ropivacaine reduce the post-tonsillectomy morbidity in pediatric patients? Int J Pediatr Otorhinolaryngol. 2008;72:361–5.

    Article  PubMed  Google Scholar 

  10. Petrenko AB, Yamakura T, Baba H, Shimoji K. The role of N-methyl-d-aspartate (NMDA) receptors in pain: a review. Anesth Analg. 2003;97:1108–16.

    Article  CAS  PubMed  Google Scholar 

  11. Tong Y, Ding XB, Wang X, Ren H, Chen ZX, Li Q. Ketamine peritonsillar infiltration during tonsillectomy in pediatric patients: an updated meta-analysis. Int J Pediatr Otorhinolaryngol. 2014;78:1735–41.

    Article  PubMed  Google Scholar 

  12. Tekelioglu UY, Apuhan T, Akkaya A, Demirhan A, Yildiz I, Simsek T, Gok U, Kocoglu H. Comparison of topical tramadol and ketamine in pain treatment after tonsillectomy. Paediatr Anaesth. 2013;23:496–501.

    Article  PubMed  Google Scholar 

  13. Canbay O, Celebi N, Uzun S, Sahin A, Celiker V, Aypar U. Topical ketamine and morphine for post-tonsillectomy pain. Eur J Anaesthesiol. 2008;25:287–92.

    Article  CAS  PubMed  Google Scholar 

  14. Vlajkovic GP, Sindjelic RP. Emergence delirium in children: many questions, few answers. Anesth Analg. 2007;104:84–91.

    Article  PubMed  Google Scholar 

  15. Lauder G, Emmott A. Confronting the challenges of effective pain management in children following tonsillectomy. Int J Pediatr Otorhinolaryngol. 2014;78:1813–27.

    Article  PubMed  Google Scholar 

  16. Husband AD, Davis A. Pain after tonsillectomy. Clin Otolaryngol Allied Sci. 1996;21:99–101.

    Article  CAS  PubMed  Google Scholar 

  17. Patel RI, Verghese ST, Hannallah RS, Aregawi A, Patel KM. Fast-tracking children after ambulatory surgery. Anesth Analg. 2001;92:918–22.

    Article  CAS  PubMed  Google Scholar 

  18. 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;28:155–60.

    CAS  PubMed  Google Scholar 

  19. Marret E, Flahault A, Samama CM, Bonnet F. Effects of postoperative, nonsteroidal, antiinflammatory drugs on bleeding risk after tonsillectomy: meta-analysis of randomized, controlled trials. Anesthesiology. 2003;98:1497–502.

    Article  PubMed  Google Scholar 

  20. Souza LR, Oliveira MVM, Basile JR, Souza LN, Souza ACR, Haikal DS, De-Paula AMB. Anatomical and physiopathological aspects of oral cavity and oropharynx components related to oropharyngeal dysphagia. In: Speyer R, Bogaardt H, editors. Seminars in dysphagia. InTech; 2015. pp 10–11.

  21. Unal Y, Pampal K, Korkmaz S, Arslan M, Zengin A, Kurtipek O. Comparison of bupivacaine and ropivacaine on postoperative pain after tonsillectomy in paediatric patients. Int J Pediatr Otorhinolaryngol. 2007;71:83–7.

    Article  PubMed  Google Scholar 

  22. Akoglu E, Akkurt BC, Inanoglu K, Okuyucu S, Dagli S. Ropivacaine compared to bupivacaine for post-tonsillectomy pain relief in children: a randomized controlled study. Int J Pediatr Otorhinolaryngol. 2006;70:1169–73.

    Article  PubMed  Google Scholar 

  23. Beyer JE, McGrath PJ, Berde CB. Discordance between self-report and behavioral pain measures in children aged 3–7 years after surgery. J Pain Symptom Manag. 1990;5:350–6.

    Article  CAS  Google Scholar 

  24. Carlton SM. Peripheral NMDA receptors revisited − hope floats. Pain. 2009;146:1–2.

    Article  PubMed  Google Scholar 

  25. Coggeshall RE, Carlton SM. Ultrastructural analysis of NMDA, AMPA, and kainate receptors on unmyelinated and myelinated axons in the periphery. J Comp Neurol. 1998;391:78–86.

    Article  CAS  PubMed  Google Scholar 

  26. Davidson EM, Coggeshall RE, Carlton SM. Peripheral NMDA and non-NMDA glutamate receptors contribute to nociceptive behaviors in the rat formalin test. NeuroReport. 1997;8:941–6.

    Article  CAS  PubMed  Google Scholar 

  27. Kopsky DJ, Keppel Hesselink JM, Bhaskar A, Hariton G, Romanenko V, Casale R. Analgesic effects of topical ketamine. Minerva Anestesiol. 2015;81:440–9.

    CAS  PubMed  Google Scholar 

  28. Sawynok J. Topical and peripheral ketamine as an analgesic. Anesth Analg. 2014;119:170–8.

    Article  CAS  PubMed  Google Scholar 

  29. Poyhia R, Vainio A. Topically administered ketamine reduces capsaicin-evoked mechanical hyperalgesia. Clin J Pain. 2006;22:32–6.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea

    Boohwi Hong, Chae Seong Lim, Yoon-Hee Kim, Jung Un Lee, Choonho Jung & Yumin Jo

  2. Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Hospital, Daejeon, Korea

    Yong Min Kim

Authors
  1. Boohwi Hong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chae Seong Lim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yoon-Hee Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jung Un Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yong Min Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Choonho Jung
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yumin Jo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chae Seong Lim.

Ethics declarations

Conflict of interest

All authors have no conflict of interest.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hong, B., Lim, C.S., Kim, YH. et al. Comparison of topical ropivacaine with and without ketamine on post-surgical pain in children undergoing tonsillectomy: a randomized controlled double-blind study. J Anesth 31, 559–564 (2017). https://doi.org/10.1007/s00540-017-2353-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00540-017-2353-z

Keywords

Search

Navigation