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ManuscriptAnesth Analg. Author manuscript; available in PMC 2013 ctober 01.Publishe! in "inal e!ite!
"orm as# Anesth Analg. 2012 ctober ; 11$%&'# (13)(20. !oi#10.1213*AN+.0b013e31,2-$2a-a.A Comparison
Between Dexamethasone and Methylprednisolone for Vomiting
Prophylaxis After Tonsillectomy in Inpatients Children: A Randomied
TrialMarie T Ao!ad" MD, Department of Anesthesiology, American University of Beirut Medical enter, Beirut,
!e"anonVi#iane $ %asr" MD, Department of Anesthesiology, American University of Beirut Medical enter,
Beirut, !e"anon #urrent Affiliation$ Department of Anesthesiology, %ufts Medical enter, Boston,
Massachusetts&Corresponding Author: .ahar .i!!i/0 .a11i!2 M32 American 4niversit1 o" 5eirut Me!ical Center2 3epartment o" Anesthesiolog1
American 4niversit1 o" 5eirut Me!ical Center 5eirut 6ebanon2 Phone# (-1 1 3$0000 +7t. -3,02 8A9# (-1 1 :&$2&(2 ss01;aub.e!u.lb.Publisher's
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Mohamma! A 5itar has seen the original stu!1 !ata2 revie=e! the anal1sis o" the !ata2 an! approve! the "inal manuscript !ame: Micheline 5ou Chalil2
M3 Contribution: <his author helpe!2 con!uct the stu!12 an! =rite the manuscript Attestation: Micheline 5ou Chalil has seen the original stu!1 !ata2
revie=e! the anal1sis o" the !ata2 an! approve! the "inal manuscript !ame: rnella 5e1routh12 M3 Contribution: <his author helpe! con!uct the stu!1
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seen the original stu!1 !ata2 revie=e! the anal1sis o" the !ata2 an! approve! the "inal manuscript !ame: Norma <errin2 Ph3 Contribution: <his author
helpe! anal1?e the !ata an! =rite the manuscript Attestation: Norma <errin has seen the original stu!1 !ata2 revie=e! the anal1sis o" the !ata2 an!
approve! the "inal manuscript !ame: .ahar .i!!i/0 .a11i!2 M3 Contribution: <his author helpe! !esign the stu!12 con!uct the stu!12 anal1?e the !ata2
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manuscript "his manuscript #as handled b$: Peter D. 3avis2 M3
ManuscriptAoua! et al. Page 2Vanda $ &a'ec()*aram" MD, Department of Anesthesiology,
American University of Beirut Medical enter, Beirut, !e"anon #urrent Affiliation$ Department of Anesthesiology, !e"anese American University, Beirut, !e"anon&Mohammad A Bitar" MD, Department of Anesthesiology, American University of Beirut Medical enter, Beirut, !e"anonMicheline Bo! *halil" MD, Department of Anesthesiology, 'afic Hariri University Hospital, Beirut, !e"anon+rnella Beyro!thy" MD, Department of Anesthesiology, American University of Beirut Medical enter, Beirut, !e"anonDiala ,arfo!che" MD, Department of Anesthesiology, American University of Beirut Medical enter, Beirut, !e"anon%orma Terrin" PhD, and Institute for linical 'esearch and Health Policy (tudies, %ufts Medical enter, Boston, Massachusetts-ahar -iddi() -ayyid" MD Department of Anesthesiology, American University of
Beirut Medical enter, Beirut, !e"anonA'stractBac(gro!nd.<he "reEuent inci!ence o"
postoperative vomiting in chil!ren un!ergoing tonsillectom12 in a!!ition to the occurrence o" severe pain2 ma1 !ela1 postoperative oral inta/ean! lea! to increase! ris/ o" !eh1!ration. <hus2 proph1lactic therap1 is in!icate! in this high0ris/ group. Alucocorticoi!s2 such as !e7amethasone an! meth1lpre!nisolone2 have antiin"lammator1 an! antiemetic properties =ith !e7amethasone being "reEuentl1 use!. Fe h1pothesi?e! that meth1lpre!nisolone shoul! be nonin"erior to !e7amethasone "or the prevention o" vomiting in chil!ren a"ter tonsillectom1.Methods.Fe !esigne! a ran!omi?e! !ouble0blin!e! trial to compare the e""icac1 o" a single proph1lactic !ose o" 0.$mg*/g !e7amethasone =ith a !ose o" 2.$ mg*/g meth1lpre!nisolone onthe inci!ence o" postoperative vomiting !uring the "irst 2& hours %primar1 outcome' in chil!ren un!ergoing total or partial tonsillectom1 =ith a nonin"eriorit1 margin set at (G. ne hun!re! si7t1 chil!ren un!ergoing total or partial tonsillectom1 un!er general anesthesia =ere ran!oml1 assigne! to receive either I@ !e7amethasone 0.$ mg*/g %nH:(' or meth1lpre!nisolone 2.$ mg*/g %nH,1' a"ter in!uction o" anesthesia. .econ!ar1 anal1sis o" all stu!ie! outcomes =as also per"orme! accor!ing to the t1pe o" surger1.Res!lts. An intention0to0treat anal1sis sho=e! an overall inci!ence o" vomiting o" 30G in the !e7amethasone group an! o" 22G in the meth1lpre!nisolone group %!i""erence# ,G2 ($G CI# 0$ to21G'. A per protocol anal1sis sho=e! an inci!ence o" vomiting o" 32G an! 23G respectivel1 %!i""erence# (G2 an! ($G CI o" the !i""erence# 0$ to 23G2 PH0.2,'. <he time an! Eualit1 o" oral inta/e2 the !uration o" I@ h1!ration2 as =ell as pain an! satis"action scores an! the nee! "or analgesics =ere similar bet=een the 2 groups. <he inci!ence o" vomiting =as also similar in patients =ho ha! total versus partial tonsillectom1; ho=ever2 time to "irst oral inta/e2 !uration o" I@ h1!ration2 an! the nee! "or analgesics =ere less =ith better satis"action scores in partial versus total tonsillectom1 patients.supConcl!sion.Meth1lpre!nisolone is at =orst $G less e""ective than !e7amethasone b1 the intention0to0treat anal1sis2 an! b1 the per protocol anal1sis. <hus2 it is nonin"erior to!e7amethasone in preventing vomiting a"ter tonsillectom1 in chil!ren.Anesth Analg. Author
