A narrative review of pediatric tonsillectomy and adenoidectomy pain management: evidence-based strategies and emerging trends

Introduction

Tonsillectomy, with or without adenoidectomy, remains one of the most commonly performed pediatric surgical procedures in the USA, with more than 500,000 cases annually (1). Sleep-disordered breathing with obstructive sleep apnea (OSA) and recurrent tonsillitis are the two most common indications for adenotonsillectomy. Post tonsillectomy pain is common, with severe pain occurring on days 2–4, then decreasing over the following 10 days (2). Ongoing pain and subsequent reduced oral intake may result in dehydration which has been associated with an increased risk of post-tonsillectomy hemorrhage leading to hospital readmission which can result in increased healthcare cost and resource use (3,4). Therefore, management of post-tonsillectomy pain is essential.

Background

Historically, acetaminophen and codeine were used to treat postoperative pain. However, a change in prescribing practices occurred after the USA Food and Drug Administration (FDA) issued a black box warning on the use of codeine in children (5). Evidence regarding opioid sensitivity in the presence of OSA along with reports of death or neurologic injury after tonsillectomy (6), the increasing rate of opioid dependence and opioid-related deaths has prompted the introduction of guidelines with recommendations to use acetaminophen, ibuprofen and other adjuncts to enhance postoperative pain relief (7,8).

Rationale and knowledge gap

There is known opioid related respiratory depression risk in these patients, with disparity of evidence for alternative analgesic approaches. This can make choosing the “best” analgesic approach challenging. For example, despite the concern with the use of opioids in this patient population, a recent study of children undergoing tonsillectomy found that intraoperative methadone administration may decrease total post-tonsillectomy opioid use compared to fentanyl with no difference in pain scores (9,10). This study broadened the options for the already variable management of pain after tonsillectomy. Those caring for such patients need to understand evidence based, patient centric analgesia that balances patient risk factors with adequate pain control as this understanding is essential for safe patient care.

Objective

Our objective is to provide a narrative review of the important preoperative patient factors, perioperative considerations, impact of surgical techniques on postoperative pain, and an evidence-based optimized patient centric approach to analgesia. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0003/rc).

Methods

A comprehensive literature search was conducted from March 1993 to March 2026, as shown in Table 1. Cited references in identified papers were evaluated for inclusion. English-language manuscripts, pediatric tonsillectomy with or without adenoidectomy, perioperative care of children for procedure, society guidelines, and discussion of indications and risk factors were included. As a narrative review, references were not assessed for risk of bias and no meta-analysis was performed.

Indications for tonsillectomy and adenoidectomy

Two of the most common indications for tonsillectomy are recurrent infections and sleep-disordered breathing. Treatment of these conditions increases health care utilization and cost, including but not limited to antibiotic use and frequent hospital visits. Additional socioeconomic costs include multiple absences from school and caregivers missing work, among others (7).

Recurrent tonsillitis is defined as 7 or more episodes in one year, 5 or more episodes a year for 2 consecutive years, or 3 or more episodes in a year for 3 consecutive years (11). Tonsillectomy may be recommended if a patient meets criteria for recurrent tonsillitis.

Sleep-disordered breathing is a spectrum of disorders ranging from primary snoring to OSA. Clinical signs of OSA include poor sleep quality, daytime napping and fatigue, and behavioral issues like enuresis, hyperactivity, aggression, and difficulty focusing (12).

Preoperative diagnosis

The testing standard for diagnosing OSA is a polysomnogram, which provides assessment of apnea/hypopnea index and severity of desaturation during sleep (13). Only a minority of children undergo this study, largely due to resource limitations, cost, or the child’s inability to tolerate the procedure. In the absence of polysomnography, an alternative method to identify children with moderate to severe OSA who are at risk for postoperative opioid-related adverse events is based on a thorough history and physical examination. Some factors that are associated with adverse perioperative respiratory events post-adenotonsillectomy in children are listed in Table 2 (14). Abbreviated OSA questionnaires for children assess snoring, sleepiness, and inattention/hyperactive behavior are derived from the Pediatric Sleep Questionnaire-Sleep-related Breathing Disorder (PSQ-SRBD) and may be predictive of moderate to severe OSA (15). Conditions that warrant overnight polysomnography include age under 2 years old, Down syndrome, obesity, craniofacial abnormalities, neuromuscular disorders, sickle cell disease or mucopolysaccharidosis (7).

