Design: Triple-blind randomised controlled trial
Population: 180 children aged 2–15 having tonsillectomy or adenotonsillectomy
Primary outcome: Need for rescue intravenous opioid after extubation
Effect: 53% vs 73%; difference 20.0 points (95% CI 6.2 to 33.8)

A triple-blind randomised trial in Paediatric Anaesthesia, published in June, assigned 188 children aged 2 to 15 having tonsillectomy or adenotonsillectomy to intraoperative hydromorphone 10 micrograms/kg or fentanyl 1 microgram/kg; 180 were analysed.

Rescue intravenous opioid in recovery was needed by 53% after hydromorphone and 73% after fentanyl (difference 20 percentage points, 95% CI 6.2 to 33.8). Early pain scores and total opioid use in recovery were also lower with hydromorphone. Adverse events, including desaturation, were similar.

Children having tonsillectomy, many with obstructive sleep apnoea, are at higher risk of opioid-related respiratory events, so a longer-acting intraoperative opioid that reduces repeated rescue doses is attractive. The trial was not large enough to detect rare respiratory complications.

Discuss with anaesthesia a longer-acting intraoperative opioid such as hydromorphone for tonsillectomy.
Continue multimodal analgesia — paracetamol and an NSAID — after tonsillectomy.
Monitor children with obstructive sleep apnoea closely whatever opioid is used.
Review recovery-room rescue opioid use as an audit measure.

Why it matters

Fewer rescue doses in recovery may mean fewer opportunities for respiratory events in a vulnerable group.

The statistics, in plain English

A 20-point absolute reduction means about one fewer child needing rescue opioid for every five treated. The trial was too small to show whether rare but serious respiratory events differ.