manuscript; available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page 3Introd!ction<onsillectom1 =ith or =ithout a!enoi!ectom1 is one o" the
most "reEuentl1 per"orme! surgical operations in chil!ren an! is associate! =ith a "reEuent inci!ence o" postoperative vomiting %P@' that ma1 e7cee! :0G.1 <he "reEuent inci!ence o" P@ in a!!ition to the occurrence o" severe pain ma1 !ela1 postoperative oral inta/e an! lea! to ina!eEuate oral "ee!ing2 =hich ma1 increase the ris/ o" !eh1!ration. <hus2 proph1lactic therap1 is in!icate! in this high0ris/ group.1Alucocorticoi!s2 such as !e7amethasone an! meth1lpre!nisolone2 !ecrease local in"lammation b1 bloc/ing the chemical me!iators o" in"lammation an! subseEuentl1 have analgesic properties.2 <he1 also possess antiemetic properties =hich occur b1 a mechanism as 1et un/no=n. <he1 ma1 e7ert their antiemetic action via prostaglan!in antagonism2 release o" en!orphins2 an! re!uction o" serotonin level in the gut an! neural tissue.3 Also2 the1 enhance the e""ect o" other antiemetics b1 sensiti?ing their pharmacological receptors.<here"ore2 their antiemetic e""ects in a!!ition to their analgesic e""ects ma/e them particularl1 use"ul a"ter tonsillectom1.3Numerous stu!ies using !i""erent !oses o" !e7amethasone have sho=n that I@ !e7amethasone !ecreases the inci!ence o" P@ an! improves oral inta/e a"ter tonsillectom1 in chil!ren.12&)12 Iecentl12 the clinical practice gui!eline issue! "or tonsillectom1 in chil!ren ma!e a strong recommen!ation that clinicians a!minister a single intraoperative !ose o" I@ !e7amethasone to chil!ren un!ergoing tonsillectom12 the 0.$ mg*/g !ose being the most "reEuentl1 use!. Also2 the panel state! that !e7amethasone a!ministration =oul! not onl1 lea! to !ecrease! inci!ence o" postoperative nausea an! vomiting %PN@'2 an important morbi!it1 associate! =ith pe!iatric tonsillectom12 but =oul! also !ecrease throat pain an! time to resumption o" oral inta/e.13Meth1lpre!nisolone2 another glucocorticoi!2 has also been sho=n to be a potent antiemetic in the setup o" chemotherap10in!uce! emesis1& or intractable h1peremesis gravi!arum1$ an! has recentl1 emerge! as a use"ul !rug "or analgesia a"ter orthope!ic surger121- breast surger121:1, an! total /nee arthroplast1 =ith eEual analgesic e""icac1 as nonsteroi!al antiin"lammator1 !rugs1-21: but =ith a more sustaine! e""ect.1- .ome o" these stu!ies1:21,reporte! as a secon!ar1 outcome a signi"icant !ecrease in the inci!ence an! severit1 o" PN@ in patients receiving meth1lpre!nisolone versus placebo or nonsteroi!al antiin"lammator1 !rugs. nl1 one stu!1 per"orme! a hea!0to0hea! comparison bet=een !e7amethasone an! meth1lpre!nisolone as proph1lactic treatment "or PN@ in a!ult "emale patients un!ergoing ab!ominal or laparoscopic surger1.3 In this stu!12 meth1lpre!nisolone &0 mg I@ =as "oun! to be signi"icantl1 better than placebo =ith an inci!ence o" PN@ o" 1$G versus 3$G respectivel1 an! a number0nee!e!0to0treat o" $2 =hile no signi"icant !i""erence =as "oun! bet=een !e7amethasone , mg I@ an! placebo =ith an inci!ence o" 2(G versus 3$G respectivel1 an! a number0nee!e!0to0treat o" 1:. Fith onl1 &0 patients per group2 this stu!1 =as not su""icientl1 po=ere! to !etect an1 statisticall1 signi"icant !i""erence bet=een !e7amethasone an! meth1lpre!nisolone..ince !e7amethasone is the onl1 representative o" its class "or PN@ proph1la7is in chil!ren2 an alternative ma1 be nee!e!21(20 especiall1 in this era o" multiple !rug shortages.Fe h1pothesi?e! that meth1lpre!nisolone shoul! be nonin"erior to !e7amethasone "or the prevention o" P@ in chil!ren a"ter tonsillectom1. <hus2 =e !esigne! a ran!omi?e! !oubleblin!e! trial to compare the e""icac1 o" a single proph1lactic !ose o" 0.$mg*/g I@ !e7amethasone =ith an eEuipotent !ose o" 2.$ mg*/g I@ meth1lpre!nisolone1&221 on P@ !uring the "irst 2& hours %as primar1 outcome' in chil!ren un!ergoing total or partial tonsillectom1 =ith or =ithout a!enoi!ectom1 an! m1ringotom1. Postoperative pain2 Eualit1Anesth Analg. Author manuscript; available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page &Methodso" oral inta/e2 parentsJ satis"action2 an! !i""erences in pain or
vomiting relate! to the t1pe o" surger1 =ere consi!ere! secon!ar1 outcomes.A"ter II5 approval an! =ritten parental*guar!ian consent2 =e con!ucte! a ran!omi?e! prospective stu!1 in A.A I an! II chil!ren age! bet=een 2 an! 12 1ears presenting "or total or partial tonsillectom1 =ith or =ithout a!enoi!ectom1 an! m1ringotom1 un!er general anesthesia. Patients =ho receive! antiemetics2 steroi!s2 antihistaminics2 or ps1choactive !rugs =ithin 2& hours be"ore surger1 or those =ith !iabetes or in =hom I@ in!uction =as in!icate! =ere e7clu!e!.Preme!ication consisting o" oral mi!a?olam 0.$ mg /g01 %ma7imal !ose 1$ mg' =as a!ministere! 30 minutes be"ore anticipate! in!uction. A"ter establishing stan!ar! patient monitoring2 inhale! in!uction =as initiate! =ith sevo"lurane2 "ollo=e! b1 the insertion o" an I@ cannula. Anesthesia =as maintaine! =ith :0 G N an! 2)&G sevo"lurane. All chil!ren receive! 