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Duan B, Gan M, Xu Z, Chen WX. Tonsil microbiome in pediatric patients with post tonsillectomy hemorrhage for tonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 2024; 176:111788. [PMID: 38039804 DOI: 10.1016/j.ijporl.2023.111788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/20/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE This study aimed to compare the tonsillar microbiota between post tonsillectomy patients with bleeding and without bleeding, and to investigate the potential role of tonsillar microbiota in the development of post-tonsillectomy hemorrhage (PTH). METHODS Nineteen tonsillar tissues from PTH patients and 21 tissues from control patients were collected. Metagenomic sequencing was used to compare the microbiota in PTH and control groups. Alpha diversity indices were used to compare the richness and evenness of the microbiota between the two groups. PCoA and NMDS analyses were used to evaluate beta diversity. LDA analysis was conducted to identify significantly abundant genera. RESULTS No significant difference in alpha diversity indices was found between PTH and control patients. The dominant bacteria in the tonsillar microbiota were Haemophilus, Streptococcus, and Fusobacterium. PCoA and NMDS analyses showed significant differences in beta diversity between PTH and control patients. PTH patients had a significantly higher relative abundance of Neisseria, Capnocytophaga, and Veillonella. Capnocytophaga was also identified as a significantly abundant genus by LDA analysis. CONCLUSION This study demonstrates that there is a difference in the tonsillar microbiota between PTH and control patients. The results suggest that Neisseria, Capnocytophaga, and Veillonella may be associated with the development of PTH. These findings provide new insights into the potential role of the tonsillar microbiota in the development of PTH, and may help to develop new strategies for preventing and treating this potentially life-threatening complication.
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Affiliation(s)
- Bo Duan
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
| | - Mingyu Gan
- Center for Molecular Medicine, Children's Hospital of Fudan University, National Children's Medical Center 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
| | - Zhengmin Xu
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
| | - Wen-Xia Chen
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
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Wentzel S, Craft A, Onwuka A, Lind M. Racial, ethnic and language disparities in healthcare utilization in pediatric patients following tonsillectomy. Int J Pediatr Otorhinolaryngol 2024; 176:111805. [PMID: 38043184 DOI: 10.1016/j.ijporl.2023.111805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 12/05/2023]
Abstract
IMPORTANCE Tonsillectomy is one of the most common surgical procedures performed in the United States. However, there is little known about the intersectionality of race, ethnicity, and language and how these factors influence post-tonsillectomy outcomes such as ED utilization and hospital readmission rates. OBJECTIVE To examine disparities in emergency department (ED) utilization and hospital readmissions for post-tonsillectomy complications based on insurance status, patient race, ethnicity and language spoken. DESIGN This was retrospective cohort over four years. SETTING Tertiary Care Children's Hospital. PARTICIPANTS All children (n = 10,215) who underwent tonsillectomy or adenotonsillectomy at a tertiary children's hospital from January 2015 to December 2018 were identified and included. There were no exclusion criteria. EXPOSURE The exposure of interest was tonsillectomy. MAIN OUTCOMES AND MEASURES Outcomes and variables of interest were defined prior to data collection. The primary outcome of this study was emergency department (ED) utilization defined as any ED or urgent care visit within 21 days of the tonsillectomy for surgery-related concerns. The secondary outcome of this study was readmissions following tonsillectomy. RESULTS A total of 10215 pediatric patients (median age, 6 years; 5096 [50 %] male) who underwent tonsillectomy were included in the analysis. 13 % of patients presented to the ED with surgery-related complaints. Among English proficient patients, multi-racial patients were the only group with an elevated odds of ED utilization (OR:1.5, 95 % CI: 1.2, 1.9). Non-English language preference (NELP) patients of Black, Hispanic, Asian, and American Indian/Alaskan Native race/ethnicity also had elevated odds of ED use post-tonsillectomy compared to non-Hispanic White English proficient patients. Six percent of all patients had an unplanned hospital readmission. Asian patients with non-English language preference had 2.1 times the odds of readmission (95 % CI: 1.2, 3.6); and were disproportionately admitted for post-tonsillectomy hemorrhage. CONCLUSIONS and Relevance: Language disparities in ED use and readmission persist after adjusting for risk factors. Non-English language preference populations have a higher rate of ED utilization, especially for minor complications. Disparities may result from differential health literacy or predispositions to complications. Future directions include additional research on mechanisms and targeted interventions to increase education and access to language-appropriate resources.
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Affiliation(s)
- Stephanie Wentzel
- Medical Student Research Program, The Ohio State University College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aaron Craft
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Meredith Lind
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA; Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Cohen N, Schissler K, Jeter J, Stathas A, Lozano J, Dave S, Lowe D. Change in Pediatric Adenotonsillectomy Postoperative Visit Patterns After Opioid Food and Drug Administration Warning. Pediatr Emerg Care 2024; 40:38-44. [PMID: 36972489 DOI: 10.1097/pec.0000000000002926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
STUDY OBJECTIVE This study aimed to determine the association between opioid prescriptions given after tonsillectomy with adenoidectomy (T + A) and pain-related return visit rates in pediatric patients. Determine association between Food and Drug Administration (FDA) black box warning against opioid use in this population and pain-related return visit rates. METHODS This was a single-institution retrospective cohort study of pediatric patients who underwent T + A between April 2012 and December 2015 and had return visits to the emergency department or urgent care center. Data were obtained from the hospital electronic warehouse using International Classification of Diseases-9/10 procedure codes. Odds ratios (ORs) with 95% confidence intervals (CIs) for return visits were calculated. Multivariate logistic regression analysis was used to measure association between opioid prescriptions and return visit rates as well as FDA warning and return visit rates adjusting for confounders. RESULTS There were 4778 patients who underwent T + A, median age, 5 years. Of these, 752 (15.7%) had return visits. Pain-related return visits were higher in patients who received opioid prescriptions (adjusted OR, 1.31; 95% CI, 1.09-1.57). After FDA warning, opioids were prescribed at a lower rate (47.9%) compared with previous (98.6%) (OR, 0.01; 95% CI, 0.008-0.02). Pain-related return visits were lower after FDA warning (OR, 0.73; 95% CI, 0.61-0.87). Steroid prescription rate increased after FDA warning (OR, 415; 95% CI, 197-874). CONCLUSIONS Opioid prescriptions were associated with higher pain-related return visits after T + A, whereas issuance of FDA black box warning against codeine use was associated with lower pain-related return visits. Our data suggest that the black box warning potentially had unintended benefits in pain management and health care usage.
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Affiliation(s)
- Naiomi Cohen
- From the Department of Pediatric Emergency Medicine, Nicklaus Children's Hospital, Miami, FL
| | - Kathryn Schissler
- Department of Pediatric Emergency Medicine, Connecticut Children's, University of Connecticut School of Medicine, Hartford, CT
| | | | - Adam Stathas
- Department of Medical Education, Nicklaus Children's Hospital, Miami, FL
| | - Juan Lozano
- Division of Medical and Population Health Sciences Education and Research, College of Medicine, Florida International University, Miami, FL
| | - Sandeep Dave
- Division of Pediatric Otolaryngology, Nicklaus Children's Hospital, Miami, FL
| | - David Lowe
- From the Department of Pediatric Emergency Medicine, Nicklaus Children's Hospital, Miami, FL
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4
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Naser AY, Al-shehri H. Postprocedural Complications Hospitalization Pattern Among Paediatric Patients at National Health Service Trusts: An Ecological Study in England and Wales. J Multidiscip Healthc 2023; 16:3545-3554. [PMID: 38024128 PMCID: PMC10661900 DOI: 10.2147/jmdh.s441247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To analyze the hospitalization patterns associated with postprocedural complications among the pediatric population in England and Wales over the past two decades. Patients and Methods This was an ecological study using hospital admission data extracted from the Hospital Episode Statistics database in England and the Patient Episode Database for Wales for the period between April 1999 and April 2020. Postprocedural complications related hospital admissions were identified using the 10th version of the International Statistical Classification of Diseases (ICD) system (D78, E89, H59, H95, J95, L76, M96, and N99). Results The rate of hospital admissions declined by 2.1% [from 8.32 (95% CI 7.75-8.88) per 100,000 persons in 1999 to 8.15 (95% CI 7.61-8.68) per 100,000 persons in 2020, p>0.05]. The primary reasons for hospital admissions associated with postprocedural complications were related to the respiratory system, genitourinary system, and ear and mastoid process, constituting 43.0%, 23.8%, and 23.0% of cases, respectively. Conclusion The trend of postprocedural complications among the pediatric population has been stable in the past two decades. Continuous monitoring of the hospitalization pattern for this type of complication is important due to advancements in healthcare provision and to improve patient care and safety. Future studies are needed to examine gender-based differences related to postprocedural complications and identify important preventable risk factors.
