What are the guidelines for using adrenaline (epinephrine) packing during tonsillectomy?

Guidelines for Adrenaline Packing During Tonsillectomy

Current guidelines do not recommend the use of adrenaline (epinephrine) packing during tonsillectomy due to limited evidence of long-term benefit and potential safety concerns. 1

Recommended Pain Management Approach for Tonsillectomy

First-Line Recommendations

• A multimodal analgesic regimen with paracetamol (acetaminophen) and NSAIDs should be administered pre-operatively or intra-operatively and continued postoperatively as baseline therapy 2
• A single intra-operative dose of IV dexamethasone is recommended for its analgesic and anti-emetic effects 1, 2
• Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent studies and meta-analyses 1

Second-Line Options (when first-line is contraindicated)

• Pre-operative gabapentinoids may be considered when NSAIDs are contraindicated 1, 2
• Intra-operative IV ketamine (single dose) or dexmedetomidine can be considered, but should be used cautiously due to potential side effects including hallucinations, sedation, hypotension, and bradycardia 1, 2

Adjunctive Therapies

• Honey can be used postoperatively as an analgesic adjunct with no reported side effects 2
• Acupuncture may provide additional pain relief when combined with standard analgesics 2
• Opioids should be reserved as rescue analgesics only 2

Adrenaline Use in Tonsillectomy: Evidence and Concerns

Limited Evidence for Adrenaline Packing

• Peritonsillar infiltration or topical application of local anesthetics (including adrenaline) is not recommended due to concerns of serious side effects despite evidence of short-lasting effect 1
• The PROSPECT guidelines specifically list local anesthetic infiltration as not recommended for pain management in tonsillectomy 1

Potential Benefits of Adrenaline (from limited studies)

• Some research suggests bismuth subgallate and adrenaline paste may reduce intraoperative blood loss (60.8 ± 19.3 ml vs 91.2 ± 20.27 ml) 3
• Epinephrine infiltration has been shown to reduce blood loss and dissection time in older studies 4
• Bupivacaine-epinephrine infiltration may reduce intraoperative bleeding and decrease operation time 5

Safety Concerns with Adrenaline

• Epinephrine should be administered with caution in patients with heart disease, including cardiac arrhythmias, coronary artery disease, or hypertension 6
• Case reports document serious circulatory failure after local infiltration of epinephrine during tonsillectomy, including ventricular arrhythmias, hypertension followed by hypotension, and pulmonary edema 7
• Incorrect administration of epinephrine can cause tissue necrosis due to vasoconstriction 6

Surgical Technique Considerations

• Current guidelines cannot recommend a specific surgical technique to influence post-tonsillectomy pain, as most studies evaluate surgical techniques based on bleeding risk and cost-effectiveness rather than pain outcomes 1
• Coblation techniques may have slightly less postoperative pain during the first day compared with cold dissection and electrocautery techniques 1

Important Considerations and Pitfalls

• Tonsillar infiltration may not be as safe as infiltration in other areas due to the neurovascular bundle in the vicinity, explaining the high potential for side effects 1
• Adequate hydration should be maintained throughout the perioperative period 8
• Monitoring for signs of inadequate pain control is essential, as poor pain management may lead to inadequate oral intake and dehydration 2

In summary, while some older research suggests potential benefits of adrenaline use in reducing intraoperative bleeding during tonsillectomy, current guidelines do not recommend its routine use due to safety concerns and limited evidence of long-term benefit. A multimodal analgesic approach with paracetamol, NSAIDs, and a single dose of dexamethasone is the recommended standard of care.