Efficacy of bupivacaine infiltration for controlling post-tonsillectomy pain, duration of surgery and post-operative morbidities: A systematic review and meta-analysis

Abstract

The objective of the present review and meta-analysis was to evaluate the efficacy of bupivacaine during tonsillectomy in terms of reducing the mean operative procedure duration, post-operative pain and the onset of post-operative morbidities. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed to perform a systematic literature search using the MEDLINE, Scopus, EMBASE and CENTRAL databases. The present meta-analysis sought to evaluate the efficacy of bupivacaine administered during tonsillectomy as compared to the administration of normal saline. The efficacy of the intervention was evaluated based on pain scores using the visual analogue scale, the duration of the operation and the occurrence of post-operative morbidities. Out of 1,427 records, 15 articles with 729 participants (mean age, 10.2±6.7 years) were included in the study. The present systematic review supported the use of bupivacaine during tonsillectomy at a level of evidence of 1b and confirmed beneficial effects of bupivacaine intervention by demonstrating small to large effect reductions in the visual analog scale score (Hedge's g, -1.48), the mean duration of the operative procedure (Hedge's g, -1.35) and the incidence of post-operative morbidity (Hedge's g, -0.23) in comparison to the placebo groups treated with normal saline. Based on these results, the administration of bupivacaine is recommended during tonsillectomies to reduce the perceived level of pain, the duration of the operation and the post-operative morbidity.

Keywords: adenotonsillectomy; anesthesia; bupivacaine; pain; tonsillectomy.

Figure 1

Preferred Reporting Items for Systematic reviews and Meta-Analyses flow chart for the included studies.

Figure 2

Risk of bias (%) within studies according to the Cochrane risk of bias assessment tool for randomized controlled trials.

Figure 3

Publication bias funnel plot generated by the Duval and Tweedie trim and fill procedure. Each of the analyzed effects is denoted by a circle in the plot. The boundaries of the plot mark the area where 95% of all the effects would reside in the absence of publication bias. The vertical midline denotes the mean standardized effect of zero. The white and black diamond represent the overall effect size, and the adjusted effect size, respectively.

Figure 4

Forest plot for studies evaluating the perceived level of pain between groups receiving either bupivacaine or normal saline 24 h post-tonsillectomy. The weighted effect size is presented as boxes and 95% CIs are presented as horizontal lines. A negative effect represents a reduction in the perceived level of pain for patients receiving bupivacaine during tonsillectomy; a positive effect represents a reduction in the perceived level of pain for patients in the placebo group receiving normal saline during tonsillectomy.

Figure 5

Forest plot for studies evaluating the mean duration of the tonsillectomy procedure between groups receiving either bupivacaine or normal saline. The weighted effect size is presented as boxes and the 95% CIs are presented as horizontal lines. A negative effect represents a reduced duration of the tonsillectomy procedure for patients receiving bupivacaine; a positive effect represents a reduced duration of the tonsillectomy procedure for patients in the placebo group receiving normal saline.

Figure 6

Forest plot for studies evaluating the post-operative morbidity rate between groups receiving either bupivacaine or normal saline during tonsillectomy. The weighted effect size is presented as boxes and 95% CIs are presented as horizontal lines. A negative effect represents a reduced incidence of post-operative morbidity for patients receiving bupivacaine during tonsillectomy; a positive effect represents an increased incidence of post-operative morbidity for patients in the placebo group receiving normal saline during tonsillectomy.