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Affiliation(s)
- Abdallah Y Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Hassan Al-shehri
- Department of Pediatrics, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
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Hazkani I, Hajnas N, Victor M, Stein E, Richardson A, Billings KR. Tonsillectomy Outcomes in Children After Solid-Organ Transplantation: A 15-Year Single-Center Experience. Otolaryngol Head Neck Surg 2023; 168:1209-1216. [PMID: 36939520 DOI: 10.1002/ohn.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/10/2022] [Accepted: 10/15/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Solid-organ transplantation (SOT) has become the standard of care for children with terminal organ failure. Long-term immunosuppression has improved survival substantially but is associated with secondary malignancies and impaired wound healing. Our goal was to review the incidence, outcomes, complications, and rate of posttransplant lymphoproliferative disorder on pathologic examination following tonsillectomy/adenotonsillectomy (T/AT) in children after SOT. STUDY DESIGN A retrospective cohort study. SETTING Tertiary care children's hospital. METHODS Data were extracted from charts of children with a history of kidney, heart, or liver transplantation, who underwent T/AT between 2006 and 2021. RESULTS A total of 110 patients met the inclusion criteria, including 46 hearts, 41 kidneys, 19 livers, and 4 liver-and-kidney transplants. The mean age at transplantation was 4.2 years, and the mean transplantation-to-T/AT time interval was 28.8 months. The posttransplant lymphoproliferative disorder was diagnosed in 52 (47.3%) patients, and 25% of these had no tonsillar hypertrophy. There was no difference in age at transplantation, organ received, transplantation-to-T/AT time interval, immunosuppressive medications, tonsil size, or tonsillar asymmetry between patients diagnosed with the posttransplant lymphoproliferative disorder and patients with benign tonsillar/adenotonsillar hypertrophy. Posttonsillectomy complications were similar between the groups. CONCLUSION The incidence of posttransplant lymphoproliferative disorder undergoing tonsillectomy for any indication was 47.3%. There was no association between preoperative signs and symptoms and the histopathological diagnosis of posttransplant lymphoproliferative disorder. Stratification by organ received and immunosuppressive medications did not identify differences among the groups relative to the incidence of posttransplant lymphoproliferative disorder and other postoperative complications.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois, Chicago, USA.,Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Illinois, Chicago, USA
| | - Natalia Hajnas
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois, Chicago, USA.,Department of Otolaryngology-Heand and Neck Surgery, University of Illinois at Chicago, Illinois, Chicago, USA
| | - Mitchell Victor
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois, Chicago, USA.,Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Illinois, Chicago, USA
| | - Eli Stein
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois, Chicago, USA.,Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Illinois, Chicago, USA
| | - Aida Richardson
- Department of Pathology, Northwestern University Feinberg School of Medicine, Illinois, Chicago, USA.,Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, United States
| | - Kathleen R Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois, Chicago, USA.,Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Illinois, Chicago, USA
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Vaughn WL, Cordray H, Baranwal N, Rahman R, Mahendran GN, Clark A, Wright EA, Pak-Harvey E, Patel C, Evans SS. Evaluating obesity as a risk factor for complications after pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2022; 163:111333. [PMID: 36257170 DOI: 10.1016/j.ijporl.2022.111333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate associations between childhood obesity and post-adenotonsillectomy complications, informing guidelines for postoperative management. METHODS The retrospective review assessed outpatient pediatric tonsillectomy/adenoidectomy cases performed at 2 ambulatory surgery centers in 2020. Complications in the recovery unit and within 2 weeks of surgical discharge were reviewed along with clinical and demographic variables. Obesity was defined as sex-specific body mass index-for-age, or weight-for-age if height data were unavailable, at/above the 95th percentile. The 99th percentile served as the threshold for severe obesity. Analyses used Chi-square/Fisher's exact tests and independent-samples t-tests with relative risk or effect sizes. RESULTS The review included 707 cases (180 patients with obesity). Overall incidence of complications in the recovery unit was 9.1%. Patients with obesity were significantly more likely to require supplemental blow-by oxygen (P = .02); relative risk was 1.65 (95% CI: 1.16-2.35) times greater in the cohort with obesity. Obesity had a small effect on postoperative oxygen saturation nadirs, which were significantly lower among patients with obesity (d = -0.34; P < .001). No differences emerged between cohorts with and without obesity in the incidence of any other complications before or after surgical discharge. Overall incidence of post-discharge returns was 7.9%. Incidence of complications did not vary by obesity severity. CONCLUSION From this cohort, childhood obesity without other significant comorbidities may not warrant routine inpatient care following adenotonsillectomy. Patients with obesity should receive additional monitoring for oxygen desaturation events during the first hours of recovery. Further prospective studies should continue to address this important topic.
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Affiliation(s)
| | - Holly Cordray
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Navya Baranwal
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rahiq Rahman
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Geethanjeli N Mahendran
- Emory University School of Medicine, Atlanta, GA, USA; Rollins School of Public Health, Atlanta, GA, USA
| | - Addison Clark
- Department of Biological and Environmental Sciences, Georgia College and State University, USA
| | | | | | - Chhaya Patel
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean S Evans
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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7
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Costa R, Fernandes Â, Fonseca R. Evaluation of the Efficacy of Paracetamol in the Control of Pain After Adenotonsillectomy in the Pediatric Population. Cureus 2022; 14:e30807. [PMID: 36447730 PMCID: PMC9701532 DOI: 10.7759/cureus.30807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 06/16/2023] Open
Abstract
Introduction Adenotonsillectomy is a common surgical procedure in otolaryngology. Over the years, several techniques have been developed and modified in order to reduce mortality and morbidity. Postoperative pain control remains controversial. The aim of this study was to evaluate the efficacy of paracetamol alone in the control of postoperative pain. Methods A prospective study was conducted between May 2018 and February 2019, including 76 pediatric patients (age < 18 years), who underwent adenotonsillectomy. The surgeries were performed by the lead author with the same surgical technique. Patients were evaluated one week and one month after surgery through the application of the visual analog pain scale and the number of days of pain was assessed by the need for medication. Results Seventy-six total adenotonsillectomy were performed, with a total of 152 tonsils removed. The majority of patients were male (n=39, 51.3%), with an average age of 6.9 years (min 5, max 15 years). The most frequent surgical indication was sleep breathing disorders, present in 86.9% of the cases. The average duration of postoperative pain was 3 days, with no significant difference between groups (p>0.05). The average intensity of postoperative pain was 3.36 and was higher in patients with infectious criteria as surgical indications (p<0.05). Postoperative bleeding occurred in 3.9% (n=3) of the children, self-limited, without the need for readmission or surgical revision. Conclusion Pain after adenotonsillectomy was more intense in patients undergoing surgery for infectious criteria. Paracetamol used in monotherapy has shown safety and efficacy in controlling postoperative pain.
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Affiliation(s)
- Ricardo Costa
- Otolaryngology - Head and Neck Surgery, Hospital da Senhora da Oliveira, Guimarães, PRT
| | - Ângelo Fernandes
- Otolaryngology - Head and Neck Surgery, Hospital da Senhora da Oliveira, Guimarães, PRT
| | - Rui Fonseca
- Otolaryngology - Head and Neck Surgery, Hospital da Senhora da Oliveira, Guimarães, PRT
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8
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Fushimi K, Gyo K, Okunaka M, Watanabe M, Sugihara A, Tsuzuki K. Analysis of risk factors for post-tonsillectomy hemorrhage in adults. Auris Nasus Larynx 2022; 50:389-394. [PMID: 36272864 DOI: 10.1016/j.anl.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To identify the risk factors for post-tonsillectomy hemorrhage (PTH) in adult patients (>19 years). METHODS 275 adult patients who underwent tonsillectomy between 2009 and 2019 were retrospectively analyzed. Possible risk factors associated with PTH were investigated by univariate and multivariate logistic regression analyses. RESULTS PTH occurred in 39 of 275 patients (14.2%). Regarding underlying diseases, PTH occurred more frequently in focal infection of IgA nephropathy. Furthermore, bipolar electrocautery was the other risk factor for PTH on multivariate analysis. CONCLUSION Focal infection of IgA nephropathy and bipolar electrocautery were identified as the risk factors for PTH.
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Brock R, Chu A, Lu S, Brindle ME, Somayaji R. Postoperative complications after gastrointestinal pediatric surgical procedures: outcomes and socio-demographic risk factors. BMC Pediatr 2022; 22:358. [PMID: 35733099 PMCID: PMC9215078 DOI: 10.1186/s12887-022-03418-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several socio-demographic characteristics are associated with complications following certain pediatric surgical procedures. In this comprehensive study, we sought to determine socio-demographic risk factors and resource utilization of children with complications after common pediatric surgical procedures. METHODS We performed a population-based cohort study utilizing the 2016 Healthcare Cost and Use Project Kids' Inpatient Database (KID) to identify and characterize pediatric patients (age 0-21 years) in the United States with common inpatient pediatric gastrointestinal surgical procedures: appendectomy, cholecystectomy, colonic resection, pyloromyotomy and small bowel resection. Multivariable logistic regression modeling was used to identify socio-demographic predictors of postoperative complications. Length of stay and hospitalization costs for patients with and without postoperative complications were compared. RESULTS A total of 66,157 pediatric surgical hospitalizations were identified. Of these patients, 2,009 had postoperative complications. Male sex, young age, African American and Native American race and treatment in a rural hospital were associated with significantly greater odds of postoperative complications. Mean length of stay was 4.58 days greater and mean total costs were $11,151 (US dollars) higher in the complication cohort compared with patients without complications. CONCLUSIONS Postoperative complications following inpatient pediatric gastrointestinal surgery were linked to elevated healthcare-related expenditure. The identified socio-demographic risk factors should be considered in the risk stratification before pediatric surgical procedures. Targeted interventions are required to reduce preventable complications and surgical disparities.
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Affiliation(s)
- Robert Brock
- Department of Pediatric and Adolescent Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Angel Chu
- Department of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shengjie Lu
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mary Elizabeth Brindle
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
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10
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Tran AHL, Liew D, Horne RSC, Rimmer J, Nixon GM. Cost and economic determinants of paediatric tonsillectomy. AUST HEALTH REV 2022; 46:153-162. [PMID: 35380106 DOI: 10.1071/ah21100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 12/11/2021] [Indexed: 11/23/2022]
Abstract
Objective Hospital utilisation research is important in pursuing cost-saving healthcare models. Tonsillectomy is one of the most common paediatric surgeries and the most frequent reason for paediatric hospital readmission. This study aimed to report the government-funded costs of paediatric tonsillectomy in the state of Victoria, Australia, extrapolate costs across Australia, and identify the cost determinants. Methods A population-based longitudinal study was conducted with a bottom-up costing approach using linked datasets containing all paediatric tonsillectomy and tonsillectomy with adenoidectomy surgeries performed in the state of Victoria between 2010 and 2015. Results The total average annual cost of tonsillectomy hospitalisation in Victoria was A$21 937 155 with a median admission cost of A$2224 (interquartile range (IQR) 1826-2560). Inflation-adjusted annual tonsillectomy costs increased during 2010-2015 (P < 0.001), not explained by the rising number of surgeries. Hospital readmissions resulted in a total average annual cost of A$1 427 716, with each readmission costing approximately A$2411 (IQR 1936-2732). The most common reason for readmission was haemorrhage, which was associated with the highest total cost. The estimated total annual expenditure of both tonsillectomy and resulting readmissions across Australia was A$126 705 989. Surgical cost in the upper quartile was associated with younger age, male sex, lower socioeconomic status, surgery for reasons other than infection alone, overnight vs day case surgery, public hospitals and metropolitan hospitals. Surgery for obstructed breathing during sleep had the strongest association to high surgical cost. Conclusions This study highlights the cost of paediatric tonsillectomy and associated hospital readmissions. The study findings will inform healthcare reform and serve as a basis for strategies to optimise patient outcomes while reducing both postoperative complications and costs.