If OSA is left untreated, significant morbidities may develop including cardiovascular dysfunction, ventricular remodeling, endothelial dysfunction, behavioral problems that include hyperactivity, aggression, anxiety, depression and somatization, enuresis, and growth delay (16-23). In children with OSA, a significant level of parental anxiety may also be present (24). There is evidence that adenotonsillectomy is associated with significant improvement in behavior, quality of life, and polysomnogram parameters, particularly in the most severe cases (25).

Sensitivity to opioids

When treating children with OSA, it is essential to emphasize proper opioid usage as those with moderate to severe OSA may be sensitive to the respiratory depressant effects of opioids. In studies of children with OSA, those with nighttime desaturation <85% were found to require half the dose of opioids to achieve equivalent analgesia compared to children that have less severe OSA (26,27). In contrast, no difference in respiratory sensitivity in those with compared to those without OSA was found in a study of 10 children, 8–14 years old, given remifentanil infusion (28) or in a study of 73 children given fentanyl during sevoflurane anesthesia for adenotonsillectomy (29). The known risk of opioid induced respiratory depression (OIRD) following opioid administration and the interindividual variability in drug effects across ages makes careful titration or avoidance of opioids appropriate (30).

Surgical techniques and approaches

Several techniques and instruments are used to perform tonsillectomy with some approaches purported to be associated with less postoperative pain. Surgeons may perform an extracapsular tonsillectomy, which completely removes the tonsil and its capsule, or an intracapsular tonsillectomy where the pharyngeal constrictor muscles and the tonsillar pillars are left intact. A study comparing these techniques found that intracapsular tonsillectomy resulted in decreased postoperative pain (31). “Hot” electrocautery techniques use heat (typically monopolar cautery) to remove the tonsils and stop bleeding. Cold knife (steel) dissection uses a scalpel to remove the tonsil and electrocautery or suture to stop any bleeding. Cold dissection seems to cause less pain but is not used as frequently due to longer operative times and increased blood loss (32,33). Snare tonsillectomy utilizes a snare with a wire loop, the end of which is placed around the freed tonsil to reduce bleeding. Harmonic scalpel uses ultrasonic vibrations to remove the tonsil and stop the bleeding at the same time. The use of coblation has increased in recent years (34,35). This method delivers bipolar radiofrequency through a saline field, which generates less heat. Overall, cold tonsillectomy is thought to result in less postoperative pain, while some studies show that “hot” tonsillectomy results in less intraoperative blood loss and surgical time. Meta-analyses find that compared to the extracapsular surgical approach, intracapsular tonsillectomy is associated with decreased bleeding and lesser late postoperative pain, but no difference in early postoperative pain (36,37). Additional prospective studies are needed to firmly support one approach over the other.

Preoperative considerations

Patient, medical condition and other factors have been associated with adverse respiratory events following adenotonsillectomy (Table 2). Children with a diagnosis of severe OSA were found to be more sensitive to the respiratory depressant effects of opioids (26,27). Preoperative evaluation of OSA severity allows risk stratification for perioperative adverse events. Identifying children at risk for postoperative respiratory events allows adequate planning for overnight admission versus ambulatory surgery. Guidelines recommend that children with severe OSA and/or the presence of other comorbidities such as Down syndrome, cardiac complications of OSA, neuromuscular disorders, obesity and children <3 years of age warrant preemptive overnight admission (7). These recommendations represent a foundational framework for admission criteria.

Intraoperative factors

Airway control

Intraoperative factors like premedication, induction technique, and extubation are outside the scope of this discussion. However, cuffed endotracheal tubes remain the airway of choice during tonsillectomy with or without adenoidectomy, as they reduce the risk of an air leak and limit bubbling of secretions and blood, minimize operating room pollution by inhaled anesthetic agents, and lower the risk of an airway fire when electrocautery is used (38). However, a wire-reinforced flexible laryngeal mask airway (LMA) may also be utilized for this procedure when the surgeon is agreeable (39). A study of 134 patients ages 3 to 16 years compared airway management by wire reinforced LMA to endotracheal tube and found LMA use to be associated with lower maximal pain scores within 4 hours but no difference in rescue pain medication or pain scores over 24 hours (40). LMAs are preferred by some anesthesiologists because of the reduced incidence of postoperative stridor, bronchospasm and possibly laryngospasm (41,42) and ease of deep extubation. Appropriate patient selection, consideration of aspiration and bleeding risks, careful placement, and avoidance of controlled ventilation may decrease the incidence of LMA failure (43).