1)2 Kg./g01 "entan1l an! 10 to 1$ ml./g012 o" normal saline solution !uring the intraoperative perio!. Patients =ere ran!oml1 allocate! b1 using a computer0generate! ran!om table. Aroup allocation =as conceale! in seale! opaEue envelopes; these envelopes =ere numbere! an! opene! seEuentiall1 a"ter patient consent ha! been obtaine!. <hen patients =ere assigne! to receive either !e7amethasone 0.$mg*/g I@ or meth1lpre!nisolone 2.$mg*/g I@. <his =as a !ouble0blin!e! stu!12 =ith neither patients*parents nor treating ph1sicians or nurses recor!ing !ata a=are o" the treatment assignment. 3e7amethasone =as visuall1 in!istinguishable "rom meth1lpre!nisolone treatment to preserve blin!ing. <he stu!1 !rug =as prepare! b1 a resi!ent =ho =as not involve! in !ata collection an! =as a!ministere! a"ter in!uction o" anesthesia an! be"ore surger1 start time. <he atten!ing surgeon2 using an electro!issection techniEue2 per"orme! total tonsillectom1 in patients presenting "or recurrent tonsillitis. Patients =ith pre!ominant tonsillar h1pertroph1 an! obstructive s1mptoms un!er=ent micro!ebri!er0assiste! partial tonsillectom1. <he !egree o" tonsillar enlargement =as gra!e! accor!ing to the "ollo=ing scale# 1H <onsils =ithin tonsillar "ol!s2 2H <onsils >ust outsi!e tonsillar "ol!s2 3H <onsils =ell outsi!e tonsillar "ol!s but not reaching uvula2 &H <onsils reaching uvula or past uvula.( At the en! o" surger12 all chil!ren ha! their gastric contents suctione! via an orogastric tube an! receive! paracetamol %acetaminophen' 1$mg*/g I@ %Per"alganI 5ristol0M1ers .Euibb2 Mi!!lese72 4C' "or postoperative pain relie". <he1 =ere tracheall1 e7tubate! a=a/e in the operating room an! trans"erre! to the postanesthesia care unit %PAC4' =here stan!ar! monitoring =as establishe!2 an! the1 =ere observe! until stan!ar! !ischarge criteria =ere met.ur primar1 outcome =as the inci!ence o" vomiting !uring the "irst 2& hours a"ter surger1. All other outcomes =ere consi!ere! secon!ar1 outcomes.<he PAC4 nurse recor!e! the total number o" vomiting episo!es %=hich represents severit1 o" vomiting' an! antiemetics receive!2 the pain scores at arrival2 at 30 min2 an! at !ischarge "rom PAC42 using a Fong05a/er "aces rating scale. Morphine 0.1 mg*/g I@ =as a!ministere! "or pain scores L-. A"ter trans"er to the "loor2 a so"t !iet =as o""ere! to all chil!ren !uring their hospital sta1. Also2 a maintenance I@ in"usion =as /ept until their oral inta/e =as >u!ge! a!eEuate b1 the primar1 team. <he time o" removal o" the I@ line =as recor!e!. Paracetamol 1$ mg*/g continue! to be a!ministere! ever1 - hours upon reEuest. <he route o" a!ministration =as I@ in the presence o" I@ in"usion or oral %paracetamol s1rup' a"ter I@ line removal. At 2& hours %stu!1 perio!'2 the parent or the chil! %=hen possible'2 reporte! to one o" the investigators the "ollo=ing in"ormation that he =as instructe! to observe# the total number o" vomiting episo!es an! antiemetics receive!2 the time to "irst oral inta/e2 the Eualit1 o" oral inta/e assesse! b1 parents using the "ollo=ingAnesth Analg. Author manuscript; available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page $Res!ltsscale# 1H chil! reEuests "oo!2 2H chil! accepts it =hen o""ere!2 3H
chil! accepts it =hen coa7e!2 &H chil! re"uses it2 the pain scores recor!e! on the "aces scale at 12 an! 2& hours a"ter surger12 the total number o" analgesics receive!2 as =ell as parentsJ satis"action score rate! as e7cellent2 goo!2 "air or poor. +piso!es o" vomiting occurring less than $ minutes apart =ere consi!ere! one episo!e. Nausea =as not recor!e! secon!ar1 to ina!eEuate assessment in chil!ren. Ietching =as not consi!ere! vomiting. Iecurrent vomiting %L2 episo!es' =as treate! =ith on!ansetron 0.1$ mg*/g I@. Persistent vomiting !espite treatment =ith on!ansetron =as treate! =ith metocloprami!e 0.1$ mg./g01. PAC4 vomiting =as !e"ine! as vomiting in the PAC42 an! late vomiting =as !e"ine! as vomiting a"ter !ischarge "rom PAC4. <he summe! pain score =as calculate! as the sum o" pain scores at all $ time intervals.1, All chil!ren remaine! at the hospital "or 2& hours postoperativel1 %stu!1 perio!'. <he occurrence o" posttonsillectom1 blee!ing =as au!ite! b1 the atten!ing surgeon an! =as collecte! one month a"ter surger1.<he po=er anal1sis =as base! on a nonin"eriorit1 principle. Patients =ere inclu!e! in the per protocol anal1sis i" the primar1 outcome measure =as available. 5oth per protocol an! an intention0 to0treat anal1sis =ere per"orme! "or the primar1 outcome. In the intention0totreat anal1sis2 a conservative approach =as use! =here =e assume! that patients =ith missing primar1 outcome !i! not have vomiting. ur primar1 outcome =as the proportion o" patients =ho vomite! at an1 time in the 2& hours a"ter tonsillectom1. 5ase! on a previous placebo0controlle! trial o" !e7amethasone %-2G inci!ence o" vomiting in placebo group vs 2&G in the !e7amethasone'2( =e set a nonin"eriorit1 margin o" (G =hich correspon!s to 2$G o" the !i""erence in the proportions o" patient =ho vomite! a"ter tonsillectom1 bet=een !e7amethasone an! placebo. A!!itional support "or the margin o" (G can be "oun! in +ngelman et al2 =ho reporte! that the most pessimistic estimate o" the e""ect o" proph1lactic !e7amethasone in chil!ren is 32.