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Affiliation(s)
- Aimy H L Tran
- Department of Paediatrics, Monash University, Melbourne, Vic., Australia; and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Vic., Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - Rosemary S C Horne
- Department of Paediatrics, Monash University, Melbourne, Vic., Australia; and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Vic., Australia
| | - Joanne Rimmer
- Department of Otolaryngology, Head and Neck Surgery, Monash Health, Melbourne, Vic., Australia; and Department of Surgery, Monash University, Melbourne, Vic., Australia
| | - Gillian M Nixon
- Department of Paediatrics, Monash University, Melbourne, Vic., Australia; and Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, Vic., Australia
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11
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Tran AHL, Chin KL, Horne RSC, Liew D, Rimmer J, Nixon GM. Hospital revisits after paediatric tonsillectomy: a cohort study. J Otolaryngol Head Neck Surg 2022; 51:1. [PMID: 35022073 PMCID: PMC8756632 DOI: 10.1186/s40463-021-00552-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 10/31/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Tonsillectomy, with or without adenoidectomy, is the leading reason for paediatric unplanned hospital readmission, some of which are potentially avoidable. Reducing unplanned hospital revisits would improve patient safety and decrease use of healthcare resources. This study aimed to describe the incidence, timing and risk factors for any surgery-related hospital revisits (both emergency presentation and readmission) following paediatric tonsillectomy and adenotonsillectomy in a large state-wide cohort. METHODS We conducted a population-based cohort study using linked administrative datasets capturing all paediatric tonsillectomy and adenotonsillectomy surgeries performed between 2010 and 2015 in the state of Victoria, Australia. The primary outcome was presentation to the emergency department or hospital readmission within 30-day post-surgery. RESULTS Between 2010 and 2015, 46,583 patients underwent 47,054 surgeries. There was a total of 4758 emergency department presentations (10.11% total surgeries) and 2750 readmissions (5.84% total surgeries). Haemorrhage was the most common reason for both revisit types, associated with 33.02% of ED presentations (3.34% total surgeries) and 67.93% of readmissions (3.97% total surgeries). Day 5 post-surgery was the median revisit time for both ED presentations (IQR 3-7) and readmission (IQR 3-8). Predictors of revisit included older age, public and metropolitan hospitals and peri-operative complications during surgery. CONCLUSIONS Haemorrhage was the most common reason for both emergency department presentation and hospital readmission. The higher risk of revisits associated with older children, surgeries performed in public and metropolitan hospitals, and in patients experiencing peri-operative complications, suggest the need for improved education of postoperative care for caregivers, and avoidance of inappropriate early discharge.
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Affiliation(s)
- Aimy H L Tran
- Department of Paediatrics, Monash University and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Ken L Chin
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rosemary S C Horne
- Department of Paediatrics, Monash University and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joanne Rimmer
- Department of Otolaryngology, Head and Neck Surgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - Gillian M Nixon
- Department of Paediatrics, Monash University and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia. .,Melbourne Children's Sleep Centre, Monash Children's Hospital, 246 Clayton Road, Victoria, 3168, Australia.
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12
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Lloyd AM, Behzadpour HK, Schonman I, Rana MS, Espinel AG. Socioeconomic factors associated with readmission following pediatric tonsillectomy. Int J Pediatr Otorhinolaryngol 2021; 151:110917. [PMID: 34508945 DOI: 10.1016/j.ijporl.2021.110917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/25/2021] [Accepted: 09/03/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We aim to analyze factors associated with readmission after tonsillectomy to understand socioeconomic factors associated with readmission. METHODS Single institution retrospective study of pediatric patients undergoing tonsillectomy over an 8 year study period, comparing patients who required readmission for bleeding concerns or pain/dehydration to those who did not require readmission. RESULTS Of the 14,152 tonsillectomy patients, 508 (3.6%) were readmitted with 423 (83.3%) for bleeding concerns and 85 (16.7%) for pain or dehydration. Overall readmission was more likely in age >6 years (OR: 1.61, 95% CI: 1.34-1.92, P < 0.001), while poverty level below 10% (OR: 0.79, 95% CI: 0.66-0.94, P = 0.008) and parental college education above 25% (OR: 0.79, 95% CI: 0.65-0.96, P = 0.016) were associated with lower incidence of overall readmission. For patients readmitted for bleeding concerns, age >6 years (OR 1.66, 95% CI: 1.37-2.02, P < 0.001) was associated with readmission on multivariate analysis. Within the pain/dehydration group, African American race was associated with increased readmission rates, while poverty level below 10% and parental college education above 25% were associated with decreased readmission rates. CONCLUSION Socioeconomic factors and age play a role in readmission rates following pediatric tonsillectomy.
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Affiliation(s)
- Ashley M Lloyd
- Division of Otolaryngology, George Washington University Hospital, Washington, DC, USA.
| | - Hengameh K Behzadpour
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, DC, USA
| | - Ian Schonman
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Md Sohel Rana
- Department of Surgery, Children's National Hospital, Washington DC, USA
| | - Alexandra G Espinel
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, DC, USA
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Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study. Int J Pediatr Otorhinolaryngol 2021; 147:110802. [PMID: 34146910 DOI: 10.1016/j.ijporl.2021.110802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Evaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH). METHODS Based on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA. RESULTS The incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not. CONCLUSION Treatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication. LEVEL OF EVIDENCE 4.
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Nasal Sprays Containing Mometasone Furoate for Relief of Post-Adenotonsillectomy Pain in Children: A Prospective Controlled Study. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:101-107. [PMID: 33935543 PMCID: PMC8085455 DOI: 10.14744/semb.2020.75735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/10/2020] [Indexed: 11/20/2022]
Abstract
Objectives Adenotonsillectomy is one of most common surgeries performed in childhood. Post-operative pain associated particularly with tonsillectomy is still a problem for many physicians. Despite advances in surgical techniques, analgesics, or anti-inflammatory drugs, no unique strategy for post-tonsillectomy pain management has been suggested. The aim of this study is to investigate the analgesic effect of steroid containing nasal spray applied to tonsillar region after tonsillectomy. Methods Eighty-two patients were assigned into two groups as study and control. In study group, nasal spray containing steroid was applied to each tonsillar region after surgery for 5 days. Post-operative pain of all patients was assessed using a visual analog scale and results were compared. Results Pain decreased gradually over time in both the study and control groups. Although the pain scores from 4 h post-surgery to post-operative day 5 were not found to significantly decrease in children that used nasal spray containing steroid, these patients developed less pain on post-operative day 5,with statistical significance (p<0.05). Conclusion Post-tonsillectomy pain was reported to increase around post-operative day 5, which coincides with the time of intense wound inflammation. Therefore, significant pain reduction on post-operative day 5 observed in children that used nasal spray with steroid may have clinical importance for overcoming this problem.
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15
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Kang Y, Ku EJ, Jung IG, Kang MH, Choi YS, Jung HJ. Dexamethasone and post-adenotonsillectomy pain in children: Double-blind, randomized controlled trial. Medicine (Baltimore) 2021; 100:e24122. [PMID: 33466183 PMCID: PMC7808470 DOI: 10.1097/md.0000000000024122] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 12/09/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To assess the impact of intraoperative intravenous dexamethasone on the reduction of postoperative morbidity in children undergoing adenotonsillectomy. METHODS A double blind randomized controlled trial conducted among children undergoing adenotonsillectomy at a tertiary hospital in Korea from November 2018 to June 2019. Children were randomly assigned to receive dexamethasone (0.5 mg/kg, maximum dose 24 mg) or placebo intravenously after induction of anesthesia. The primary endpoint was the reduction of postoperative pain and postoperative nausea and vomiting (PONV); secondary endpoints were adverse effects like postoperative hemorrhage. RESULTS The study included 105 children, and 67 were male. Their mean age was 6.2 ± 2.1 years. There was no significant difference between the groups in terms of demographic data or the operation time. The pain scores of the dexamethasone group were lower than those of the control group, but no significant difference was found (all P > .05). The average pain visual analog scale (VAS) during the study period (day 0-7) was 3.67 ± 1.59 and 4.40 ± 2.01 in the dexamethasone group and control group, respectively (P-value = .107). When we compared early pain VAS (day 0-2) and late pain VAS (day 5-7), the dexamethasone group showed significantly lower early mean VAS compared to the control group (4.55 ± 1.78 vs 5.40 ± 2.05, P-value = .046). The mean VAS for PONV was significantly lower in the dexamethasone group than in the control group (1.89 ± 2.22 vs 3.00 ± 2.37, P value = .044). CONCLUSION In children undergoing adenotonsillectomy, dexamethasone decreased the early postoperative pain and PONV without increasing postoperative hemorrhage.
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Affiliation(s)
- Young Kang
- Department of Otorhinolaryngology-Head and Neck Surgery
| | - Eu Jeong Ku
- Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Il Gu Jung
- Department of Otorhinolaryngology-Head and Neck Surgery
| | | | | | - Hahn Jin Jung
- Department of Otorhinolaryngology-Head and Neck Surgery
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16
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Greenwell AG, Isaiah A, Pereira KD. Recovery After Adenotonsillectomy-Do Steroids Help? Outcomes From a Randomized Controlled Trial. Otolaryngol Head Neck Surg 2020; 165:83-88. [PMID: 33228459 DOI: 10.1177/0194599820973250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The primary objective was to compare pain control following adenotonsillectomy (AT) in children with and without a single postoperative dose of oral dexamethasone in addition to standard analgesic medication. The secondary objective was to compare changes in caregiver-reported snoring, return to normal diet and baseline function, and the number of phone calls and emergency department (ED) visits. STUDY DESIGN Prospective randomized controlled trial. SETTING Tertiary care university hospital. METHODS Children aged 3 to 10 years with sleep-disordered breathing who were scheduled to undergo AT were randomized to receive standard analgesia with or without dexamethasone (0.6 mg/kg) administered on the third postoperative day. Standard analgesia was defined as alternating weight-based doses of ibuprofen and acetaminophen. A nurse practitioner blinded to the study condition performed telephone surveys postoperatively, and the electronic medical record was reviewed. RESULTS Enrollment comprised 149 children, of whom 119 were included. When compared with the control group (n = 61, 51%), children who received dexamethasone (n = 58, 49%) had a greater decrease in reported pain score on day 4 (mean ± SD, 2.5 ± 3.1 vs 1.1 ± 3.5, P < .001). Additionally, steroid use was associated with fewer caregiver phone calls (18 [29.5%] vs 6 [10%]) and ED visits (6 [10%] vs 1 [2%]). CONCLUSION A single dose of dexamethasone administered on day 3 after adenotonsillectomy significantly improved pain control. There were fewer phone calls and ED visits in the steroid arm. These results support the use of oral steroids as an adjunct for postoperative pain control in children undergoing AT.
