Use of IV acetaminophen with narcotics reduces pain in children with tonsillectomies

American Society of Anesthesiologists (ASA)Oct 13 2013

Using intravenous (IV) acetaminophen with narcotics provides more effective pain relief to children having tonsillectomies, according to a study presented at the ANESTHESIOLOGY™ 2013 annual meeting. Additionally, the combination therapy saves costs due to reduced use of narcotics after surgery, reduced side effects and slightly quicker hospital discharge than in patients who receive narcotics alone.

The quintessential children's surgery performed on more than 500,000 patients a year was traditionally done for multiple tonsil infections. Today, more than 80 percent of tonsillectomies are done to correct breathing disorders that affect sleep, according to the American Society of Otolaryngology. Sleep apnea is the most common disorder.

In February 2013, the U.S. Food and Drug Administration (FDA) issued a black box warning against the use of codeine (a narcotic) in children undergoing tonsillectomies or adenoidectomies. Certain children have an inherited ability that causes their liver to convert codeine into life-threatening or fatal amounts of morphine or "ultra-rapid metabolizers." Because of the difficulty in determining which children might be ultra-rapid metabolizers of codeine, FDA issued the black box warning for all children.

A study has shown that children with sleep apnea are highly sensitive to narcotic medications because there is a direct correlation between hypoxemia (low oxygen levels in the blood) and increased morphine sensitivity for these children. "Since the majority of tonsillectomies are done for sleep apnea, physician anesthesiologists must use extreme caution when administering narcotics," said Rajeev Subramanyam, M.D., staff anesthesiologist, Cincinnati Children's Hospital Medical Center. "This study found that combining IV acetaminophen with narcotics relieved pain better, allowing patients to leave the hospital quicker and reduce costs."

The study looked at two groups of tonsillectomy patients: the first group of 73 patients received intraoperative IV acetaminophen with narcotics; the second group of 66 patients received only intraoperative IV narcotics.

The study found that routine use of IV acetaminophen with narcotics resulted in a 3.3 percent reduction in the number of patients who required additional "rescue" doses of narcotics after surgery. When patients received IV acetaminophen and narcotics, rather than narcotics alone, the acetaminophen/narcotic combination cost $17.12 less per patient. These savings were accomplished though reduced side effects and less time in the recovery room with a potential savings of $9 million per year based on the total number of tonsillectomies done in the United States.