The effectiveness of topical bupivacaine application versus placebo in managing pain in paediatric and adult adenotonsillectomy patients: a systematic review & metaanalysis

Background: There is a high incidence of severe post-operative pain experienced by patients undergoing adenotonsillectomies. During this procedure, there is often a need for local anaesthetic use which has minimal side effects, is cost effective and is easy to administer. Bupivacaine is a long acting and potent local anaesthetic that is widely available in resource constrained settings. Its topical application into the tonsillar fossa could provide sufficient analgesia whilst avoiding complications seen with its infiltrative technique. Objective: To determine the efficacy of topical bupivacaine in the management of postadenotonsillectomy pain compared to placebo using data from randomised controlled trials (RCTs). Methods: This systematic review and meta-analysis was registered with PROSPERO (CRD42020180502) and adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive search of the scientific literature was conducted on PubMed, Scopus and the Cochrane Library online databases. RevMan 5.4 software was used for statistical analysis. The risk of bias and quality of the studies included was determined using the Cochrane Risk of Bias (ROB) Tool Version 2. Results: Seven studies out of 58 were included in the systematic review with a total of 406 patients. Six of these studies had investigated post-operative pain scores for tonsillectomy alone. Three of the studies showed low risk of bias, three had some concerns and one was at high risk of bias. Topical bupivacaine produced a significant reduction in pain score estimates at 1-hour [−2.32 (95% CI: −3.98; −0.66)], 4-hours [−2.93 (95% CI: −5.05; −0.81)] and 5-6- hours [−1.73 (95% CI: −3.15, −0.30)] (standardised mean differences) postadenotonsillectomy when compared to placebo. The analysis also reports no complications associated with use of topical bupivacaine. The dose of bupivacaine was 0.5% for six of the seven studies, and 0.25% for the one study. The included trials varied according to volume and duration of application of bupivacaine. There was significant heterogeneity in the analysis undertaken. Conclusion: Topical bupivacaine was effective and safe in reducing post-adenotonsillectomy pain scores up to 6 hours post-operatively. This method of administration is ideal in resource constrained environments as it avoids potentially serious complications that are associated with the infiltration technique
A research report submitted in partial fulfilment of the requirement for the degree of Master of Medicine (MMed) in Anaesthesiology to the Faculty of Health Sciences, University of the Witwatersrand, School of Clinical Medicine, Johannesburg, 2023
Adenotonsillectomy patients, Topical bupivacaine, Pains