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Affiliation(s)
- Ariana G Greenwell
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Amal Isaiah
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Kevin D Pereira
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
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17
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Rabbani CC, Pflum ZE, Ye MJ, Gettelfinger JD, Sadhasivam S, Matt BH, Dahl JP. Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative analgesia. Int J Pediatr Otorhinolaryngol 2020; 138:110341. [PMID: 32891944 DOI: 10.1016/j.ijporl.2020.110341] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Determine the impact of ketorolac on post-tonsillectomy hemorrhage (PTH) and narcotic administration in children undergoing tonsillectomy. METHODS Retrospective case series from 2013 to 2017. Patients younger than 18 years undergoing tonsillectomy were included. PTH was the primary outcome measured. Secondary measures include percentage of patients requiring surgical intervention for PTH, average time to PTH, the number of post-operative opioid doses, and average post-operative opioid dose. Statistical methods include Chi-square, Wilcoxon rank sum, and binary logistic regression analyses. RESULTS During the study period, 669 patients received a single intraoperative dose of ketorolac (K+) and 653 patients did not receive ketorolac (K-). No differences were found in the rate of PTH (K- 6.5% vs. K+ 5.3%, RR = 0.82, 95% CI = 0.53 to 1.29, p = 0.40), surgical control of PTH (K- 4.0% vs. K+ 3.5%, RR = 0.87, CI = 0.51 to 1.51, p = 0.62), or average time [SD] to PTH (K- 6.0 [4.2] vs. K+ 5.2 [4.9] days; difference = 0.8 days; 95% CI, -1.3 to 2.9; p = 0.45). K+ patients had fewer post-operative opioid doses [SD] (K- 1.86 [1.14] vs. K+ 1.59 [1.23]; difference = -0.27; 95% CI, -0.053 to -0.49, Cohen d = 0.23) and a lower average opioid dose [SD] (K- 0.041 [0.032] vs. K+ 0.035 [0.030] mg/kg; difference = -0.006 mg/kg; 95% CI, -0.0003 to -0.012; Cohen d = 0.19). CONCLUSION Ketorolac did not increase risk of hemorrhage following tonsillectomy and decreased narcotic use.
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Affiliation(s)
| | | | - Michael J Ye
- Department of Otolaryngology-Head and Neck Surgery, USA
| | | | - Senthil Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruce H Matt
- Department of Otolaryngology-Head and Neck Surgery, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, USA.
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Agamawi YM, Cass LM, Mouzourakis M, Pannu JS, Brinkmeier JV. Pediatric Post-Tonsillectomy Opioid Prescribing Practices. Laryngoscope 2020; 131:1386-1391. [PMID: 33022125 DOI: 10.1002/lary.29157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 09/03/2020] [Accepted: 09/13/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding. METHODS Retrospective chart review of pre- and post-intervention in pediatric post-tonsillectomy patients, 0-18 years old (n = 1486). Order sets were installed with age-specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time-balanced pre- and post-intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed. RESULTS Discharge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg [95% CI, 0.092-0.099] vs. 0.079 [95% CI, 0.076-0.083], P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 [95% CI, 43.6-49.1] to 20.3 [95% CI, 19.1-21.5], P < .001). Patients <7 years old prescribed opioids remained rare in pre- and post-intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post-intervention group showed an increase in readmissions for post-tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post-intervention group after stratification by age. CONCLUSION Utilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post-tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1386-1391, 2021.
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Affiliation(s)
- Yusuf M Agamawi
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Lauren M Cass
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | | | - Jaibir S Pannu
- Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jennifer V Brinkmeier
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
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Gonçalves AI, Rato C, de Vilhena D, Duarte D, Lopes G, Trigueiros N. Evaluation of post-tonsillectomy hemorrhage and assessment of risk factors. Eur Arch Otorhinolaryngol 2020; 277:3095-3102. [PMID: 32451667 DOI: 10.1007/s00405-020-06060-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Tonsillectomy is one of the most common surgical procedures in otorhinolaryngology. Hemorrhage in the postoperative period has an incidence of up to 20% and is a potentially fatal complication. We aim to assess the incidence of hemorrhage after tonsillectomy in our institution, and to evaluate and identify the possible associated risk factors. METHODS This retrospective study included 897 patients who underwent tonsillectomy between January 2015 and December 2018, 50.7% women and 49.3% men, aged between 2 and 83 years. No coagulopathies were identified. Comparison of age, gender, surgical indication, coagulation profile, concomitant adenoidectomy, surgical technique, surgeon's experience and hemostasis method between groups with and without post-operative bleeding was made. RESULTS Our incidence of post-tonsillectomy hemorrhage was 6%. Most patients (83.3%) had secondary bleeding (> 24 h after surgery). In 22.2% of the bleeding cases, it was necessary to revise the hemostasis in the operating room. Adulthood (age ≥ 18 years) (p < 0.001), INR values ≥ 1.2 (p = 0.014), aPTT values ≥ 35 s (p = 0.001), as well as concomitant adenoidectomy (p < 0.001) were the predictors of post-tonsillectomy bleeding. CONCLUSION Recognition of adult age, INR ≥ 1.2, aPTT ≥ 35 s and concomitant adenoidectomy as risk factors can be useful in identifying the patients at higher risk for bleeding complications.
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Affiliation(s)
- Ana Isabel Gonçalves
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal.
| | - Catarina Rato
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Ditza de Vilhena
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Delfim Duarte
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Gustavo Lopes
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Nuno Trigueiros
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
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Ding XX, Zhao LQ, Cui XG, Yin Y, Yang HA. Clinical observation of soft palate-pharyngoplasty in the treatment of obstructive sleep apnea hypopnea syndrome in children. World J Clin Cases 2020; 8:679-688. [PMID: 32149052 PMCID: PMC7052550 DOI: 10.12998/wjcc.v8.i4.679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/21/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Childhood obstructive sleep apnea hypopnea syndrome (OSAHS) is a common clinical disease that can cause serious complications if not treated in time. The preferred treatment for OSAHS in children is surgery.
AIM To observe the effects of soft palate-pharyngoplasty on postoperative outcome, pharyngeal formation, and possible complications.
METHODS A total of 150 children with snoring, hernia, and mouth breathing were selected. A polysomnography test was performed to confirm the diagnosis of OSAHS. The children were randomly divided into experimental and control groups. The experimental group underwent adenoidectomy, tonsillectomy, and soft palate-pharyngoplasty. The control group underwent adenoidectomy and tonsillectomy. The t-test and chi-square test were used to compare conditions such as postoperative fever, postoperative hemorrhage, and pharyngeal reflux. Postoperative efficacy and complications were interrogated and observed in the form of outpatient follow-up and telephone follow-up at 6 mo and 1 year after surgery. The curative effects were divided into two groups: Cure (snoring, snoring symptoms disappeared) and non-cure.
RESULTS The effective rate of the experimental group was significantly higher than that of the control group, but the difference was not statistically significant (P > 0.05). The incidence of postoperative bleeding was lower in the experimental group. There was no postoperative pharyngeal reflux in either group. In the experimental group, the incidence of hyperthermia (body temperature exceeded 38.5 °C) was lower than that in the control group. The difference in postoperative swallowing pain scores between the experimental and control groups was significant.
CONCLUSION Soft palate-pharyngoplasty can more effectively enlarge the anteroposterior diameter and transverse diameter of the isthmus faucium. Compared with surgery alone, it can better treat OSAHS in children, improve the curative effect, reduce the risk of perioperative bleeding, close the surgical cavity, reduce the risk of postoperative infection, reduce the proportion of postoperative fever, and accelerate healing. Although this process takes more time, it is simple, safe, and effective.
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Affiliation(s)
- Xiao-Xu Ding
- Department of Otolaryngology Head and Neck Surgery, Department of The Sleep Medicine Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Lan-Qing Zhao
- Department of Otolaryngology Head and Neck Surgery, Department of The Sleep Medicine Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Xiang-Guo Cui
- Department of Otolaryngology Head and Neck Surgery, Department of The Sleep Medicine Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Yang Yin
- Department of Otolaryngology Head and Neck Surgery, Department of The Sleep Medicine Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Huai-An Yang
- Department of Otolaryngology Head and Neck Surgery, Department of The Sleep Medicine Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Chisholm AG, Sathyamoorthy M, Seals SR, Carron JD. Does intravenous acetaminophen reduce perioperative opioid use in pediatric tonsillectomy? Am J Otolaryngol 2019; 40:102294. [PMID: 31521403 DOI: 10.1016/j.amjoto.2019.102294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Postoperative pain control is of significant interest in pediatric otolaryngology given the safety concerns with opioid use. We sought to determine if addition of intraoperative intravenous acetaminophen decreases perioperative morphine use in pediatric tonsillectomy. METHODS This study is a retrospective cohort study performed at a tertiary care academic children's hospital. 166 pediatric patients (aged 1-16 years) who underwent tonsillectomy with or without adenoidectomy were for review. Seventy-four patients received intraoperative intravenous acetaminophen (intervention cohort), while ninety-two patients served as our control and did not receive any intraoperative intravenous acetaminophen. Perioperative (intraoperative and postoperative) morphine use was our primary outcome measure. Rate of adverse events in the post anesthesia care unit and time for discharge readiness were secondary outcome measures. Wilcoxon two-sample t-test approximation and Fisher's exact test were used for data analyses. RESULTS Patients in the intravenous acetaminophen cohort received less morphine (mg/kg) intraoperatively (0.058 versus 0.070, p = 0.089) and in the post anesthesia care unit (0.034 versus 0.051, p = 0.034) than the control cohort. The median time to discharge readiness for the intravenous acetaminophen and control groups was 108.5 versus 105 min (p = 0.018). There was no adverse respiratory event (oxygen desaturation <92% lasting more than a minute, requiring bag mask ventilation or reintubation) in either group in the post anesthesia care unit. There were 5 (7%) episodes of postoperative vomiting in the IV APAP, while 2 (2%) were recorded in the control cohort (p = 0.244). CONCLUSION Our findings suggest intraoperative intravenous acetaminophen use in pediatric tonsillectomy can decrease the perioperative use of opioid for optimal pain management.
