Authors: Albornoz A.E. et al.
Pediatric Anesthesia, October 2025. DOI: 10.1111/pan.70062
This quality improvement project evaluated the impact of a structured perioperative pain management toolkit on postoperative pain and opioid use following pediatric tonsillectomy and adenotonsillectomy. While opioids are often avoided intraoperatively to minimize postoperative respiratory adverse events (PRAEs), this practice can result in higher pain scores and increased rescue opioid administration in the postanesthesia care unit (PACU).
Pilot data from June 2018 to June 2020 revealed that 65.8% of pediatric tonsillectomy patients experienced moderate-to-severe pain in the PACU and 69% required rescue opioids. In response, investigators at The Hospital for Sick Children developed a six-component “tonsillectomy toolkit,” implemented in April 2021, designed to standardize multimodal analgesia, reduce postoperative pain, and limit opioid use. Patients were grouped by adherence: standard of care (<5/6 components), partial (5/6), and full toolkit compliance (6/6). Statistical process control charts tracked outcomes over time.
During the first year of implementation (2021–2022), the rate of moderate-to-severe PACU pain fell to 47.1% among patients with full toolkit adherence (a 28% reduction). Continued monitoring from 2022–2024 demonstrated a sustained and deepened improvement, with moderate-to-severe pain reduced to 31% (a 53% overall reduction). Similarly, rescue opioid administration in the PACU declined from 69% at baseline to 35% in the first year (49% reduction), remaining lower at 45% in subsequent years. Importantly, these improvements were achieved without increases in PRAEs, postoperative nausea or vomiting, or PACU length of stay.
The authors conclude that consistent implementation of a standardized tonsillectomy pain management toolkit can sustainably reduce early postoperative pain and opioid rescue use without compromising safety in pediatric patients.
What You Should Know
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A structured tonsillectomy analgesia toolkit reduced PACU pain and opioid use in children.
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Full adherence achieved a 53% reduction in moderate-to-severe pain over three years.
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Improvements occurred without increases in respiratory events or recovery time.
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Sustained data collection confirmed the toolkit’s long-term effectiveness and safety.
Thank you to Pediatric Anesthesia for publishing this important quality improvement initiative demonstrating that standardization and multimodal strategies can meaningfully improve pain outcomes in pediatric tonsillectomy.