Clinical trial NCT03995628: Steroids and Pain Control After Tonsillectomy
Official title: Randomized, Controlled Trial of Post-operative Steroids and Pain Control After Tonsillectomy
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: PHASE2
Conditions: Tonsillitis
Obstructive Sleep Apnea of Child
Lead sponsor: Medical University of South Carolina
Sponsor class: OTHER
First posted: 2019-06-24
Enrollment: 150
Sex: ALL
Minimum age (years): 3
Maximum age (years): 12
Standard ages: CHILD
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: This research study aims to find out if a single oral dose of steroid after tonsillectomy will reduce pain and decrease the need for narcotic medications.

Detailed description: The study will be performed prospectively and in a randomized, double-blinded, placebo controlled manner. Patients meeting inclusion and not violating exclusion criteria will be randomized to either receive a single oral steroid dose or a single placebo dose on the third day after surgery. All study patients will otherwise receive the standard of care in all other aspects of their treatment. That is, the surgery itself, the post-operative pain control strategies/medication, patient instructions, and follow up will not differ between the two groups. The pediatric otolaryngology department has standardized post-operative pain control (a specific order set is used) which will ensure no differences between different providers.

Oral dexamethasone is the study drug and will be given in 0.5mg/kg dosage and the route is 3mg capsules in increments of one capsule. Doses are calculated by weight and rounded up to the nearest 3mg up to a maximum of 12mg (4 capsules). Parents are instructed to give the medication on the morning of the third day after surgery. Parents can either have the child swallow the capsule or, if the child does not tolerate this, open the capsule and mix the contents into food the consistency of applesauce, then administer. A placebo will also be designed in the same route as the oral dexamethasone. Both the placebo and oral dexamethasone capsules will be purchased from by Tidewater Pharmacy and Compounding, an accredited pharmacy located in Mt. Pleasant, South Carolina12. Weight based instructions will be included with the study materials. During distribution, the member of the study team delivering the study materials will confirm the dosing with the parents.

Study materials will be assembled and randomized by the project lead, and will include a small container with four capsules of either placebo or oral dexamethasone. All study materials will be assigned a unique record number between 001 and 150. The materials will be block-randomized in groups of 30 to either contain placebo or oral dexamethasone, and linked to the record number in a secured file held by the project lead. This file will be inaccessible to any but the project lead during data collection. The study materials with the drug or placebo will be kept in a temperature controlled locked cabinet at the study site, MUSC Children's Health R. Keith Summey Medical Pavilion.

Immediately following the procedure in the operating room, once lack of exclusion criteria has been confirmed by the operating surgeon, patients will be assigned a subject record number in numerical order. This record number will be recorded, linked to the patient's medical record number, and kept in a secure file separate from the randomization list. The randomization process will be blinded from the parents, subjects, study coordinator, and operating surgeon. The subject's parents will then receive study materials that correspond to their unique record number, which will include either four 3mg dexamethasone capsules or four placebo capsules. Weight based instructions will be included with this dosing, and providers and/or research team members will go over these instructions with parents again when giving the study materials.

After randomization, the operating surgeon will complete a questionnaire to document details of the surgery, including: who performed the surgery, intracapsular versus extracapsular tonsillectomy, estimated blood loss, and use of suction cautery on the tonsillar bed. This will be collected by the study coordinator and linked to the patient record number.

Patients enrolled in the study will receive a "post-operative pain and medication diary" upon discharge from their procedure. Patients (parents) will be instructed to record daily pain control (on a validated visual analog scale (VAS)) and daily medication administration (opioid and non-opioid analgesic) for post-operative days 0-6 in this diary. Patients will return the diary to the study team via email, fax, text message, or a pre-addressed, stamped envelope. Reminders to return the materials will be sent to the parents periodically by the study coordinator via email, text message, or phone call. Recall bias will be reduced by the incorporation of the diary to aid parents' memory. The study coordinator will transcribe pain control and medication consumption data into the REDCap data compilation system.

The Faces Pain Scale-Revised13 will be used to assess patient pain on post-operative day 0-6. The scale will be provided to the patient in their discharge packet and a diary to record daily pain score will be provided. Mean VAS for post-operative day 1-3 and mean VAS for post-operative day 4-6 will be calculated for comparison.

Daily medication administration will be recorded by parents, specifically the number of doses of opioid and non-opioid analgesic medication consumed. For opioids, doses consumed will be cross-referenced against the weight-based dose prescribed in order to calculate daily oral morphine equivalents (OME) consumed. Mean daily OME will be calculated for post-operative day 1-3 and for post-operative day 4-6 for comparison.