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Affiliation(s)
- Allison G Chisholm
- Department of Otolaryngology, Cook Children's Hospital, 901 7th Avenue, 1st Floor, Fort Worth, TX 76104, United States of America
| | - Madhankumar Sathyamoorthy
- Scope Anesthesia, Carolinas Medical Center/Levine Children's Hospital, 1000 Blythe Blvd, Charlotte, NC 28203, United States of America
| | - Samantha R Seals
- Department of Mathematics and Statistics, University of West Florida, 11000 University Parkway, Pensacola, FL 32514, United States of America
| | - Jeffrey D Carron
- Department of Otolaryngology-Head and Neck Surgery, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, United States of America.
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Reducing Readmissions Post-tonsillectomy: A Quality Improvement Study on Intravenous Hydration. J Healthc Qual 2019; 40:217-227. [PMID: 29864070 DOI: 10.1097/jhq.0000000000000143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Dehydration is a potentially preventable complication post-tonsillectomy and can result in an Emergency Department visit and/or readmission. Our objectives were to identify risk factors for dehydration readmissions and develop interventions to prevent them. METHODS We used retrospective chart reviews to determine if increased intravenous (IV) hydration post-tonsillectomy prevented hospital readmissions for dehydration. All children aged 1-18 years who underwent tonsillectomy between July 1, 2007 and September 30, 2015 were included in this quality improvement study. Using the Pediatric Health Information System database, patients who experienced a readmission for dehydration within 72 hours of surgery were identified and validated with internal data. We analyzed the pre-implementation and post-implementation readmission rates after standardization of increased IV fluids (1.5 times maintenance). An interrupted time series analysis was used to estimate the effects of our hydration initiative. RESULTS Of 11,157 patients who underwent tonsillectomy during the study period, 96 (0.9%) met the criteria for readmissions for dehydration. The pre-implementation readmission rate was 1% compared to 0.2% post-implementation, a reduction of 82%. CONCLUSIONS The hydration initiative was associated with a significant decrease in hospital readmissions. This safe, low-cost, easy-to-implement approach to preventing dehydration post-tonsillectomy could be explored at other institutions.
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Lawlor CM, Riley CA, Carter JM, Rodriguez KH. Association Between Age and Weight as Risk Factors for Complication After Tonsillectomy in Healthy Children. JAMA Otolaryngol Head Neck Surg 2019; 144:399-405. [PMID: 29543971 DOI: 10.1001/jamaoto.2017.3431] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The 1996 Tonsillectomy and Adenoidectomy Inpatient Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Pediatric Otolaryngology Committee recommended that children younger than 3 years be admitted following tonsillectomy. Recommendations for hospital observation were not included as a key action statement in the 2011 AAO-HNS Clinical Practice Guidelines for Tonsillectomy in Children. Objective To examine the association between posttonsillectomy complication rate and the age and weight of the child at the time of surgery. Design, Setting, and Participants This was a multicenter case series study with medical record review of 2139 consecutive children ages 3 to 6 years who underwent tonsillectomy at 1 tertiary care academic center and 5 acute care centers in New Orleans, Louisiana, between 2005 and 2015. Children with moderate to severe developmental delay, bleeding disorders, and other major medical comorbidities were excluded. Main Outcomes and Measures Complications examined included respiratory distress, dehydration requiring intravenous fluids, and bleeding. Results Of the 2139 patients, 1817 met inclusion criteria. A total of 1011 (55.6%) were male. The mean (SD) age at the time of the procedure was 46 (14) months (range, 12-72 months). The mean weight at the time of the procedure was 17 (5) kg (range, 9-43 kg). A total of 95 patients (5.2%) had a postoperative complication. Of the 455 children younger than 3 years in the study, 32 (7.0%) had complications compared with 63 (4.6%) of the 1362 patients 3 years or older. The odds of having a complication in children younger than 3 years was 1.5 times greater than it was in children 3 years or older (odds ratio [OR], 1.56; 95% CI, 1.00-2.42). When examining total complications, children younger than 3 years were more likely to experience a complication within the first 24 hours after surgery than children 3 years or older (25% vs 9.5%; OR, 3.17; 95% CI, 1.00-10.11). The children admitted to the hospital had a greater risk of complication than those treated as an outpatient, independent of age (6.9% vs 93.0%; OR, 3.49; 95% CI, 2.0.18-6.05). No association between weight and complications was found on logistic regression (area under the curve = 0.5268; P = .66). Conclusions and Relevance Healthy children younger than 3 years may be at an increased risk for complication following tonsillectomy. Those children may also be at increased risk for complications within the first 24 hours after surgery compared with children 3 years or older. Our data suggest that complications are independent of weight in these patients. In our cohort, those patients selected for overnight observation were associated with an increased number of adverse events following tonsillectomy, suggesting that clinician judgment is crucial in determining which patients are safe for outpatient tonsillectomy.
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Affiliation(s)
- Claire M Lawlor
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John M Carter
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Kimsey H Rodriguez
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
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Lavin J, Lehmann D, Silva AL, Bai G, Hebal F, Manworren R, Stake C, Rychlik K, Billings KR. Variables associated with pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients. Int J Pediatr Otorhinolaryngol 2019; 123:10-14. [PMID: 31054535 DOI: 10.1016/j.ijporl.2019.04.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Returns to the emergency department (ED) for pain or dehydration after adenotonsillectomy (T&A) are frequent. Attempts to associate the specific pain regimens with these visits have been unrevealing, suggesting a need to assess for other potential factors associated with readmission. METHODS A review of a 2:1 cohort matched by age, gender and payer status compared post-T&A patients who did not return ED for pain or dehydration within 21 days to those who returned. Factors investigated included patient demographics, comorbidities, medication regimen and the presence of postoperative telephone encounters. Patients returning to the ED were further assessed for rates of medication adherence. RESULTS 7493 patients underwent T&A during the period. Of these, 144 (1.9%) returned for pain/dehydration. Comparison to 285 matched patients revealed an association between ED returns and Hispanic ethnicity (p < 0.001), Spanish language (p = 0.0002), and comorbid Down syndrome and ADHD (p = 0.011 in both). The incidence of parent telephone calls to the office was associated with ED returns (58.7 in the ED cohort, 28.4% in non-ED cohort, p < 0.0001). On multivariable analysis, Hispanic ethnicity and phone calls were associated with ED returns (p < 0.0001 and p < 0.0001, respectively). Only 64.0% of patients returning to the ED were adherent with postoperative pain regimens. CONCLUSIONS While demographic factors may be associated with rate of ED returns for pain and dehydration, post-operative phone calls were most highly associated with returns. The majority of patients returning to the ED were non-adherent with recommended pain regimens, suggesting an opportunity to investigate medication adherence in all post-tonsillectomy patients.
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Affiliation(s)
- Jennifer Lavin
- Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, USA
| | - David Lehmann
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Astrid Leon Silva
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA
| | - Guangyu Bai
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Ferdynand Hebal
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA
| | - Renee Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA; Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Nursing, Chicago, IL, USA
| | - Christine Stake
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, USA
| | - Karen Rychlik
- Stanley Manne Children's Research Institute, Biostatistics Research Core, Chicago, IL, USA; Northwestern University-Feinberg School of Medicine, Department of Pediatrics, Chicago, IL, USA
| | - Kathleen R Billings
- Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, USA.
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He Y, Cai Z, Yang J. Revisit rates following pediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 2019; 122:130-132. [PMID: 31009921 DOI: 10.1016/j.ijporl.2019.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/04/2019] [Accepted: 04/13/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To explore the rate of emergency department (ED) revisits and hospital readmissions following coblation tonsillectomy in children with sleep-disordered breathing (SDB) and/or recurrent tonsillitis. METHODS A total of 2045 children underwent coblation tonsillectomy were recruited in the retrospective study. The number of revisits or readmissions was recorded and the reasons were analyzed. RESULTS Overall, 119 (5.8%) had unplanned revisits after surgery. Of those children, 98 (4.8%) had one revisit, 19 (0.92%) had second revisits, and 2 (0.097%) had third revisits. The interval between surgery and first revisit or second revisit was 7.1 ± 5.2 days and 11.3 ± 4.8 days, respectively. The reasons for first revisits were hemorrhage, fever, pain, nausea/vomiting, dehydration. The reasons for second revisits were pain, hemorrhage, fever. Children with younger age (1-3 years old) and more blood loss during surgery had higher rate of first revisit rate. Most revisits were controlled well and only 4 cases of re-surgery was needed. CONCLUSIONS Revisit rate and reason after coblation tonsillectomy in children were similar to other surgical methods. Coblation tonsillectomy is a safe and effective surgery for children.
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Affiliation(s)
- Yuxia He
- Department of Otolaryngology, Affiliated Renhe Hospital of China Three Gorges University, Yichang, Hubei, China.
| | - Zhangqiao Cai
- Emergency Department, Affiliated Renhe Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Jing Yang
- Emergency Department, Affiliated Renhe Hospital of China Three Gorges University, Yichang, Hubei, China
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Evans SS, Cho DY, Richman J, Kulbersh B. Revisiting age-related admission following tonsillectomy in the pediatric population. Laryngoscope 2019; 129:E389-E394. [PMID: 30644565 DOI: 10.1002/lary.27795] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 12/04/2018] [Accepted: 12/17/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objectives of this study were to examine patient outcomes using a 36-month age cutoff as a strict admission criterion following tonsillectomy, and review the safety and determine the plausibility of same-day discharge of children under 3 years old following tonsillectomy. STUDY DESIGN Retrospective chart review. METHODS A chart review of patients aged 24 to 42 months undergoing tonsillectomy over a 3-year period was conducted. Patients were stratified into <36 months and ≥ 36 months cohorts. Data collected included demographics, medical/sleep history, inpatient records, 30-day emergency department visits, and readmission data. Bivariate comparisons were made using χ2 and Wilcoxon tests for categorical and continuous variables. RESULTS Between July 2014 and July 2017, 427 patients aged 24 to 42 months underwent tonsillectomy at our institution. Thirty-day emergency department visit, readmission, and greater-than-expected length of stay rates were 3.0% versus 3.7% (P = .75), 1.0 versus 1.8% (P = .61), and 4.7% versus 4.5% (P = 1.00) between the younger and older cohorts, respectively, with no difference in complication rates identified based on age. CONCLUSIONS No significant difference in adverse outcomes was appreciated based on a cutoff of 36 months of age at a tertiary center over 3 years. There should continue to be ongoing studies addressing strict age-related admission criteria. LEVEL OF EVIDENCE 4 Laryngoscope, 129:E389-E394, 2019.
