Improving Pain Management after Tonsillectomy

T onsillectomy is among the most common of pediatric operations.In this issue of Anesthesiology, Einhorn et al. 1 report on a prospective controlled trial of single-dose intravenous methadone administered intraoperatively to children and adolescents ages 3 to 17 yr undergoing elective tonsillectomy with or without adenoidectomy.They evaluate the impact of the intraoperative methadone on postoperative rescue opioid administration (primary outcome), as well as several secondary outcomes (some preplanned and some in response to reviewers' requests) including side effects, recovery parameters, and pain scores.Given the current trend toward reduced perioperative opioid prescribing, 2 a reader might ask whether adding a long-acting opioid represents "a step backward."Consensus guidelines, 3 clinical trials, and scoping reviews support managing pain after tonsillectomy by scheduled administration of a combination of acetaminophen and nonsteroidal anti-inflammatory drugs, commonly ibuprofen.This approach can generate mild to moderate postoperative pain scores for the majority of pediatric-age patients.Nevertheless, even with combined use of acetaminophen and ibuprofen, a substantial percentage of patients, particular older children and adolescents, experience episodes of moderate to severe pain both in the early postoperative period 4 and for up to 2 weeks postoperatively. 5A subset of patients experience inadequate pain relief even with combination regimens that include codeine, tramadol, or advisory board of Akelos, Inc. (New York, New York), a biotechnology company developing novel analgesics.Dr.