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Effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in school-age children following tonsillectomy
Kimberly A. Sutters, RN, PhD1, Christine Miaskowski, RN, PhD, FAAN2, Steven Paul, PhD3, Marilyn C. Savedra, RN, DNS, FAAN4, Steven Waite, PharmD1, Danielle Holdridge-Zeuner, RN2, Karla Mahoney, RN2, and Brent Lanier, MD5. (1) Children's Hospital Central California, 9300 Valley Children's Place (FC08), Madera, CA 93638-8762, (2) Department of Physiological Nursing, University of California, San Francisco, 2 Koret Way, N631, Box 0610, San Francisco, CA 94143-0610, (3) School of Nursing, University of California, San Francisco, 2 Koret Way, N337A, Box 0604, San Francisco, CA 94143-0604, (4) Department of Family Health, University of California, San Francisco, 2 Koret Way, San Francisco, CA 94143-0610, (5) Central California Ear, Nose, Throat Medical Group, 1351 East Spruce, Fresno, CA 93720
The purpose of this RCT, with children undergoing tonsillectomy, was to determine the effectiveness of scheduled analgesic administration, with or without nurse coaching, over time, compared to standard care with PRN dosing. Children (ages 6 to 15 years; N=113), were randomized to one of three treatment groups to receive acetaminophen with hydrocodone (167mg/2.5mg/5ml) for 3 days after surgery; Group A (N=39) – every 4 hours PRN, with standard postoperative instructions; Group B (N=34) – every 4 hours ATC, with standard postoperative instructions, without nurse coaching; and, Group C (N=40) – every 4 hours ATC, with standard postoperative instructions with coaching. Pain intensity was recorded at discharge, then twice a day, for the first 3 days at home, using a 0-10 scale. Parents completed a medication log. No differences were found in analgesic administration or pain intensity scores between the 2 ATC groups; therefore, they were combined for comparison to the PRN group. Pain intensity scores decreased over time for children in both the PRN and ATC groups at rest (p<0.0001) and with swallowing (p<0.0001). Children in the PRN group had higher pain intensity scores compared to children in the ATC group, both at rest (F(1,107)=5.849, p=0.017) and with swallowing (F(1,107)=4.36, p=0.017). Pain intensity scores for both groups were higher in the morning compared to the evening (F(1,110)=35.984, p<0.0001). Children in the ATC group received significantly greater amounts of analgesic than children in the PRN group (F(2,101)=28.384, p<0.0001). Study results suggest that scheduled dosing of acetaminophen with hydrocodone is more effective than PRN dosing at reducing pain intensity in children following tonsillectomy. Pain intensity is higher in the morning compared to the evening. Prescribed ATC dosing results in greater analgesic consumption compared to PRN dosing, and nurse coaching does not impact parent's adherence to the ATC dosing schedule. Supported by a grant from NINR-NR04826.