Hydromorphone beat fentanyl for pain after children's tonsillectomy

Design

Triple-blind, randomised controlled trial

Population

180 children aged 2 to 15 undergoing tonsillectomy or adenotonsillectomy

Primary outcome

Need for rescue intravenous opioid after extubation

Effect

53% (hydromorphone) vs 73% (fentanyl); difference 20 points (95% CI 6.2-33.8, P=0.005)

Tonsillectomy is among the most common paediatric operations, and these children are at raised risk of opioid-related breathing problems, yet there is little evidence to guide the intraoperative opioid. This triple-blind randomised trial compared hydromorphone with fentanyl.

Among 180 children aged 2 to 15 given a single intraoperative dose (hydromorphone 10 mcg/kg or fentanyl 1 mcg/kg), fewer in the hydromorphone group needed rescue intravenous opioid after extubation: 53% versus 73% (difference 20 percentage points, 95% CI 6.2 to 33.8, P=0.005). Hydromorphone also gave lower early pain scores and lower total opioid equivalents in recovery, with similar adverse events between groups.

For practice this supports intraoperative hydromorphone over fentanyl for better early analgesia after paediatric tonsillectomy. Because the population is prone to respiratory events, the usual post-tonsillectomy monitoring still applies, particularly in children with obstructive sleep apnoea, in whom opioid sensitivity is heightened.

• Triple-blind randomised trial of 180 children comparing intraoperative hydromorphone with fentanyl for tonsillectomy.
• Rescue opioid after extubation was needed in 53% (hydromorphone) versus 73% (fentanyl), a 20-point reduction.
• Hydromorphone also gave lower early pain scores and lower total recovery-room opioid equivalents.
• Adverse events were similar between the two groups.
• Maintain standard post-tonsillectomy respiratory monitoring, especially in children with sleep apnoea.

Why it matters

It gives an evidence-based choice for the intraoperative opioid in a common operation where that choice has been largely arbitrary.

Don't overread it

This was a single-centre trial not powered for rare respiratory complications, so standard monitoring remains essential, particularly in children with obstructive sleep apnoea.

The statistics, in plain English

A 20-percentage-point reduction with an interval from 6.2 to 33.8 excludes no difference, so the benefit is real though its size is imprecise; similar adverse-event rates are reassuring but the trial was not powered to detect rare respiratory events.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.