Preoperative High-Dose Oral Paracetamol for Postoperative Analgesia in Children Undergoing Tonsillectomy"

Tonsillectomy is one of the most commonly performed surgical procedures in children, yet it is often associated with significant postoperative pain. Effective pain management is critical to minimizing complications, and a multimodal approach to analgesia is recommended to reduce opioid consumption while providing effective pain relief. Paracetamol is a widely used and safe analgesic component within these multimodal regimens.

While previous studies indicate that an oral paracetamol loading dose of 30 mg/kg effectively reduces fever and provides consistent serum levels, there remains a limited direct comparison of clinical outcomes between an oral preoperative loading dose and a standard dose within preemptive standardized multimodal analgesia protocols for pediatric tonsillectomy. This randomized controlled trial aims to evaluate whether an oral paracetamol loading dose yields a superior opioid-sparing effect compared to a standard dose in this patient population.

A total of 54 pediatric patients, aged 3 to 15 years with ASA physical status I-III, scheduled for elective tonsillectomy (with or without adenoidectomy) will be enrolled. Participants will be randomized in a 1:1 ratio into two groups:

Group L (Loading Dose): Will receive a preoperative oral paracetamol dose of 30 mg/kg (adjusted body weight, maximum 1000 mg) 30-60 minutes before anesthesia induction.

Group C (Standard Dose): Will receive a preoperative oral paracetamol dose of 15 mg/kg (maximum 1000 mg) 30-60 minutes before anesthesia induction.

To maintain strict quadruple blinding, both groups will receive the same commercial paracetamol syrup formulation (250 mg/5 mL) prepared in opaque oral syringes by independent research staff. Participants, caregivers, treating anesthesiologists, surgeons, and outcome assessors (ward nurses) will be blinded to the group allocation.

All participants will undergo general anesthesia with endotracheal intubation and receive a standardized multimodal analgesia protocol. This protocol includes preoperative ibuprofen (10 mg/kg), intraoperative IV dexamethasone (0.2 mg/kg), local infiltration with 1% lidocaine with epinephrine, IV ondansetron (0.1 mg/kg), and postoperative oral paracetamol (15 mg/kg every 6 hours), ibuprofen (10 mg/kg every 8 hours).

Postoperative pain will be evaluated using age-appropriate validated tools: the revised FLACC scale for children aged 3-7 years (or those with cognitive impairment) and the Numerical Rating Scale (NRS) for children aged 7-15 years. Pain assessments will occur upon arrival at the post-anesthesia care unit (PACU) (hour 0), before transfer to the ward (hour 1), and at 6 and 12 hours postoperatively on the ward. If a patient reports a pain score of 4 or greater, rescue IV fentanyl (0.25 mcg/kg) will be administered according to protocol guidelines.

The primary outcome of the study is the total postoperative opioid (fentanyl) consumption within the first 12 hours after surgery. Secondary outcomes include postoperative pain scores at multiple time points, time to first rescue opioid requirement, the number of rescue opioid doses administered, and the incidence of adverse events such as nausea, vomiting, and sedation. The observation window is confined to the initial 12 hours post-surgery because most patients are discharged within 24 hours without oral opioid prescriptions, and the drug's pharmacological effects are expected to be most pertinent during this early recovery phase.

Inclusion criteria

• Children aged 3 to 15 years
• ASA physical status I-III
• Scheduled for elective tonsillectomy with or without adenoidectomy

Exclusion criteria

• Known allergy or contraindication to paracetamol or any agents in the study protocol
• Chronic opioid use