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Affiliation(s)
- Sean S Evans
- The Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Do Yeon Cho
- The Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brian Kulbersh
- Pediatric Ear, Nose, and Throat Associates of Alabama, Children's Hospital of Alabama, Birmingham, Alabama, U.S.A
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Billings KR, Manworren RCB, Lavin J, Stake C, Hebal F, Leon AH, Barsness K. Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients. Laryngoscope Investig Otolaryngol 2018; 4:165-169. [PMID: 30828635 PMCID: PMC6383296 DOI: 10.1002/lio2.237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Identify demographic variables related to emergency department (ED) returns, and analgesic administration in the ED for postoperative pain after adenotonsillectomy (T&A). Study Design Pediatric Health Information System (PHIS) database analysis. Methods Forty-seven children's hospitals included in the PHIS database were queried for all ED visits within 30 days of surgery with a diagnosis of acute postoperative pain (n = 2459) from 2014 to 2015. The subset of postoperative T&A patients (n = 861) was further analyzed for variables associated with return, and for pain management strategies, specifically opioids, employed by the ED. Results Of the 2459 pediatric patients returning to the ED for acute postoperative pain, the largest subset included T&A patients (n = 861, 35%). Patients were seen an average of 4 days (SD 2.4) after their surgery. ED administration of opioids was not associated with gender, race, surgical diagnosis, or ethnicity. The rate of opioid administration by the ED increased with advancing age of the children analyzed (P = .01). The incidence was also higher for those with commercial versus Medicaid insurance carriers. A total of 204 (23.7%) patients received opioids while in the ED, 439 (51%) received both opioids and non-opioids, and only 51 (5.9%) received no pain medication. Conclusion T&A patients make up the largest subset of patients returning to the ED for postoperative pain. A total of 74.7% of patients receive opioids, either alone or in combination with non-opioids, on return to the ED. ED opioid administration was associated with older age of the child and payer, but not with gender, race, surgical diagnosis, or ethnicity. Level of Evidence 4.
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Affiliation(s)
- Kathleen R Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois.,Department of Otolaryngology-Head and Neck Surgery Northwestern University Feinberg School of Medicine Chicago Illinois
| | - Renee C B Manworren
- Department of Nursing Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois.,Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago Illinois
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology-Head and Neck Surgery Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois.,Department of Otolaryngology-Head and Neck Surgery Northwestern University Feinberg School of Medicine Chicago Illinois
| | - Christine Stake
- Department of Surgery Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois
| | - Ferdynand Hebal
- Department of Surgery Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois
| | - Astrid H Leon
- Department of Surgery Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois
| | - Katherine Barsness
- Department of Surgery Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois.,Division of Pediatric Surgery Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois
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Liming BJ, Ryan M, Mack D, Ahmad I, Camacho M. Montelukast and Nasal Corticosteroids to Treat Pediatric Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2018; 160:594-602. [DOI: 10.1177/0194599818815683] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To systematically review the literature on anti-inflammatory medications for treating pediatric obstructive sleep apnea and perform meta-analysis of the available data. Data Sources PubMed/MEDLINE and 4 additional databases. Review Methods Three authors independently and systematically searched through June 28, 2018, for studies that assessed anti-inflammatory therapy for treatment of pediatric obstructive sleep apnea (OSA). Data were compiled and analyzed using Review Manager 5.3 (Nordic Cochrane Centre). Results After screening 135 studies, 32 were selected for review with 6 meeting inclusion criteria. In total, 668 patients aged 2 to 5 years met inclusion criteria for meta-analysis. Of these, 5 studies (166 children) that evaluated montelukast alone as treatment for pediatric OSA found a 55% improvement in the apnea-hypopnea index (AHI) (mean [SD] 6.2 [3.1] events/h pretreatment and 2.8 [2.7] events/h posttreatment; mean difference [MD] of −2.7 events/h; 95% confidence interval [CI], –5.6 to 0.3) with improvement in lowest oxygen saturation (LSAT) from 89.5 (6.9) to 92.1 (3.6) (MD, 2.2; 95% CI, 0.5-4.0). Two studies (502 children) observing the effects of montelukast with intranasal corticosteroids on pediatric OSA found a 70% improvement in AHI (4.7 [2.1] events/h pretreatment and 1.4 [1.0] events/h posttreatment; MD of −4.2 events/h; 95% CI, –6.3 to −2.0), with an improvement in LSAT from 87.8 (3.1) to 92.6 (2.2) (MD, 4.8; 95% CI, 4.5-5.1). Conclusions Treatment with montelukast and intranasal steroids or montelukast alone is potentially beneficial for short-term management of mild pediatric OSA.
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Affiliation(s)
- Bryan J. Liming
- Otolaryngology Head and Neck Surgery, Tripler Army Medical Center, Hawaii, USA
| | - Matthew Ryan
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Douglas Mack
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Iram Ahmad
- Department of Otolaryngology, Stanford University, Stanford, California, USA
| | - Macario Camacho
- Otolaryngology Head and Neck Surgery, Tripler Army Medical Center, Hawaii, USA
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Peritonsillar infiltration of lidocaine with adrenaline is associated with increased risk of secondary post-tonsillectomy haemorrhage. The Journal of Laryngology & Otology 2018; 132:911-922. [PMID: 30296953 DOI: 10.1017/s0022215118001731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In order to evaluate the safety of tonsillectomy among children, we retrospectively studied the incidence of post-operative complications, adverse events and their association with peri-operative medication. METHODS Data were collected from the medical records of 691 patients aged 1-16 years, including details of post-operative complications (any unplanned contact with the hospital), analgesics, dexamethasone, 5-HT3 antagonists, local anaesthetic and haemostatic agents. RESULTS Recovery was complicated in 13.6 per cent of patients, of whom 8.4 per cent were re-admitted to the ward. The most common complication was post-tonsillectomy haemorrhage, experienced by 7.1 per cent of patients. Re-operation under general anaesthesia (for grade III post-tonsillectomy haemorrhage) was required by 4.2 per cent of patients. Peritonsillar infiltration of lidocaine with adrenaline increased the risk of post-tonsillectomy haemorrhage (odds ratio = 4.1; 95 per cent confidence interval = 2.1 to 8.3). CONCLUSION Every seventh paediatric patient experienced a complicated recovery after tonsillectomy, caused by post-tonsillectomy haemorrhage in most cases. Local peritonsillar infiltration of lidocaine with adrenaline was associated with an increased risk of post-tonsillectomy haemorrhage.
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Schwartz CM, Honsinger K, Fischer BA, Elmaraghy CA. Evaluation of the effect of pre-operative oral midazolam on post-operative oral fluid intake after tonsillectomy. Int J Pediatr Otorhinolaryngol 2018; 113:248-251. [PMID: 30173995 DOI: 10.1016/j.ijporl.2018.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The objective of this study was to determine if pre-operative oral midazolam administration decreased postoperative oral fluid intake after tonsillectomy with or without adenoidectomy. METHODS A retrospective chart review identified 104 patients who were undergoing tonsillectomy with and without adenoidectomy who were not given midazolam preoperatively and 182 who were given midazolam preoperatively. Indications for tonsillectomy with or without adenoidectomy included obstructive sleep apnea, recurrent acute streptococcal pharyngotonsillitis, and, in selected cases, periodic fever with aphthous stomatitis, pharyngitis and adenopathy. All patients were evaluated in the pre-operative area by the attending anesthesiologist, who then determined whether or not he/she felt the patient would benefit from premedication with oral midazolam prior to surgery. Patients whom the attending anesthesiologist judged would benefit from midazolam were then given a 0.12-1.06 mg/kg dose (mean 0.35 mg/kg, STD 0.12), at the discretion of the anesthesiologist. Various methods were used to perform tonsillectomy, such as coblation and electrocautery, at the discretion of the otolaryngologist. Results were not stratified by surgical technique. Oral fluid intake was calculated by establishing the time of return to the floor from surgery and determining the documented oral fluid intake for the next 12 h. Oral fluid intake per kg per hour was then calculated. The amount of midazolam given was documented. RESULTS There was no significant difference in oral fluid intake by group when adjusting for age and weight, F(1, 282) = 0.383, p = 0.537. Also, there was no significant difference in ml/kg/hr by group when adjusting for age and weight, F(1, 282) = 2.813, p = 0.095. CONCLUSIONS There was no significant difference in oral fluid intake between the no midazolam and midazolam groups, indicating that clinicians can continue to use their judgement in administering midazolam to select anxious patients prior to tonsillectomy with or without adenoidectomy. Future work could include multi-center retrospective reviews or a randomized placebo-controlled trial to examine more carefully the effects of midazolam on postoperative oral fluid intake. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Kristen Honsinger
- Department of Otolaryngology, Cook Children's Health Care System, USA
| | - Beth A Fischer
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, USA
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Tumin D, Raman VT, Tobias JD. Insurance Coverage and Acute Care Revisits After Pediatric Ambulatory Tonsillectomy. Clin Pediatr (Phila) 2018; 57:821-826. [PMID: 28945103 DOI: 10.1177/0009922817733695] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We investigated whether patterns of health insurance coverage were associated with 30-day all-cause acute care revisits after ambulatory tonsillectomy at a free-standing quaternary-care pediatric hospital. Insurance patterns were classified from past encounters as continuous private, continuous Medicaid, Medicaid-to-private change, or private-to-Medicaid change. Among 478/675 boys/girls (age 9 ± 4 years) selected for analysis, 148 (13%) had 30-day revisits, whereas 96 (8%) changed from Medicaid to private insurance, and 99 (9%) changed from private insurance to Medicaid. Revisits were most common in the private-to-Medicaid group, compared with continuous private coverage (19% vs 10%; 95% CI of difference: 1%-18%; P = .007). The private-to-Medicaid group was most likely to be overweight, have symptoms of sleep disordered breathing, and have more past clinical encounters. In multivariable analysis, the greater risk of acute care revisits among children with private-to-Medicaid change in coverage was attributable to greater comorbidity burden and past health care utilization.