&G =hen the baseline ris/ is $$G2 an! is 1:.:G =hen baseline ris/ is 30G. I" the rate =ith meth1lpre!nisolone =ere (G higher than =ith !e7amethasone2 it =oul! still be =ell belo= the baseline rate. <hus2 meth1lpre!nisolone =oul! have clinical value i" "or some reason treatment =ith !e7amethasone =as not possible or a!visable.22 Fith :- patients per group %total sample si?e o" 1$2'2 an! assuming 2&G as the true inci!ence o" vomiting =ith !e7amethasone2 an! 1$G inci!ence =ith meth1lpre!nisolone2 =e ha! ,0G po=er to establish nonin"eriorit1 o" meth1lpre!nisolone at the 0.02$ level %one0si!e!'. <here"ore2 the target number o" patients to be recruite! =as at least ,0 in each group.Normall1 !istribute! !ata =ere reporte! as meanM.3 an! con"i!ence intervals o" the !i""erences an! anal1?e! using stu!entJs t0test =ith eEual variances. Categorical !ata =ere reporte! as numbers an! percentages an! =ere anal1?e! using 8isherJs e7act test. Con"i!ence intervals "or !i""erence o" percentages =ere calculate! using FilsonNs proce!ure =ithout continuit1 correction http#**vassarstats.net*prop2Oin!.html.23 ./e=e! !ata =ere reporte! as me!ian an! range2 an! anal1?e! using Mann Fhitne1 40test. P P0.0$ =as consi!ere! signi"icant. <he !ata =ere teste! "or normalit1 using the Colmogorov0 .mirnov normalit1 test =ith 6illie"ors correction an! =ere consi!ere! normall1 !istribute! i" PL0.0$. All anal1ses =ere per"orme! using .P.. %version 1(2 Chicago2 Illinois'.ne hun!re! sevent1 chil!ren =ere screene! "or the stu!1 "rom .eptember 200: to Dune 2011. <en =ere e7clu!e! %not meeting inclusion criteria' an! 1-0 chil!ren =ere ran!omi?e!. " the 1-0 chil!ren enrolle!2 : patients =ere e7clu!e! "rom "urther anal1sis because o" incomplete !ata collection2 & "rom the !e7amethasone group an! 3 "rom the meth1lpre!nisolone group. " the remaining 1$3 chil!ren2 :$ receive! !e7amethasone an!Anesth Analg. Author manuscript; available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page -:, receive! meth1lpre!nisolone %8igure 1'. PatientsJ as =ell as surgical
characteristics =ere comparable bet=een the t=o groups %<able1'.3ischarge time "rom PAC4 =as appro7imatel1 -0 min in both groups. Meth1lpre!nisolone =as nonin"erior to !e7amethasone in terms o" overall inci!ence o" vomiting !uring the "irst 2& hours. An intention0to0treat anal1sis sho=e! an overall inci!ence o" vomiting o" 30G in the !e7amethasone group an! o" 22G in the meth1lpre!nisolone group %!i""erence# ,G2 ($G CI#0$ to 21G'. A per protocol anal1sis sho=e! an overall inci!ence o" vomiting o" 32G in the !e7amethasone group an! 23G in the meth1lpre!nisolone group %!i""erence# (G2 ($G CI#0$ to 23G'.All secon!ar1 outcomes =ere comparable bet=een the t=o groups# the PAC4 an! post PAC4 !ischarge inci!ence an! severit1 o" P@ an! the number o" antiemetics receive!2 the overall severit1 o" P@ an! antiemetics receive! !uring the "irst 2& hours a"ter surger12 the Eualit1 an! time to "irst oral inta/e2 !uration o" I@ h1!ration2 satis"action scores %<able 2'2 as =ell as pain scores at all time intervals %<able 3'. <hree patients in each group receive! one !ose o" morphine in the PAC4. <he me!ian number o" paracetamol !oses receive! !uring the stu!1 perio! =as 3 %1)&' in !e7amethasone group versus 2 %0)&' in the meth1lpre!nisolone group % PH0.2-'. <he me!ian values o" summe! pain scores %a!!e!0up pain scores' =ere 1& %0)&2' in group !e7amethasone an! 10 %0)&0' in group meth1lpre!nisolone %PH0.2'.<he !ata =ere anal1?e! accor!ing to the t1pe o" surger12 i.e.2 micro!ebri!er0assiste! partial tonsillectom1 versus total tonsillectom12 using an electro!issection techniEue. Patients =ho ha! partial tonsillectom1 =ere 1ounger =ith larger tonsils than total tonsillectom1 patients %<able &'. .ubseEuentl12 no correlation =as "oun! bet=een age an! the highest pain scores in the PAC4 %PearsonJs r2H0.0,2 PH0.31'. 3ata on vomiting =ere comparable bet=een total an! partial tonsillectom1 patients %<able $'. Ho=ever2 time to "irst oral inta/e an! !uration o" I@ h1!ration =ere shorter an! satis"action scores =ere better in partial tonsillectom1 patients %<able $'. Pain scores =ere signi"icantl1 lo=er at 30 min a"ter surger1 an! at PAC4 !ischarge in partial tonsillectom1 patients %<able -'. .i7 tonsillectom1 patients receive! one !ose o" morphine in the PAC4 versus none "rom the partial tonsillectom1 group %PH0.03:'. <he me!ian number o" paracetamol !oses receive! !uring the stu!1 perio! =as 3 %1)&' in the total tonsillectom1 group versus 2 %0)&' in the partial tonsillectom1 group %PH0.00&'. <he summe! pain scores %a!!e!0up pain scores' =ere 1& %0)&2' in group total tonsillectom1 an! 10 %0)&0' in group partial tonsillectom1 %PH0.003'.No blee!ing =as recor!e! in
an1 o" the patients =ithin one month a"ter surger1.Disc!ssionur stu!1 sho=e! that
meth1lpre!nisolone %2.$ mg*/g' is nonin"erior to !e7amethasone %0.$ mg*/g' in the prevention o" vomiting in chil!ren un!ergoing total or partial tonsillectom1 =ith an overall inci!ence o" vomiting o" 30G in the !e7amethasone group an! o" 22G in the meth1lpre!nisolone group %intention0to0treat anal1sis' an! 32G versus 23G respectivel1 %per protocol anal1sis'. <ime to "irst oral inta/e2 Eualit1 o" oral inta/e2 !uration o" I@ h1!ration2 as =ell as satis"action scores =ere also comparable bet=een the t=o groups as evi!ence! b1 narro= ($G con"i!ence intervals %<able 2'. Fhen anal1?e! accor!ing to the t1pe o" surger1 our !ata sho=e! that patients un!ergoing micro!ebri!er0assiste! partial tonsillectom1 =ere 1ounger an! e7perience! less !iscom"ort a"ter surger1 an! higher satis"action as compare! to chil!ren un!ergoing electro!issection total tonsillectom1.<he !ose o" !e7amethasone "or PN@ proph1la7is in chil!ren un!ergoing tonsillectom1 ranges bet=een $0 Kg*/g an! 1000 Kg*/g(21322& =ith the 0.$ mg*/g !ose being the mostAnesth Analg. Author manuscript; available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page :"reEuentl1 use!.13 Fe electe! to use the 0.$ mg*/g !ose because it has been
