To the Editor:—

The article by Korpela et al.  1regarding the morphine-sparing effects of different doses of acetaminophen concerns us in several ways. Although the study design takes into account a “placebo” group, we think that this group is unnecessary and its use provokes significant ethical questions. It is unlikely that any anesthetic technique for this sort of surgery would be planned to involve no analgesia at all, as in the untreated group. Although the placebo effect is undoubtedly of some value, this group did not even have analgesia in the intraoperative and immediate postoperative periods until rescue anesthesia was given.

Two groups (groups I and II) received inadequate analgesia intraoperatively and in the immediate postoperative period. These groups also had consequent side effects from rescue intravenous morphine that was necessary. Surely, one of the aims of day-care anesthesia is to minimize side effects.

Second, the recent vogue of using ever increasing doses of acetaminophen—in this article 60 mg/kg acetaminophen is recommended—brings into question the principal of using simple and normally safe pediatric drugs in a way that could lead to difficult problems. The study design ensured that study patients received no further acetaminophen; however, acetaminophen is probably the most common drug used in the home. There are recent case reports of severe, reversible hepatic toxicity when acetaminophen is used in therapeutic amounts. 2To use a single high dose of the drug simply to provide an adequate therapeutic level more quickly merely indicates the inadequacy of the single-drug technique, and reinforces what we already know: Treating postoperative pain using perioperative analgesia, including local anesthesia, and simple analgesics (e.g.,  acetaminophen, nonsteroidal antiinflammatory drugs) is far more beneficial. Encouraging ever increasing doses of this safe drug potentially could lead to serious morbidity. Surely it is better to use a “balanced” anesthetic technique.

Korpela R, Korvenoja P, Meretoja OA: Morphine-sparing effect of acetaminophen in pediatric day-case surgery. A NESTHESIOLOGY 1999; 91:442–7
Morton NS, Arana A: Paracetamol induced fulminant hepatic failure in a child after 5 days of therapeutic doses. Paediatr Anaesth 1999; 9:463–5