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Affiliation(s)
- Dmitry Tumin
- 1 Nationwide Children's Hospital, Columbus, OH, USA.,2 The Ohio State University College of Medicine, Columbus, OH, USA
| | - Vidya T Raman
- 1 Nationwide Children's Hospital, Columbus, OH, USA.,2 The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- 1 Nationwide Children's Hospital, Columbus, OH, USA.,2 The Ohio State University College of Medicine, Columbus, OH, USA
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Ordemann AG, Hartzog AJ, Seals SR, Spankovich C, Stringer SP. Is weight a predictive risk factor of postoperative tonsillectomy bleed? Laryngoscope Investig Otolaryngol 2018; 3:238-243. [PMID: 30062141 PMCID: PMC6057213 DOI: 10.1002/lio2.155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/16/2017] [Accepted: 03/13/2018] [Indexed: 12/27/2022] Open
Abstract
Objective To determine if a correlation exists between weight-for-age percentile and post-tonsillectomy hemorrhage in the pediatric population. Study Design Retrospective study. Methods 1418 patients under the age of 15 who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital between June 2012 and March 2015 were included in this retrospective study. Patient demographic information, operative and postoperative variables, as well as category and day of postoperative tonsillectomy bleed, if one occurred, were recorded. Fisher's exact and ordinal logistic regression analyses were performed on the full cohort. Results The overall post-tonsillectomy hemorrhage prevalence was found to be 2.2%, with primary and secondary rates of 0.78% and 1.34%, respectively. Weight-for-age percentile, sex, indication for or method of tonsillectomy, or postoperative use of NSAIDs, antibiotics or narcotics were not significantly associated with post-tonsillectomy hemorrhage. There was a significant relationship between postoperative use of dexamethasone and higher rate of Category 3 post-tonsillectomy hemorrhage (P = .028). Conclusion The post-tonsillectomy hemorrhage rate in our study is consistent with that cited in the literature. No correlation was demonstrated between weight-for-age percentile and occurrence of post-tonsillectomy hemorrhage. Postoperative administration of dexamethasone was associated with a significant increased rate of post-tonsillectomy hemorrhage requiring surgical intervention, a novel finding. Level of Evidence 4.
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Affiliation(s)
- Allison G Ordemann
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
| | - Anna Jade Hartzog
- Department of Anesthesiology Vanderbilt University Medical Center Nashville Tennessee U.S.A
| | - Samantha R Seals
- Department of Mathematics and Statistics University of West Florida Pensacola Florida U.S.A
| | - Christopher Spankovich
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
| | - Scott P Stringer
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
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Keefe KR, Byrne KJ, Levi JR. Treating pediatric post-tonsillectomy pain and nausea with complementary and alternative medicine. Laryngoscope 2018; 128:2625-2634. [PMID: 29729030 DOI: 10.1002/lary.27231] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/15/2018] [Accepted: 03/21/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Although tonsillectomy is a common and largely safe procedure, pain management in children remains a controversial topic. In addition to the challenge of choosing appropriate analgesia, there is often low parent and child adherence. This article presents a review, and evaluates the potential role, of a range of complementary and alternative therapies that may be sought out by parents. METHODS A literature review of complementary and alternative interventions performed using PubMed, Cochrane Library, and EMBASE, supplemented by searches from Google and hand searches of cross-references of selected articles, yielded 32 studies for qualitative analysis. RESULTS The studies included for analysis investigated a wide variety of alternative treatment modalities: acupuncture and related therapies, aromatherapy, homeopathy, honey, intravenous fluid, speech therapy, hyaluronic acid, behavioral therapies, ice/cold, hydrogen peroxide rinse, and chewing gum. CONCLUSION At this time, stronger conclusions cannot be made about the therapies investigated because there are many methodology limitations of the studies analyzed. However, our results suggest merit for these treatments as adjuvant therapies that can enhance analgesia and decrease requirements of controversial medications. Honey and acupuncture have the greatest amount of evidence for postoperative pain and nausea; however, all interventions examined were cost-effective and safe. We recommend against hydrogen peroxide rinses and chewing gum. Laryngoscope, 2625-2634, 2018.
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Affiliation(s)
| | - Kevin J Byrne
- Boston University School of Medicine, Boston, Massachusetts, U.S.A
| | - Jessica R Levi
- Boston University School of Medicine, Boston, Massachusetts, U.S.A.,Boston Medical Center, Boston, Massachusetts, U.S.A
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Padia R, Hall D, Sjogren P, Narayanan P, Meier JD. Sequelae of Tympanostomy Tubes in a Multihospital Health System. Otolaryngol Head Neck Surg 2018; 158:930-933. [DOI: 10.1177/0194599817752633] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Reema Padia
- Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daniel Hall
- Intermountain Healthcare, Surgical Services Clinical Program, Murray, Utah, USA
| | - Phayvanh Sjogren
- Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Prem Narayanan
- Intermountain Healthcare, Surgical Services Clinical Program, Murray, Utah, USA
| | - Jeremy D. Meier
- Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Discontinuous insurance coverage predicts prolonged hospital stay after pediatric adenotonsillectomy. J Surg Res 2017; 218:86-91. [DOI: 10.1016/j.jss.2017.05.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 04/25/2017] [Accepted: 05/19/2017] [Indexed: 11/18/2022]
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Patel PN, Arambula AM, Wheeler AP, Penn EB. Post-tonsillectomy hemorrhagic outcomes in children with bleeding disorders at a single institution. Int J Pediatr Otorhinolaryngol 2017; 100:216-222. [PMID: 28802375 DOI: 10.1016/j.ijporl.2017.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/12/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To report on the post-tonsillectomy bleeding outcomes and factors associated with hemorrhage among children with pre- or post-operatively diagnosed bleeding disorders treated with an institutional protocol. METHODS Retrospective cohort study of patients with hematologic disorders who underwent tonsillectomy between 2003 and 2016 and were treated with perioperative desmopressin or factor replacement and/or aminocaproic acid. Postoperative outcomes were compared to controls matched for age, sex, and indication for surgery. Analysis of factors associated with hemorrhage was performed in patients with bleeding disorders using Mann-Whitney U or chi-squared tests. RESULTS 45 patients with hematologic disorders met inclusion criteria. Platelet dysfunction, including von Willebrand Disease (vWD), was the most common diagnosis (77.8%). Most patients had a preoperative diagnosis of a bleeding disorder and received perioperative hematologic medications (86.7%). Compared to matched controls, patients with hematologic disorders experienced more postoperative bleeding (15.5%; 12 bleeds, 7 patients vs. 1.7%; 1 bleed, 1 patient, p = 0.05) and had longer postoperative stays (1.3 days vs. 0.4 days, p < 0.001). Among the patients with hematologic disorders, patients who experienced a postoperative bleed were significantly more likely to have a factor deficiency (e.g. Hemophilia over vWD) and have a postoperative diagnosis (compared to preoperative diagnosis) for which they did not receive perioperative hematologic medication. Of patients with a postoperative bleed, all those diagnosed postoperatively required at least one surgical intervention to control bleeding compared to 33% of patients with a preoperative diagnosis. A history of post-surgical bleeding, male sex, age at surgery, and pharyngitis as surgical indication were not associated with higher hemorrhage rates in this group. CONCLUSIONS This study suggests a clinically important magnitude of increased bleeding risk in patients with hematologic disease. This risk appears to decrease with the use of an institutional protocol consisting of desmopressin or factor replacement and an antifibrinolytic agent extending through postoperative day 10.
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Affiliation(s)
- Priyesh N Patel
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | | | - Allison P Wheeler
- Division of Hematology-Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward B Penn
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA
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Baker AB, Farhood Z, Brandstetter KA, Teufel RJ, LaRosa A, White DR. Tonsillectomy in Children with Down Syndrome: A National Cohort of Inpatients. Otolaryngol Head Neck Surg 2017; 157:499-503. [PMID: 28762292 DOI: 10.1177/0194599817711377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To describe the cost, length of stay, and incidence of postoperative hemorrhage associated with Down syndrome (DS) patients undergoing tonsillectomy in a national sample of inpatient children. Study Design This study uses a national cross-sectional cohort to analyze children with and without DS undergoing tonsillectomy with or without adenoidectomy. Setting 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. Subjects and Methods The database was analyzed for postoperative hemorrhage and respiratory compromise, length of stay, and total charges of hospital stay. These outcomes were compared between patients with DS vs patients without DS. Results In total, 7512 patients were identified who underwent tonsillectomy: 7159 patients without DS and 353 patients with DS. The non-DS group was younger with a median age of 3 years (range, 0-18) compared with a DS median age of 4 years (range, 0-20), P = .004. The DS group had a significant increase in postoperative hemorrhage compared with non-DS (10 [2.8%] vs 87 [1.2%], respectively), P = .024. However, the DS and non-DS groups were comparable for respiratory complications (5 [1.4%] vs 106 [1.5%], respectively), P = .922. Median length of stay was significantly increased in the DS group (1 [interquartile range (IQR), 1-3]) compared with the non-DS group (1 [IQR, 1-2]), P < .001. Median charges for hospital stay totaled $17,451 (IQR, $11,901-$24,949) for the DS group compared with $14,395 (IQR, $9739-$21,890) for the non-DS group, P < .001. Conclusion Across the United States, children with DS hospitalized for tonsillectomy have an increased length of stay and cost of care. These data also suggest an increased risk of postoperative hemorrhage during the initial admission without an increased risk of respiratory complications.
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Affiliation(s)
- Andrew B Baker
- 1 Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Zachary Farhood
- 2 Department of Otolaryngology-Head and Neck Surgery, St Louis University, St Louis, Missouri, USA
| | - Kathleen A Brandstetter
- 3 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ronald J Teufel
- 4 Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Angela LaRosa
- 4 Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David R White
- 3 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Burton K, Hanke S, Gungor A. Reduced post-tonsillectomy bleeding rates through a refined technique. Am J Otolaryngol 2017; 38:438-441. [PMID: 28427798 DOI: 10.1016/j.amjoto.2017.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/22/2017] [Indexed: 11/26/2022]
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Tumin D, Walia H, Raman VT, Tobias JD. Acute care revisits after adenotonsillectomy in a pediatric Medicaid population in Ohio. Int J Pediatr Otorhinolaryngol 2017; 94:17-22. [PMID: 28167005 DOI: 10.1016/j.ijporl.2017.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 01/04/2017] [Accepted: 01/06/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Guidelines for inpatient admission after pediatric tonsillectomy have been proposed to improve the safety of this procedure. This study examined the association between performing adenotonsillectomy in an inpatient setting and acute care revisits within 30 days among children enrolled in a Medicaid Accountable Care Organization in Ohio. METHODS The Accountable Care Organization's claims database was queried for adenotonsillectomies performed in children ages 0-18 years in 2008-2014. Procedures associated with an inpatient facility stay were classified as inpatient adenotonsillectomies. The primary outcome was emergency department visit or inpatient re-admission within 30 days. Secondary outcomes were revisits within 7 days and >7 days post-discharge. Logistic regression was used to test for association between inpatient procedure and need for revisits. RESULTS Adenotonsillectomies in 8835 girls and 7773 boys (age 6.8 ± 3.8 years) were analyzed, of which 842 (5%) were inpatient procedures. Revisits were required in 2511 (15%) cases and were primarily visits to the emergency department. In multivariable analysis, inpatient and outpatient procedures had comparable need for 30-day revisits (OR = 0.85; 95% CI: 0.69, 1.05; p = 0.124). In sub-analyses, inpatient adenotonsillectomy was associated with lower odds of early (≤7 days post-discharge; OR = 0.76; 95% CI: 0.58, 0.99; p = 0.045) but not later (≥8 days) revisits. CONCLUSIONS In a pediatric Medicaid population, inpatient adenotonsillectomy was not associated with greater odds of acute care revisits, compared to outpatient procedures. Appropriate risk stratification of children undergoing adenotonsillectomy can reduce the need for early acute care revisits by scheduling high-risk patients for prolonged observation.