sho=n that the antiemetic e""ect o" !e7amethasone =as !ose0!epen!ent.2& In"ormation !erive! "rom stu!ies on proph1la7is o" chemotherap10in!uce! PN@ suggest that 20 mg o" !e7amethasone is as e""ective as 100mg o" meth1lpre!nisolone =hich is $ times more potent.1& In our stu!12 the !oses o" both !rugs =ere calculate! accor!ing to this potenc1 ratio. 3i""erences in pharmaco/inetics %longer biological hal"0li"e o" 3-)$& hours "or !e7amethasone versus shorter onset o" action an! hal"0li"e o" 1,)3- hours "or meth1lpre!nisolone21' !i! not account "or an1 !i""erence in their antiemetic e""ect !uring the "irst 2& hours a"ter tonsillectom1. ther !oses ma1 provi!e !i""erent results. More than (0G reporte! e7cellent or goo! satis"action in both groups. 3espite the high satis"action rate in our stu!1 population2 the inci!ence o" vomiting !uring the "irst 2& hours range! bet=een 23 an! 32G an! ma1 be still consi!ere! high. <he use o" nitrous o7i!e ma1 have contribute! to this "reEuent inci!ence. <hus2 a combination therap1 =ith on!ansetron ma1 be in!icate! as recommen!e! b1 the association o" pe!iatric anesthesiologists o" Areat 5ritain an! Irelan!.2$<onsillectom1 in chil!ren is a pain"ul proce!ure associate! =ith !iscom"ort lasting "or several !a1s a"ter the operation.2- It ma1 lea! to poor oral inta/e an! !eh1!ration. .teroi!s inhibit the earl1 process o" in"lammation2 =hich ma1 re!uce e!ema2 "ibrin !eposition2 capillar1 !ilation2 migration o" l1mphoc1tes an! phagoc1tic activit1. In a!!ition2 there is accumulating evi!ence "or their potent analgesic e""icac1.13 <here"ore2 steroi!s are consi!ere! an important opioi!0re!ucing measure =hich ma1 be particularl1 use"ul in chil!ren =ith obstructive s1mptoms an! "urther re!uce the ris/ o" PN@. In our stu!12 postoperative analgesia =as provi!e! =ith the combination o" a single !ose o" steroi! an! paracetamol upon reEuest2 =ith morphine reserve! "or severe pain. <he proce!ure =as accompanie! b1 an acceptable level o" !iscom"ort2 as evi!ence! b1 me!ian pain scores not e7cee!ing & on most time intervals an! a mean time to "irst oral inta/e o" 3 hours across the groups. It is suggeste! that the combination o" co!eine an! paracetamol is not superior to paracetamol alone.13 Postoperative pain ma1 be "urther !ecrease! b1 a!!ing an N.AI3 =ithout increasing the ris/ o" blee!ing.13It has been sho=n that high !ose !e7amethasone %0.$ mg*/g' is associate! =ith posttonsillectom1 blee!ing.2& In our stu!12 =e prospectivel1 "ollo=e! the occurrence o" blee!ing up to one month postoperativel1. Fe note! an absence o" posttonsillectom1 blee!ing reEuiring me!ical attention in a series o" 1$3 sub>ects receiving steroi!s a"ter tonsillectom1 =ith a ($G con"i!ence interval o" blee!ing bet=een 0G an! 2G compare! to the much higher rates note! in the article b1 C?arnets/i et al.2& <his is a ver1 important "in!ing given the surprising results publishe! b1 the above0Euote! article. Ho=ever2 their "in!ings have been challenge! on the groun!s that there =ere other con"oun!ing "actors such as the lac/ o" statistical po=er "or the secon!ar1 outcome o" blee!ing2 in a!!ition to the surgical techniEue an! N.AI3 consumption. <he lac/ o" blee!ing in our stu!1 is in concor!ance =ith the results o" Aunter et al. =ho reporte! a ver1 lo= inci!ence o" 0.&G o" sel"0limite! posttonsillectom1 hemorrhage in 230 patients =ho receive! 0.12$ to 0.$ mg*/g !e7amethasone.2: Moreover2 the clinical practice gui!eline issue! "or tonsillectom1 in chil!ren strongl1 recommen!s base! on ran!omi?e! controlle! trials an! s1stematic revie=s o" ran!omi?e! controlle! trials =ith a prepon!erance o" bene"it over harm that clinicians shoul! a!minister a single2 intraoperative !ose o" I@ !e7amethasone to chil!ren un!ergoing tonsillectom1.13 Ho=ever2 the panel recommen!s also that clinicians =ho per"orm tonsillectom1 shoul! !etermine their rate o" primar1 an! secon!ar1 posttonsillectom1 hemorrhage at least annuall1.13<he lea!ing in!ication "or tonsillectom1 in the 4nite! .tates no= is obstructive sleep apnea s1mptoms.2, <his is in contrast =ith the "igures reporte! in the 4nite! Cing!om =here onl1Anesth Analg. Author manuscript; available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page ,(G o" tonsillectom1 patients report a histor1 o" obstructive sleep apnea =ith
