Abstract :
Objectives: This study aimed to evaluate the postoperative (PO) analgesic efficacy of pre-incisional peritonsillar (PT) infiltration using tramadol or ketamine used alone or in combination with bupivacaine. Patients Methods: The study included 180 patients randomly divided into 6 study equal groups: Group I received saline infiltration as placebo, Group II received bupivacaine (5 mg!ml) infiltration, Groups III IV received tramadol (2 mg/kg) and ketamine (0.5mg/kg) infiltration, respectively, and Groups V VI received infiltration of a combination of bupivacaine (5mg!ml) and tramadol (2mg/kg) or ketamine (0.5mg/kg), respectively. All medications prepared as 2 ml and were injected as 1 ml per tonsil 3 min prior to incision. At post-anesthetic care unit (PACU), the efficacy of PO analgesia was judged using duration of PO analgesia, duration till be ready to discharge from PACU and duration till return home. PO pain sensation was evaluated using the objective pain scale (OPS) score which evaluates 5 parameters that were assessed at time of admission to PACU and every 15 min for one hour and every 30 minutes till patients were ready for discharge from PACU. Rescue analgesia with morphine 0.05mg!kg i.v. was administered, after operation; for OPS score ?5. At time of home-return, parents were asked to rate their satisfaction with PO analgesia. Results: Collective OPS scores determined since admission to PACU till hospital discharge were significantly higher in Group I compared to the other groups and in Group II compared to groups III-VI. However, patients received ketamine infiltration showed significantly higher OPS scores compared both to those received tramadol alone or tamadol!bupivacaine combination. All patients enrolled in Group I requested rescue analgesia and 14 patients requested it twice. Nine patients in Group II did not request for rescue analgesia till home-discharge, 18 patients requested it once and 3 patients requested it twice. In Groups III-VI, 68 patients did not request rescue analgesia till home discharge and 52 patients requested it once. Patients received PT had significantly longer duration of PO analgesia compared to Group I and patients enrolled in Group VI had significantly longer duration of PO analgesia compared to all other groups. Hospital stay durations were significantly shorter in Groups V VI compared to other groups and Groups III-VI showed significantly shorter post-PACU and total hospital stay compared to Group II. PT induced significantly higher parents satisfaction compared to placebo; however, tramadol PT alone or in combination with bupivacaine was highly satisfactory. Conclusion: PT infiltration is a safe and effective modality for post-tonsillectomy pain, irrespective of drug used and the infiltration of combined bupivacaine and tramadol or ketamine is the appropriate for achieving superior PO analgesia with a more favorable effect with bupivacaine! tramadol combination.