Impact of maintenance anesthetic

Additional perioperative strategies to enhance post-tonsillectomy analgesia beyond acetaminophen, ibuprofen, or opioids are under investigation. Both propofol and sevoflurane are established techniques for maintaining anesthesia during adenotonsillectomy. A recent pediatric randomized controlled trial found no significant difference in postoperative analgesic requirements after adenotonsillectomy between pediatric patients who received maintenance anesthesia with propofol or with sevoflurane (44).

A multicenter randomized controlled clinical trial evaluated maintenance of anesthesia with propofol infusion, inhaled sevoflurane or combined propofol-sevoflurane during tonsillectomy, adenoidectomy, or both. The primary outcome studied was the incidence of postoperative respiratory adverse events (PRAEs). In 744 children up to 12 years old, administration of propofol infusion alone had the lowest incidence of PRAE (18.8%), while propofol plus sevoflurane maintenance had less PRAE (28.5%) than sevoflurane maintenance (43.4%) (45). PRAEs were more common in children with preoperative respiratory symptoms compared to asymptomatic children. Secondary outcomes included emergence delirium, which occurred most frequently in the sevoflurane group, and Wong-Baker pain scale scores >3 which determined supplemental analgesics; these were comparable across the groups.

Postoperative analgesia

Multiple factors affect pediatric post-tonsillectomy pain control (Table 3). One crucial factor is the patient’s caregiver who is primarily responsible for managing postoperative pain after discharge. Perioperative staff should educate caregivers on pharmacologic and nonpharmacologic options for pain control prior to discharge (7). Other considerations such as the child’s ability to take medications, developmental maturity, and the presence of cognitive deficits also influence postoperative analgesia. In addition, medication-specific characteristics such as palatability and availability must be considered (46). If opioids are prescribed, side effects and adverse effects should be discussed with instructions on what to do if such effects were to occur. Oral medications are the mainstay of postoperative pain control following outpatient tonsillectomy. As noted, the majority of children undergoing tonsillectomy are those with sleep-disordered breathing, thus the risks for OIRD should be considered in caregiver education when prescribing (46). For patients at high risk of OIRD, avoidance of opioid analgesic medications is wise. A nonopioid analgesic regimen can include routine oral administration of acetaminophen, alternating with ibuprofen, with one or the other medication given every 3–6 hours. Assuring the caregiver understands limits on the number of administrations (total dose) in 24 hours is critically important.

Medications

Numerous factors contribute to the success of post-tonsillectomy pain control in children and despite advances, pain management remains challenging. Adequate analgesia is essential to avoid potential dehydration, which is associated with post-operative bleeding, emergency department visits and readmission. Adequate analgesia can mitigate increased parental anxiety which can trigger phone calls to providers and further resource utilization (4,47). Opioids are associated with an increased likelihood of life-threatening complications such as OIRD, apnea, and long-term sequalae like chronic use and subsequent opioid use disorder (6,48).

Ongoing advances in understanding the safety and efficacy of analgesics for pediatric tonsillectomy patients do not replace the critically important necessity of correct medication administration for successful and safe analgesia. Several studies have demonstrated wide variations in caregiver appreciation and accuracy of perception of the extent of pain after tonsillectomy (49-51). The initial clinical practice guidelines by the American Academy of Otolaryngology-Head & Neck Surgery recommended that clinicians advocate for pain management and educate caregivers about the importance of managing and reassessing pain (52). The updated guidelines added the need to “reinforce this counseling at the time of surgery” (7). Another key consideration, especially when administering opioids, is the identification of clinical predictors for post-tonsillectomy respiratory complications (Table 2).

Several clinical practice guidelines have played a significant role in the development of effective multimodal analgesia protocols that minimize perioperative opioids for adenotonsillectomy (7,19,53). The optimal analgesic regimen for tonsillectomy should include acetaminophen, ibuprofen, and intravenous dexamethasone. Additional pharmacologic agents have been studied in this patient population (Table 4).