the remaining (0G presenting "or recurrent or chronic tonsillitis.2( 8ort10three percent o" our stu!1 population presente! =ith a me!ian tonsillar si?e o" & "or micro!ebri!er0assiste! intracapsular partial tonsillectom1 to relieve obstructive s1mptoms. <he remaining $:G came "or recurrent tonsillitis =hich man!ates complete removal o" the tonsils. ur results sho=e! a similar inci!ence o" P@ a"ter both techniEues =ith less !iscom"ort2 shorter time to "irst oral inta/e an! better satis"action in partial tonsillectom1 chil!ren. Chil!ren un!ergoing tonsillar re!uction =ere smaller than those un!ergoing total tonsillectom1. Ho=ever2 1oung age !oes not seem to be responsible "or the lo=er pain scores2 as sho=n b1 the lac/ o" correlation bet=een age an! pain reporte! in the PAC4. A surve1 con!ucte! in the 4nite! Cing!om consi!ere! that aspects relate! to surgical techniEues =ere be1on! the scope o" their surve1230 an opinion share! b1 the authors o" a recent revie= on anesthesia aspects "or tonsillectom1 an! abrasion in chil!ren.31 In contrast to the scarce interest in the surgical techniEue in the anesthesia literature2 interesting !ata can be retrieve! "rom the otolar1ngolog1 literature. A revie= o" the recor!s o" &::- patients age! 1 to 1, 1ears sho=e! that micro!ebri!er0assiste! technolog1 =as associate! =ith the lo=est inci!ence o" ma>or complications such as !eh1!ration an! posttonsillectom1 hemorrhage %0.:G' versus 3.1G "or electrocauter1 an! 2.,G "or coblation.2, In a prospective long0term "ollo=0up2 5itar an! Iameh "oun! that micro!ebri!er0assiste! intracapsular tonsillectom1 =as associate! =ith less analgesic consumption an! severit1 o" pain2 =ith t=o0thir!s o" the patients pain0"ree a"ter !a1 3 as compare! to electro!issection techniEue.32ne limitation o" our stu!1 is the omission o" a control group. <his =as !ue to the "act that the II5 consi!ere! it unethical to omit steroi! proph1la7is since it =as our stan!ar! o" care2 especiall1 because there is strong evi!ence regar!ing its e""icac1 in this high ris/ group.Another limitation is the short "ollo=0 up time o" onl1 2& hours.13In conclusion2 our stu!1 sho=e! that meth1lpre!nisolone is nonin"erior to !e7amethasone "or the prevention o" vomiting a"ter tonsillectom1 in chil!ren. <his report also she!s light on the !i""erence in postoperative morbi!it1 relate! to the surgical techniEue. Micro!ebri!erassiste! intracapsular partial tonsillectom1 is associate! =ith less !iscom"ort a"ter surger1 an! better satis"action than total tonsillectom1 using electro!issection techniEue. Ho=ever2 the inci!ence an! severit1 o" P@
remain the same bet=een the t=o techniEues.Ac(nowledgments%unding: 3epartmental "un!ing; <his
publication =as supporte! b1 grant number 461 II02$:$2 "rom the National Center "or Iesearch Iesources %NCII'. <he content is solel1 the responsibilit1 o" the authors an! !oes not necessaril1 represent the o""icial vie=s o" the National Center "or Iesearch
Iesources or the National Institutes o" Health.References1. 5olton CM2 M1les P.2 Nolan <2 .terne DA. Proph1la7is
o" postoperative vomiting in chil!ren un!ergoing tonsillectom1# a s1stemic revie= an! meta0anal1sis. 5r D Anaesth. 200-; (:#$(3)-0&. QPubMe!# 1:00$$0:R2. Cehlet H. Alucocorticoi!s "or peri0operative analgesia# ho= "ar are =e "rom general recommen!ationsS Acta Anaesthesiol .can!. 200:; $1#1133)11$$. QPubMe!# 1:,$0$$:R3. Feren M2 3emeere D6. Meth1lpre!nisolone vs. !e7amethasone in the prevention o" post0operative nausea an! vomiting# a prospective2 ran!omi?e!2 !ouble0blin!2 placebo0controlle! trial. Acta Anaesth 5elg. 200,; $(#1)$. QPubMe!# 1,&-,010R&. .te=ar! 362 Arisel D2 Mein?en03err D. .teroi!s "or improving recover1 "ollo=ing tonsillectom1 in chil!ren. Cochrane 3atabase .1st Iev. 2011; 10 C3003((:.Anesth Analg. Author manuscript; available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page ($. +lha/im M2 Ali NM2 Iashe! I2 Iia! MC2 Ie"at M. 3e7amethasone re!uces
postoperative vomiting an! pain a"ter pe!iatric tonsillectom1. Can D Anesth. 2003; $0#3(2)3(:. QPubMe!# 12-:0,1,R-. Celi/er @2 Celebi N2 Canba1 2 5asgul +2 A1par 4. Minimum e""ective !ose o" !e7amethasone a"ter tonsillectom1. Pe!iatric Anesthesia. 200&; 1&#---)--(. QPubMe!# 1$2,3,2-R:. Caan MN2 !abasi 2 Ae?er +2 3al!al A. <he e""ect o" preoperative !e7amethasone on earl1 oral inta/e2 vomiting an! pain a"ter tonsillectom1. Int D Pe!iatr torhinolar1ngol. 200-; :0#:3):(. QPubMe!# 1$(:(:3$R,. Aoua! M<2 .i!!i/ ..2 Ii?/ 652 Ta1toun AM2 5ara/a A.. <he e""ect o" !e7amethasone on postoperative vomiting a"ter tonsillectom1. Anesth Analg. 2001; (2#-3-)-&0. QPubMe!# 1122-0(1R(. Pappas A.2 .u/hani I2 Hotaling AD2 Mi/at0.tevens M2 Davors/i DD2 3on?elli D2 .heno1 C. <he e""ect o" preoperative !e7amethasone on the imme!iate an! !ela1e! postoperative morbi!it1 in chil!ren un!ergoing a!enotonsillectom1. Anesth Analg. 1((,; ,:#$:)-1. QPubMe!# (--1$&-R10. April MM2 Callan N32 No=a/ 3M2 Haus!or"" MA. <he e""ect o" intravenous !e7amethasone in pe!iatric a!enotonsillectom1. Arch tolar1ngol Hea! nec/ .urg. 1((-; 122#11:)120. QPubMe!# ,-30203R11. .plinter FM2 Ioberts 3D. 3e7amethasone !ecreases vomiting b1 chil!ren a"ter tonsillectom1. Anesth Analg. 1((-; ,3#(13)(1-. QPubMe!# ,,($2-2R12. hlms 6A2 Fil!er I<2 Feston 5. 4se o" intraoperative corticosteroi!s in pe!iatric tonsillectom1. Arch tolar1ngol Hea! nec/ .urg. 1(($; 121#:3:) :&2. QPubMe!# :$(,,&(R13. 5augh I82 Archer .M2 Mitchell I52 Iosen"el! IM2 Amin I2 5urns DD2 3arro= 3H2 Aior!ano <2 6itman I.2 6i CC2 Manni7 M+2 .ch=art? IH2 .et?en A2 Fal! +I2 Fall +2 .an!berg A2 Patel MM. Clinical practice gui!eline# tonsillectom1 in chil!ren. tolar1ngol Hea! Nec/ .urg. 2011; 1&&#.1).30. QPubMe!# 21&(32$:R1&. 6ehoc?/1 2 4!var1 D2 5agameri A2 Pula1 <. 