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Affiliation(s)
- Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Hina Walia
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Vidya T Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, OH, USA
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Francis DO, Fonnesbeck C, Sathe N, McPheeters M, Krishnaswami S, Chinnadurai S. Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children. Otolaryngol Head Neck Surg 2017; 156:442-455. [PMID: 28094660 PMCID: PMC5639328 DOI: 10.1177/0194599816683915] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/22/2016] [Indexed: 01/21/2023]
Abstract
Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.
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Affiliation(s)
- David O. Francis
- Department of Otolaryngology, Vanderbilt University Medical Center
| | - Chris Fonnesbeck
- Department of Biostatistics, Vanderbilt University Medical Center
| | - Nila Sathe
- Department of Health Policy, Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center
| | - Melissa McPheeters
- Department of Health Policy, Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center
| | - Shanthi Krishnaswami
- Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center
| | - Siva Chinnadurai
- Department of Otolaryngology, Vanderbilt University Medical Center
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Cohn JE, Weitzel M, Zwillenberg D. In Reference to “Informed Consent in Pediatric Otolaryngology: What Risks and Benefits Do Parents Recall?”. Otolaryngol Head Neck Surg 2017; 156:385. [DOI: 10.1177/0194599816674914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Redmann AJ, Wang Y, Furstein J, Myer CM, de Alarcón A. The use of the FLACC pain scale in pediatric patients undergoing adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2017; 92:115-118. [PMID: 28012511 DOI: 10.1016/j.ijporl.2016.11.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES 1) Determine the usage rate of opioid pain medication after adenotonsillectomy (T&A). 2) Review the use of the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale for T&A patients 3) Determine the rate of postoperative physician contacts for pain related complaints. METHODS A retrospective case series review was performed on 125 pediatric patients undergoing T&A and subsequent 23-hour postoperative observation at an academic tertiary care center from June-August of 2015. Postoperative pain scores using the FLACC pain scale, the utilization of opioid pain medications, and the number of postoperative contacts for pain were recorded. RESULTS Average age of patients was 5.7 years and 50% were female. 90% of T&A's were performed for adenotonsillar hypertrophy. The post-tonsillectomy hemorrhage rate was 4%. 70 (56%) patients required postoperative opioid pain medication, with (30) 43% of these patients requiring more than one dose. The mean number of opioid doses was 1.64 ± 0.9 and was not related to age, weight or gender. FLACC scores were highly associated (spearman correlation 0.77) with the amount of opioid medication given. Mean FLACC scores decreased over time after T&A. 20% of patients contacted a physician for unsatisfactory pain control postoperatively with 6% requiring emergency department visits and 14% contacting the office via phone call. CONCLUSIONS A significant portion of pediatric patients undergoing T&A require postoperative opioids for pain control. The FLACC scale is a valuable way of quantifying post-operative T&A pain in pediatric patients. Despite routine pain management postoperatively, a significant proportion of patients require contact with a physician postoperatively for pain management.
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Affiliation(s)
- Andrew J Redmann
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, United States.
| | - Yu Wang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - James Furstein
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Charles M Myer
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Alessandro de Alarcón
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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Rodríguez MC, Villamor P, Castillo T. Assessment and management of pain in pediatric otolaryngology. Int J Pediatr Otorhinolaryngol 2016; 90:138-149. [PMID: 27729121 DOI: 10.1016/j.ijporl.2016.09.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/10/2016] [Accepted: 09/13/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Pain is a disease by itself and it's a public health concern of major implication in children, not just because of the emotional component of the child and his family, but also due to the potential morbidity and mortality involving it. A proper assessment of pain it's a challenge in the pediatric population, due to their lack of understanding and verbalization of hurt. Additionally, a satisfactory treatment of pediatric pain can be arduous due to a lack of clinical knowledge, insufficient pediatric research, and the fear to opioid side effects and addiction. OBJECTIVES The aim of this review is to address the current definitions of pain, its physiological mechanisms and the consequences of its inadequate management, as well as, to guide the clinicians in the assessment and management of pain in the pediatric population at otolaryngology services. METHODOLOGY Narrative review by selective MeSH search terms: Children, Pediatrics, Otolaryngology, Pain measurement, Pain Management, Analgesics and Analgesia, from databases: MEDLINE/PubMed, Cochrane, ISI, Current Contents, Scielo and LILACS, between January 2000 and May 2016. RESULTS 129 articles were reviewed according to the requirements of the objectives. Pain measurement is a challenge in children as there are no physical signs that constitute an absolute or specific indicator of pain, and its diagnosis must rely on physiological, behavioral and self-report methods. Regarding treatment, a suitable alternative are the non-pharmacological cognitive/behavioral therapies helped by pharmacological therapies tailored to the severity of pain and the child's age. We provide evidence-based recommendations on pain treatment, including non-opioid analgesics, opioid analgesics and adjuvant medicines to improve the management of pain in children in otolaryngology services. CONCLUSIONS We present a global review about assessment and management of pain in pediatric otolaryngology, which leads to future specific reviews on each topic. Research gaps on pain assessment and pharmacological interventions in neonates, infants and children are very wide and it should be promoted ethical and safe research on pain control in this population.
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Affiliation(s)
- Maria Claudia Rodríguez
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Perla Villamor
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia.
| | - Tatiana Castillo
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
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Sowder JC, Gale CM, Henrichsen JL, Veale K, Liljestrand KB, Ostlund BC, Sherwood A, Smith A, Olsen GH, Ott M, Meier JD. Primary Caregiver Perception of Pain Control following Pediatric Adenotonsillectomy. Otolaryngol Head Neck Surg 2016; 155:869-875. [DOI: 10.1177/0194599816661715] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 07/08/2016] [Indexed: 11/16/2022]
Abstract
Objectives To (1) review pain medications prescribed following pediatric adenotonsillectomy (T&A), (2) identify pain medications reported to be helpful, and (3) compare parent-reported outcomes among various combinations of pain medications. Study Design Case series with planned data collection. Setting Multihospital network. Subjects and Methods The primary caregivers of children aged 1 to 18 years who underwent isolated T&A from June to December 2014 were contacted 14 to 21 days after surgery. Data collected included pain medications prescribed, medications most helpful in controlling pain, and duration that pain medication was required. Parents rated their children’s pain on postoperative days 2, 3, 7, and 14 and reported the time to resumption of normal diet/activity, as well as any hospital return visits. Results The study cohort included 672 subjects of 1444 potential participants (46% response rate). The mean age of the patients was 7.9 ± 3.6 years. Narcotics were prescribed in 71.9%, and 70.4% were told to use ibuprofen. Children who took ibuprofen alone were significantly younger ( P < .001). Pain was significantly less on postoperative days 2 and 3 in the ibuprofen-only group as compared with the groups taking narcotics only ( P < .001) and ibuprofen with narcotics ( P = .002). Those taking ibuprofen alone returned to normal activity ( P < .001) and diet ( P = .026) sooner than those taking ibuprofen with narcotics. No difference was seen in pain control on subgroup analysis comparing oxycodone and hydrocodone. Conclusions For pediatric T&A, significant variation exists in the management of postoperative pain. Parents of children given ibuprofen reported less pain than those given narcotics with and without ibuprofen. Further studies are needed to identify the optimal pain regimen for children after T&A.
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Affiliation(s)
- Justin C. Sowder
- Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Craig M. Gale
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Jacob L. Henrichsen
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Kristy Veale
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Katie B. Liljestrand
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Barbara C. Ostlund
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Aaron Sherwood
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Austin Smith
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Griffin H. Olsen
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Mark Ott
- Surgical Services Clinical Program, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA
| | - Jeremy D. Meier
- Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Risk factors for pediatric post-tonsillectomy hemorrhage. Int J Pediatr Otorhinolaryngol 2016; 84:151-5. [PMID: 27063772 DOI: 10.1016/j.ijporl.2016.03.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/04/2016] [Accepted: 03/07/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To determine pre-operative risk factors for post-tonsillectomy secondary hemorrhage in children, and quantify the magnitude of their risk. MATERIALS AND METHODS Retrospective case-control study of all pediatric tonsillectomy patients experiencing post-operative bleeding from 2005 to 2010 in a community practice consisting of three fellowship-trained pediatric otolaryngologists were identified. The 91 cases were matched with 151 controls that underwent tonsillectomy by the same surgeon on the same day as each identified case. All charts were reviewed, and 41 pre-operative variables were extracted and statistically analyzed with contingency and regression analysis to calculate significance and odds ratios. RESULTS Three significant predictors of post-operative bleeding were identified. Performing a tonsillectomy on a child with recurrent tonsillitis (vs. other indications) increased the risk of post-operative hemorrhage by 4.5 times (p<0.0001, 95% confidence intervals 2.41-8.38). Performing a tonsillectomy on a child with attention deficit hyperactivity disorder (ADHD) increased the risk by 8.7 times (p=0.029, 95%CI 1.4-53.6). Older children were more predisposed to post-operative bleeding. For every increase in age by one year, the hemorrhage risk increased by 1.1 times (p=0.0025, 95%CI 1.032-1.162). Children 11 years of age and older had double the risk of bleeding compared to younger children (odds ratio 1.98, p=0.0381, 95%CI 1.04-3.79). None of the remaining 38 variables showed significant differences between cases and controls. CONCLUSIONS The risk of post-tonsillectomy hemorrhage is significantly increased in older children and those with recurrent tonsillitis and ADHD.
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