Page 324 Acute Pain Management

children (Honarmand et al, 2008 Level II; Erhan et al, 2007 Level II) although the effects of ketamine
infiltration were not significantly different to an equivalent IV dose (Dal et al, 2007 Level II).
A systematic review of analgesia for tonsillectomy in children was unable to generate clear
conclusions due to heterogeneity of the trials; however no single prophylactic dose of an
analgesic provided adequate pain relief for the entire first postoperative day; orally
administered paracetamol was more effective than rectal, and prophylactic NSAIDs were at
least as effective as opioids in reducing post‐tonsillectomy pain (Hamunen & Kontinen, 2005
Level I).
In meta‐analyses of tonsillectomy in both adult and paediatric patients, nsNSAIDs were found
to increase the risk of reoperation for bleeding (NNH 29 to 60) (Marret et al, 2003 Level I;
Moiniche et al, 2003 Level I) but surgical blood loss was not significantly increased (Moiniche et al,
2003 Level I) (see also Section 4.2.2). Looking at studies in children only, there was no increase
in the risk of reoperation for bleeding after tonsillectomy (Cardwell et al, 2005 Level I). Aspirin,
which irreversibly inhibits platelet aggregation, increased the risk of post‐tonsillectomy
haemorrhage (Krishna et al, 2003 Level I).
Diclofenac (Romsing et al, 2000 Level II; Schmidt et al, 2001 Level II) or ketorolac (Rusy et al, 1995
Level II) were no more effective than paracetamol in providing analgesia in children post‐
tonsillectomy. Rofecoxib provided effective analgesia for up to 24 hours after surgery, and led
to decreased nausea but no increased blood loss (Joshi et al, 2003 Level II). IV paracetamol
administered 6‐hourly for the first postoperative day reduced pain and rescue analgesia
requirements in adults following tonsillectomy (Atef & Fawaz, 2008b Level II).
Gabapentin may reduce analgesia requirements for up to 48 hours and pain on swallowing
for up to 4 hours, following tonsillectomy in adults (Jeon et al, 2008 Level II; Mikkelsen et al, 2006
Level II).
In children, dexamethasone produced a significant but clinically moderate reduction in post‐
tonsillectomy pain on the first postoperative day (Afman et al, 2006 Level I). There was a
reduced risk of postoperative nausea and vomiting and reduced use of ibuprofen but also an
increased risk of bleeding (Czarnetzki et al, 2008 Level II).
Acute pain associated with oral ulceration, including mucositis
CHAPTER 9 simplex), drugs, radiation or chemotherapy (mucositis) may be extremely painful and
Acute oral ulceration due to trauma (physical, chemical, thermal), infection (eg herpes

debilitating. Mucosal analgesia may be achieved by topical application of EMLA® cream
(eutectic mixture of lignocaine and prilocaine) and 5% lignocaine (Vickers & Punnia‐Moorthy,
1992 Level II).
Mucositis may also be due to side effects of chemoradiotherapy for solid and blood
malignancies and may be complicated by opportunistic infections including HSV and
candidiasis. Quality of life and nutrition can be greatly impaired.
In treating the pain of cancer‐related acute mucositis, there was no significant difference in
analgesia between PCA and continuous opioid infusion, except that PCA was associated with
reduced opioid requirements and pain duration (Clarkson et al, 2007 Level I).
There was weak evidence that allopurinol mouthwash, granulocyte macrophage‐colony
stimulating factor (GM‐CSF), immunoglobulin or human placental extract improved or
eradicated mucositis; benzydamine HCl, sucralfate, tetrachlorodecaoxide, chlorhexidine,
lignocaine solution, diphenhydramine hydrochloride and aluminum hydroxide suspensions
were ineffective (Clarkson et al, 2007 Level I).
Polymyxin E, tobramycin and amphotericin B (PTA), GM‐CSF, oral cooling and amifostine,
significantly reduced the incidence and severity of oral mucositis (Stokman et al, 2006 Level I).
276 Acute Pain Management: Scientific Evidence