3oes increasing the steroi! !ose enhance the e""icac1 o" the antiemetic combination o" granisetron an! meth1lpre!nisolone in g1necologic cancer patients0 a ran!omi?e! stu!1. +ur D bstet A1necol Iepro! 5iol. 200&; 113#(&)(:. QPubMe!# 1$03-:1(R1$. Chan 6B2 6am MH2 6au <C2 Chin IC. .uccess"ul treatment o" recurrent2 intractable h1peremesis gravi!arum =ith meth1lpre!nisolone. A case report. D Iepro! Me!. 2003; &,#2(3)2($. QPubMe!# 12:&-((-R1-. Iomun!sta! 62 5reivi/ H2 Niemi A2 Helle A2 .tubhaug A. Meth1lpr!nisolone intravenousl1 1 !a1 a"ter surger1 has sustaine! analgesic an! opioi!0sparing e""ects. Acta Anaesthesiol .can!. 200&; &,#1223)1231. QPubMe!# 1$$0&1,0R1:. Iomun!sta! 62 5reivi/ H2 Ioal! H2 ./olleborg C2 Haugen <2 Narum D2 .tubhaug A. Meth1lpre!nisolone re!uces pain2 emesis2 an! "atigue a"ter breast augmentation surger1# a single!ose2 ran!omi?e!2 parallel0group stu!1 =ith meth1lpre!nisolone 12$ mg2 pareco7ib &0 mg2 an! placebo. Anesth Analg. 200-; 102#&1,)&2$. QPubMe!# 1-&2,$3-R1,. 6unn <H2 Cristensen 552 An!ersen 6U2 Huste! H2 tte C.2 Aaarn06arsen 62 Cehlet H. +""ect o" high0!ose preoperative meth1lpre!nisolone on pain an! recover1 a"ter total /nee arthroplast1# a ran!omi?e!2 placebo0controlle! trial. 5r D Anaesth. 2011; 10-#230)23,. QPubMe!# 211313:1R1(. 6e Henan"" A2 Airau!eau 52 5aron A2 Iavau! P. Vualit1 o" reporting o" nonin"eriorit1 an! eEuivalence ran!omi?e! trials. DAMA. 200-; 2($#11&:)11$1. QPubMe!# 1-$22,3$R20. 3e liveira A.2 <heil/en 6.2 McCarth1 ID. .hortage o" perioperative !rugs# implications "or anesthesia practice an! patient sa"et1. Anesth Analg. 2011; 113#1&2() 1&3$. QPubMe!# 21$(-,,:R21. Pehuet08igoni2 M.; 6uton2 DP. Aluco0corticoi!es. In# Airou!2 DP.; Mathe2 A.; Me1niel2 A.2 e!itors. Pharmacologie cliniEue. 2n! e!.. Paris# +7pansion .cienti"iEue 8rancaise; 1(($. p. 21:-021(-.22. +ngleman +2 .alengros DC2 5arvais 6. Ho= much !oes pharmacologic proph1la7is re!uce postoperative vomiting in chil!renS Calculation o" proph1la7is e""ectiveness an! e7pecte! inci!ence o" vomiting un!er treatment using 5a1esian meta0anal1sis. Anesthesiolog1. 200,; 10(#1023)103$. QPubMe!# 1(03&0((R23. Ne=combe IA. Interval +stimation "or the 3i""erence 5et=een In!epen!ent Proportions# Comparison o" +leven Metho!s. .tat Me!. 1((,; 1:#,:3),(0. QPubMe!# ($($-1:RAnesth Analg. Author manuscript; available in PMC 2013 ctober 01.
NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author
ManuscriptAoua! et al. Page 102&. C?arnet?/i C2 +lia N2 61sa/o=s/i C2 3umont 62 6an!is 5N2 Aiger I2 3ulguerov
P2 3esmeules D2 <ramWr MI. 3e7amethasone an! ris/ o" nausea an! vomiting an! postoperative blee!ing a"ter
tonsillectom1 in chil!ren# a ran!omi?e! trial. DAMA. 200,; 300#2-21)2-30. QPubMe!# 1(0--3,2R2$. Carr2 A.;
5rennan2 6.; Courtman2 ..; 5aines2 3.; Holtb12 H.; 6onnEvist2 PA.; Morton2 N.; Pope2 D.; Dacobson2 .. Aui!elines on
the prevention o" postoperative nausea an! vomiting in chil!ren. <he Association o" Anaesthetists o" Areat 5ritain an!
Irelan!. 6on!on# Churchill House; 200,.2-. Farnoc/ 882 6an!er D. Pain progression2 intensit1 an! outcomes "ollo=ing
tonsillectom1. Pain. 1((,; :3#3:)&$. QPubMe!# ($3(-:2R2:. Aunter D52 McAuli""e DD2 5ec/man +C2 Fitt/ugel +P2
.paeth DP2 @arughese AM. A "actorial stu!1 o" on!ansetron2 metocloprami!e2 an! !e7amethasone "or emesis
proph1la7is a"ter a!enotonsillectom1 in chil!ren. Pe!iatr Anesth. 200-; 1-#11$3)11-$.2,. Aallagher <V2 Filco7 62
McAuire +2 3er/a1 C.. Anal1?ing "actors associate! =ith ma>or complications a"ter a!enotonsillectom1 in &::-
patients# comparing three tonsillectom1 techniEues. tolar1ngol Hea! Nec/ .urg. 2010; 1&2#,,-),(2. QPubMe!#
20&(33-3R2(. 5ro=n2 P.; I1an2 I.; Bung2 M. n behal" o" the 5ritish Association o" torhinolar1ngologistsHea! an!
Nec/ .urgeons Comparative Au!it Aroup an! the Clinical +""ectiveness 4nit. 6on!on# <he Io1al College o" .urgeons
o" +nglan!; 200$. National Prospective <onsillectom1 Au!it# 8inal Ieport o" an au!it carrie! out in +nglan! an!
Northern Irelan! bet=een Dul1 2003 an! .eptember 200&.30. All"or! M2 Aurus=am1 @. A national surve1 o" the
anesthetic management o" tonsillectom1 surger1 in chil!ren. Pe!iatr Anesth. 200(; 1(#1&$)1$2.31. Iae!er D.
Ambulator1 anesthesia aspects o" tonsillectom1 an! abrasion in chil!ren. Curr pin Anaesthesiol. 2011; 2&#-2:)-32.
QPubMe!# 21::21&2R32. 5itar MA2 Iameh C. Micro!ebri!er0assiste! partial tonsillectom1# short an! long term
outcomes. +ur Arch torhinolar1ngol. 200,; 2-$#&$()&-3. QPubMe!# 1:(0(,2(RAnesth Analg. Author manuscript;
available in PMC 2013 ctober 01.
ManuscriptAoua! et al. Page 11%igure &'Consort "lo= !iagramAnesth Analg. Author manuscript; available in PMC
2013 ctober 01.
Aoua! et al. Page 12Characteristics o" Patients an! .urger1(roup De)amethasone !*+,Ta'le /(roup
Meth$lprednisolone !*+-PAge %1ears' &.-M1., &.&M1.( 0.&- .e7 %M*8' &,*2: &:*31 0.:& Feight %Cg' 1(M-.( 1,.$M-.1 0.-1
Anesthesia <ime %min' -$.(M1(.$ --.&M1(.: 0.,: .urger1 <ime %min' &,.3M1(.- &:.2M20.1 0.:3 <1pe o" .urger1<otal <onsillectom1
Partial <onsillectom1&$ 30&2 3-0.$1<onsillar .i?e 3%1)&' 3%1)&' 0.:, 6actate! IingerNs solution receive! %m6' 223.(M110.&
23(.$M100 0.3,@alues are meansM.32 numbers or me!ian %range'NIH-PA Author ManuscriptNIH-PA Author
ManuscriptNIH-PA Author ManuscriptAnesth Analg. Author manuscript; available in PMC 2013 ctober 01.