Acetaminophen

As practice has evolved toward non-opioid analgesia after adenotonsillectomy, acetaminophen has become the most frequently administered analgesic in this setting (56,57). It is typically used as part of a multimodal pain management strategy (46). Although it has minimal side effects, the potential for hepatic injury exists, particularly when administered in high sustained doses to young children (58).

Following the introduction of intravenous acetaminophen, various dosing regimens have been investigated with the hopes of improving perioperative pain control. A recent study comparing a single oral loading of 30 mg/kg to intravenous acetaminophen at 15 mg/kg found that opioid sparing effects did not differ in patients who received standardized multimodal postoperative analgesia (59). Acetaminophen levels did not exceed the predetermined safety level in any patient, and acetaminophen levels were higher at 3 hours following oral administration. Similarly, previously studied regimens of oral loading doses of 20–40 mg/kg did not result in acetaminophen toxicity (60,61). The lower acquisition cost of oral acetaminophen could result in significant cost savings, thus making the oral route more desirable. However, many hospital pharmacies will not allow a 30 mg/kg oral dose of acetaminophen due to toxicity concerns; thus, they limit administration to a 15 mg/kg dose. In addition, anxious young children may have limited cooperation with oral medication in the preoperative setting. Thus, a single intravenous dose of acetaminophen may be easier to administer intraoperatively as a first dose followed by the oral route postoperatively. The updated clinical practice guidelines by the American Academy of Otolaryngology-Head & Neck Surgery endorse acetaminophen 10–15 mg/kg/dose every 4 to 6 hours, with a maximum dose of 75 mg/kg/day or 4,000 mg, whichever is less (7).

Opioids

Opioids are commonly used in tonsillectomy patients, albeit cautiously given the prevalence of OSA or sleep disordered breathing in these patients. The more frequently used opioids include fentanyl, morphine, and oxycodone. While they are beneficial in reducing surgical pain, they are not without side effects including OIRD, nausea, and constipation. One study that evaluated injury claims in children following tonsillectomy found that opioid related injury was 16.3% of fatal and 4.2% of non-fatal injuries (9). Recently, it was shown that there was a 34% increase in return visits with pain related issues following tonsillectomy in patients given opioid prescription compared to those who were not [adjusted odds ratio (OR), 1.31; 95% CI: 1.09–1.57] (62). Notably, an initial opioid prescription in teenagers has been associated with a 30–40% increase in substance related morbidity (48). These risks underscore the imperative to judiciously consider opioid administration.

Codeine

Codeine, a morphine analog, was historically frequently prescribed following tonsillectomy. In 2013, codeine received an FDA “Boxed Warning”, their strongest warning, specifically following tonsillectomy and/or adenoidectomy. This was following reports of death in children with OSA (5). Codeine, through cytochromes in the liver, is metabolized to morphine. The children who died were found to be ultra-metabolizers of codeine, which resulted in dangerous levels of morphine, and codeine administration to these patients has thus fallen out of favor (5).

Tramadol

Tramadol is a synthetic opioid that acts on mu receptors and additionally provides further analgesic benefit as a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI). Tramadol increases available serotonin and norepinephrine, thus inhibiting pain signaling. Tramadol has been used “off label” in children. It is converted to its active metabolite, O-desmethyltramadol, and like codeine, children who are ultra-rapid metabolizers can have a surge of the active metabolite which can lead to dangerous levels of O-desmethyltramadol. This can lead to OIRD, especially in those undergoing tonsillectomy. In 2017, tramadol received the FDA’s strongest label, contraindication (the risk always outweighs the benefits) for use in children under 18 years of age undergoing tonsillectomy and/or adenoidectomy. In addition, an FDA “warning” was issued against the use of tramadol in children with obesity, OSA or any other conditions that predispose them to an increased respiratory risk (63).

Methadone

Methadone is a long-acting opioid that works on the mu receptors and is also an N-methyl-D-aspartate (NMDA) receptor antagonist. Methadone has been evaluated in randomized control trials based on the assessment that pain may be under-treated in children post-tonsillectomy. A study of children undergoing tonsillectomy found that intraoperative methadone administration may decrease total post-tonsillectomy opioid use compared to fentanyl with no difference in pain scores (10). However, this was a small initial study and determined with polysomnography offered to all patients, which is not feasible in all practices. A study of adult patients undergoing tonsillectomy found that while 5-day opioid use was less in those that received methadone, post-operative nausea and vomiting (PONV) was significantly increased (64).