At 30-days following surgery, participant patient charts will be queried by the study coordinator for presentation to the emergency room, readmission, and oropharyngeal hemorrhage. Presentation to the emergency room and readmission will be included if considered related to the procedure. Related emergency room presentation or readmission is defined as that due to throat pain, neck pain, ear pain, poor oral intake due to pain, dehydration due to poor oral intake caused by pain, and bleeding from the mouth or nose. Regarding oropharyngeal hemorrhage, any subjective or objective bleeding from the mouth or nose within 30 days of the procedure will be considered related to the procedure. Oropharyngeal hemorrhage will be divided into three groups: mild (not requiring admission, manifested as phone call or presentation to the emergency room), moderate (requiring admission but not return to the operating room), and severe (requiring urgent or emergent intubation and/or control of hemorrhage in the operating room).

If patients are experiencing pain uncontrolled by oral medications after tonsillectomy, providers at our institution will occasionally choose to give a dose of steroids prior to the third postoperative day or a second dose of steroids after the third postoperative day to help with pain control. If study patients have pain prior to the third postoperative day and a provider believes steroids are indicated, the patient should be given this medication, and then will be instructed not to take the study medication and will be excluded from analysis. If patients have pain on the third postoperative day and have already taken the study medication, they will be instructed to wait at least 6 hours before receiving another dose of steroids. All of this will be discussed in detail when obtaining consent, and will be included in the study materials given to parents.

Eligibility criteria: Inclusion Criteria:

* Age 3-12
* Tonsillectomy with or without adenoidectomy for any indication
* Outpatient (same day) surgery

Exclusion Criteria:

* Bleeding disorder
* Intra-operative surgical or anesthetic complication or unplanned admission
* Pre-operative steroid use (defined as any steroid use greater than three days duration within 30 days prior to tonsillectomy)
* Pre-operative opioid use (defined as any opioid use within 30 days prior to tonsillectomy)
* Inability of parent/guardian to be contacted by phone for follow up
* Inability or unwillingness of subject or legal guardian/representative to give informed consent

Primary outcomes:
measure: Mean Visual Analog Score of Pain
timeFrame: Postoperative day 6
Secondary outcomes:
measure: Mean Opioid Consumption
timeFrame: Postoperative day 6
measure: Mean NSAID and Acetaminophen Consumption
timeFrame: Postoperative day 6
measure: Rate of Nausea and Vomiting
timeFrame: Postoperative day 6
measure: Diet and Activity Levels
timeFrame: Postoperative day 6
measure: Rate of 30-Day Readmission
timeFrame: Postoperative day 30
measure: Rate of 30-Day Emergency Room Visits
timeFrame: Postoperative day 30
measure: Rate of Postoperative Oropharyngeal Hemorrhage
timeFrame: Postoperative day 30
Other outcomes:
Locations:
city: Charleston
country: United States
facility: Medical University of South Carolina
state: South Carolina
Study officials:
affiliation: Medical University of South Carolina
name: Phayvanh Pecha, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain. 2001 Aug;93(2):173-183. doi: 10.1016/S0304-3959(01)00314-1.
citation: Tan GX, Tunkel DE. Control of Pain After Tonsillectomy in Children: A Review. JAMA Otolaryngol Head Neck Surg. 2017 Sep 1;143(9):937-942. doi: 10.1001/jamaoto.2017.0845.
citation: Batistaki C, Kaminiotis E, Papadimos T, Kostopanagiotou G. A Narrative Review of the Evidence on the Efficacy of Dexamethasone on Postoperative Analgesic Consumption. Clin J Pain. 2017 Nov;33(11):1037-1046. doi: 10.1097/AJP.0000000000000486.
citation: Vlok R, Melhuish TM, Chong C, Ryan T, White LD. Adjuncts to local anaesthetics in tonsillectomy: a systematic review and meta-analysis. J Anesth. 2017 Aug;31(4):608-616. doi: 10.1007/s00540-017-2310-x. Epub 2017 Jan 24.
citation: Redmann AJ, Maksimoski M, Brumbaugh C, Ishman SL. The effect of postoperative steroids on post-tonsillectomy pain and need for postoperative physician contact. Laryngoscope. 2018 Sep;128(9):2187-2192. doi: 10.1002/lary.27167. Epub 2018 Mar 24.
citation: Rosen HI, Bergh IH, Oden A, Martensson LB. Patients experiences of pain following day surgery - at 48 hours, seven days and three months. Open Nurs J. 2011;5:52-9. doi: 10.2174/1874434601105010052. Epub 2011 Jul 6.
citation: Cronin J, Kennedy U, McCoy S, An Fhaili SN, Crispino-O'Connell G, Hayden J, Wakai A, Walsh S, O'Sullivan R. Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial. Trials. 2012 Aug 21;13:141. doi: 10.1186/1745-6215-13-141.