Aoua! et al. Page 133ata on @omiting an! ral Inta/eTa'le 0(roup De)amethasone !*+,(roup Meth$lprednisolone
!*+-Psup95% Confidence interval of the differencePatients @omiting in PAC4 11%1$' :%(' 0.32 0$ to 1-G @omiting episo!es in
PAC4 0%0)3' 0%0)3' 0.1- Patients Ieceiving Antiemetics in PAC4 2%3' 1%1' 0.-2 Patients @omiting a"ter PAC4 !ischarge 1:%23'
1$%1(' 0.-( 0( to 1-G @omiting episo!es a"ter PAC4 !ischarge 0%0)2' 0%0)2' 0.-- Patients @omiting !uring "irst 2& h %per protocol
anal1sis' 2&%32' 1,%23' 0.2, 0$ to 23GPatients @omiting !uring "irst 2& h %per intention0to0treat anal1sis' X 2&*:( %30' 1,*,1%22' 0.2,
0$ to 21G@omiting episo!es !uring "irst 2&h 0%0)&' 0%0)&' 0.31 <ime to "irst ral Inta/e %hours' 3M1.& 3.1M2.1 0.$- 00.:$ to 0.&1 h
<ime to Iemoval o" I@ 6ine %hours' 12M,.2 11.3M,.$ 0.-: 02.23 to 3.&: hVualit1 o" ral Inta/e %+7cellent*goo!' XX $( %,2' -0 %,2' 1
012 to 12G.atis"action rate! as e7cellent XX 2, %3(' 3& %&:' 0.& 0, to 23GPAC4H Postanesthesia Care 4nit. @alues are numbers %G'2
me!ian %range' or meansM.3 XIn the intention0to0treat anal1sis2 =e assume! that patients =ith missing primar1 outcome !ata !i! not
have vomiting %nH:( in !e7amethasone group an! nH,1 in meth1lpre!nisolone group'.XX 3 missing values "rom !e7amethasone group
an! $ missing values "rom meth1lpre!nisolone groupNIH-PA Author ManuscriptNIH-PA Author
ManuscriptNIH-PA Author ManuscriptAnesth Analg. Author manuscript; available in PMC 2013 ctober 01.
Aoua! et al. Page 1&Pain .cores at 3i""erent <ime Intervals(roup De)amethasoneTa'le 1(roup
Meth$lprednisolonePArrival to PAC4 2 %0)10' 0 %0)10' 0.0( 30 minutes a"ter arrival to PAC4 0 %0)10' 0 %0)10' 0.&: 3ischarge
"rom PAC4 0 %0),' 0 %0)10' 0.-, 12 hours postoperativel1 - %0)10' & %0)10' 0.$- 2& hours postoperativel1 & %0),' & %0)10' 0.$-
.umme! Pain score 1& %0)&2' 10 %0)&0' 0.2PAC4H Postanesthesia Care 4nit. @alues are me!ian %range'NIH-PA Author
ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptAnesth Analg. Author
manuscript; available in PMC 2013 ctober 01.
Aoua! et al. Page 1$Ta'le 2Characteristics o" Patients an! .urger1 accor!ing to t1pe o" surger1"otal
"onsillectom$ !*-+Partial "onsillectom$ !*..PAge %1ears' $.1M2.1 3.:M1.1 P0.001 .e7 %M*8' $2*3$ &3*23 0.$1 Feight %Cg'
20.$M:.3 1-.&M&.2 P0.001 Anesthesia <ime %min' --.:M20.( -$.$M1:.- 0.: .urger1 <ime %min' &,.$M21.1 &-.,M1,.2 0.-1 <1pe o"
steroi! receive!3e7amethasone Meth1lpre!nisolone&$ &230 3-0.$1<onsillar .i?e 3%1)&' &%3)&' P0.001 6actate! Iinger receive!
%m6' 2&$.2M120.$ 21&.-M:,.( 0.0,@alues are meansM.32 numbers or me!ian %range'NIH-PA Author
ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptAnesth Analg. Author
manuscript; available in PMC 2013 ctober 01.
"onsillectom$ !*-+Partial "onsillectom$ !*..Psup95% Confidence interval of the differencePatients @omiting in PAC4 12%1&' -%(' 0.&$ 0- to 1&G @omiting episo!es in PAC4 0%0)3' 0%0)2' 0.&- Patients Ieceiving Antiemetics in PAC4 2%2' 1%2' 1 Patients @omiting a"ter PAC4 !ischarge 21%2&' 11%1:' 0.32 0$ to 1(G @omiting episo!es a"ter PAC4 !ischarge 0%0)2' 0%0)2' 0.3- Patients @omiting !uring "irst 2& h 2-%30' 1-%2&' 0.&: 0, to 1(G @omiting episo!es !uring "irst 2&h 0%0)&' 0%0)3' 0.$- <ime to "irst ral Inta/e %hours' 3.&M1.: 2.$M1.: 0.002 0.32 to 1.&: h <ime to Iemoval o" I@ 6ine %hours' 1&.1M,.- ,.$M-., P0.001 2.,$ to ,.2: hVualit1 o" ral Inta/e %+7cellent* Aoo!' X -& %:,' $$ %,:' 0.2 03 to 21G.atis"action rate! as e7cellent X 2- %32' 3- %$:' 0.002 ( to &0GPAC4H Postanesthesia Care 4nit. @alues are numbers %G'2 me!ian %range' or meansM.3 X$ missing values "rom total
tonsillectom1 group an! 3 missing values "rom partial tonsillectom1 groupNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptAnesth Analg. Author manuscript; available in PMC 2013
ctober 01.
Aoua! et al. Page 1:Ta'le 3Pain .cores Accor!ing to <1pe o" .urger1 at 3i""erent <ime Intervals"otal
"onsillectom$Partial "onsillectom$PArrival to PAC4 2 %0)10' 0 %0)10' 0.12 30 minutes a"ter arrival to PAC4 0 %0)10' 0 %0)10'
0.00( 3ischarge "rom PAC4 0 %0)10' 0 %0),' 0.02 12 hours postoperativel1 - %0)10' & %0)10' 0.1 2& hours postoperativel1 & %0)10' &
%0)10' 0.&: .umme! Pain score 1& %0)&2' 10 %0)&0' 0.003PAC4H Postanesthesia Care 4nit. @alues are me!ian %range'NIH-PA
Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptAnesth Analg.
Author manuscript; available in PMC 2013 ctober 01.