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are commonly used for postoperative tonsillectomy pain, with ibuprofen the most frequently administered.

Ibuprofen

The potential association of NSAID administration and increased post tonsillectomy bleeding has been an ongoing concern. Ibuprofen has not been shown to increase bleeding compared to other analgesics (65). Conversely, ketorolac is rarely administered due to the risk of increased intraoperative bleeding. In one meta-analysis, researchers found that pediatric tonsillectomy patients who received ibuprofen experienced less postoperative pain and PONV without an increased risk of bleeding (66). Compared with ibuprofen, morphine administration showed no improvement in pain scores with increased desaturation events (65).

Caldolor®

An intravenous ibuprofen injection is available (Caldolor®, Cumberland Pharmaceuticals Inc., Nashville, TN, USA). Authors of a Cochrane review concluded that the studies to date leave uncertainty about the analgesic efficacy of intravenous ibuprofen in children. There is a paucity of research on the matter, although one study demonstrated ibuprofen provided superior analgesia compared to IV paracetamol (67). One retrospective study found no increased risk of bleeding in those that received intravenous ibuprofen (68). The updated American Academy of Otolaryngology-Head & Neck Surgery guidelines recommend the use of ibuprofen in multimodal analgesia for children undergoing tonsillectomy (7).

Ketorolac

Ketorolac is a common NSAID that is used in the perioperative period but not used as often in pediatric tonsillectomy due to the increased risk of bleeding. One study showed that receiving ketorolac on the day of surgery resulted in an increased risk of primary and secondary hemorrhage (69), while other studies have not demonstrated an increased risk (70). A study of children undergoing intracapsular tonsillectomy showed no increased risk in post-tonsillar hemorrhage when ketorolac was given, with a decrease in opioid use (54). Given the mixed results in literature, there is a need for more studies and the decision to administer ketorolac should account for risks and benefits.

Corticosteroids

Corticosteroids are routinely given to tonsillectomy patients, to help reduce swelling and because of demonstrated opioid sparing in these children with the additional associated decrease in PONV. A meta-analysis showed that there may be a slight reduction in hemorrhage risk after tonsillectomy when steroids are given (55). A Cochrane review showed that children receiving intraoperative dexamethasone were half as likely to have nausea or vomiting in the first 24 hours following surgery and had improved pain scores (71). The American Academy of Otolaryngology-Head and Neck Surgery Foundation 2019 update recommends a single intraoperative dose of dexamethasone be given to each patient, although dosage is not specified (7). Another meta-analysis shows dexamethasone administration provides clear analgesic benefits (9).

Alpha 2 agonists

• Dexmedetomidine administration provides many benefits to children coming for tonsillectomy. These children can have anxiety, but midazolam has been shown to increase the risk of PRAEs in children while dexmedetomidine has been shown to be protective against PRAE. Children undergoing tonsillectomy have also been shown to have increased incidence of post-operative emergence delirium. In one meta-analysis, dexmedetomidine was found to be as effective as morphine and fentanyl in treating post tonsillectomy pain (72). In another meta-analysis, dexmedetomidine was shown to decrease opioid requirements and decrease emergence delirium (73).
• Clonidine was used more frequently in the late 1990’s early 2000s but has been eclipsed by the newer alpha 2 agonist, dexmedetomidine. One study compared intramuscular clonidine 2 mcg/kg and found no difference in pain scores and recommended against its use in tonsillectomy patients (74). Another randomized controlled trial compared oral clonidine to IV fentanyl and found no difference in postoperative pain scores, demonstrating it to be an effective analgesic (75). However, a retrospective study found that clonidine was shown to prolong emergence from anesthesia (76). Given the ready availability of dexmedetomidine, clonidine is now rarely used.

Ketamine

Ketamine is another commonly used perioperative analgesic that has a primary mechanism of action as an NMDA receptor antagonist. Secondarily, ketamine also interacts with mu opioid receptors. Ketamine has been shown to effectively decrease postoperative pain and decrease analgesic use (77). Ketamine does have well known side effects including increased secretions, tachycardia and vivid dreams.

Local anesthetics

Local anesthetics, including lidocaine, bupivacaine, and ropivacaine, have been used to decrease post-operative pain in pediatric tonsillectomy patients. A meta-analysis evaluated the benefits of local anesthetic infiltration in pediatric tonsillectomy and found a decrease in pain scores on postoperative day (POD) 0 and POD 1 (78). Another meta-analysis compared the analgesic efficacy of bupivacaine and ropivacaine and found no significant difference between them (79). A meta-analysis confirmed the efficacy of ropivacaine to provide a significant decrease in pain, without an increase in time to first analgesic or intraoperative/postoperative bleeding, or nausea/vomiting (80). In contrast, another meta-analysis showed only minor analgesic benefit, very early in recovery, with high variability in techniques (53).

Non-pharmacologic methods

There is some evidence that non-pharmacologic methods can improve post-tonsillectomy pain.

• Honey was shown to reduce pain scores after tonsillectomy and promote wound healing. The method of application varies with injection in the peritonsillar fossa intraoperatively, applied onto the fossa, or swallowed and gargled with no consistent correlation between method of application or dose and reported outcome measures (81). In addition, not all honeys are the same as far as medicinal potential and which biologically active compound within is responsible for any reported benefits. Further study is needed with formal research methodology to confirm the findings.
• Guided imagery, when utilized with routine analgesics, appeared to decrease pain scores and anxiety in children following tonsillectomy and/or adenoidectomy in the first 4 hours postoperatively but not after discharge at 22–27 hours (82). Educating caregivers in adequate home administration of analgesics may improve the effectiveness of this distraction method.
• Acupuncture, in addition to conventional analgesics, is suggested to offer analgesia following tonsillectomy in children in several studies (83,84). Larger scale studies are needed to determine the duration of benefit and feasibility of this approach.

Overall, these low-risk non-pharmacologic methods are easily tolerated and appear promising. However, most trials are small, and additional studies are needed to validate the benefits.

Strengths and limitations

Strengths of this review include basing recommendations for analgesic options in pediatric tonsillectomy patients on literature evidence including randomized controlled trials and meta-analyses. Importantly, the recommendation to minimize or avoid post-discharge opioid administration to these patients is underscored by guidelines and enhanced recovery protocols that now include the same recommendation. There are several limitations to this review. We included only manuscripts published in English. Further, sample size was small in some of the trials of various techniques or analgesic interventions, and there is significant heterogeneity across studies. Additionally, as is not uncommon in pediatric medicine, there is a paucity of literature available for many adjuncts proposed to benefit these patients. As noted, further study is needed prior to making firm recommendations for those. Well-designed randomized controlled trials could be carried out to elucidate the potential benefits of physical measures, complementary medicine interventions including acupuncture, and psychosocial approaches such as guided imagery.

Conclusions

Tonsillectomy, with or without adenoidectomy, is among the most commonly performed surgical procedures in children. Postoperative pain following adenotonsillectomy is common and may result in poor oral intake, dehydration, and secondary hemorrhage often requiring hospitalization. Many children undergoing tonsillectomy have associated comorbidities that place them at an increased risk for adverse respiratory events, including heightened sensitivity to opioids.

Current clinical guidelines support the use of acetaminophen, NSAIDs, and a single intraoperative dose of an intravenous corticosteroid for pain management. Additional strategies, such as intraoperative administration of low-dose opioids, dexmedetomidine or ketamine, may be considered. Codeine is specifically advised against administration to these children, while other opioids may be considered for standard risk patients in whom non-opioid techniques have failed. Opioids should be avoided or used with extreme caution in high-risk patients such as those with severe OSA or complex comorbid conditions. Regional anesthetic technique or local anesthetic infiltration may improve immediate analgesia but none has been shown to provide additional postoperative analgesic benefit to date.

This narrative review further highlights the need for clearer guidance regarding opioid prescribing after hospital or ambulatory center discharge.

Acknowledgments

We would like to acknowledge Edgardo E. Reynoso from the Loma Linda University School of Medicine, Department of Anesthesiology for his administrative support in preparation of this manuscript. The authors used an AI tool (OpenEvidence) as part of the search strategy but did not use AI tools to prepare this article.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0003/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0003/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0003/coif). R.L.A.II served as Principal Investigator in sponsored studies; reports that all fundings were paid to the University; and served in an unpaid volunteer capacity in the California Society of Anesthesiologists. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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