1
|
Bromfalk Å, Hultin M, Myrberg T, Engström Å, Walldén J. Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine. Paediatr Anaesth 2023; 33:962-972. [PMID: 37528645 DOI: 10.1111/pan.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2-6 years. METHODS In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured. RESULTS After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups. CONCLUSIONS No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2 -agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.
Collapse
Affiliation(s)
- Åsa Bromfalk
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sunderbyn), Umeå University, Umeå, Sweden
| | - Åsa Engström
- Division of Nursing and Medical Technology, Department of Health, Education and Technology, Lulea University of Technology, Luleå, Sweden
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sundsvall), Umeå University, Umeå, Sweden
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Kuo CC, DeGiovanni JC, Carr MM. The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis. Ann Otol Rhinol Laryngol 2021; 131:834-843. [PMID: 34515540 DOI: 10.1177/00034894211045264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy. METHODS We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk. RESULTS Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373). CONCLUSIONS Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.
Collapse
Affiliation(s)
- Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jason C DeGiovanni
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Michele M Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| |
Collapse
|
4
|
Abstract
Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.
Collapse
Affiliation(s)
- Anthony L Kovac
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 1034, Kansas City, KS, 66160, USA.
| |
Collapse
|
5
|
Postoperative care after tonsillectomy: what's the evidence? Curr Opin Otolaryngol Head Neck Surg 2017; 25:498-505. [DOI: 10.1097/moo.0000000000000420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
6
|
Shin HC, Kim JS, Lee SK, Kwon SH, Kim MS, Lee EJ, Yoon YJ. The effect of acupuncture on postoperative nausea and vomiting after pediatric tonsillectomy: A meta-analysis and systematic review. Laryngoscope 2016; 126:1761-7. [PMID: 26864736 DOI: 10.1002/lary.25883] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/21/2015] [Accepted: 12/27/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Tonsillectomy is one of the most frequently performed pediatric surgical procedures worldwide. The complications of this procedure include postoperative nausea and vomiting (PONV) and pain; therefore, both the treatment and prevention of PONV are important. Classical antiemetics include drug therapies such as ondansetron, which are undesirable because they often carry a high cost and several side effects. Therefore, in this study we aimed to evaluate the antiemetic effect of acupuncture after pediatric tonsillectomy. METHODS We searched for eligible articles that reported on the antiemetic effects of acupuncture after tonsillectomy using the three databases, MEDLINE, Embase, and Cochrane, through July 2015. We included full-length original articles with adequate data for evaluating the antiemetic effects on pediatric tonsillectomy in the form of a relative ratio. The Newcastle-Ottawa scale was used to assess the quality of case control and cohort studies, and the Cochrane risk of bias tool was employed for randomized controlled trials (RCTs). RESULTS The search identified 415 publications. After screening, we selected eight articles for review (4 RCTs, 3 prospective cohorts, and 1 pilot study). A meta-analysis of acupuncture in pediatric tonsillectomy revealed that the number of patients with PONV was significantly reduced with acupuncture compared to the control group, with a risk ratio of 0.77 (95% confidence interval: 0.63-0.94, P < 0.05). CONCLUSION When acupuncture at PC6 (neiguan) was used to prevent PONV after pediatric tonsillectomy, the risk ratio was significantly lower compared to that of conventional drug therapy. Although further randomized controlled trials are needed, acupuncture at PC6 is considered an economic and effective treatment for emesis after pediatric tonsillectomy. Laryngoscope, 126:1761-1767, 2016.
Collapse
Affiliation(s)
- Hwang Cheol Shin
- Department of Anesthesiology and Pain Medicine, Chonbuk National University, Jeonju
| | - Jong Seung Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju.,Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju
| | - Sang Kyi Lee
- Department of Anesthesiology and Pain Medicine, Chonbuk National University, Jeonju
| | - Sam Hyun Kwon
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju.,Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju
| | - Min Su Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Jung Lee
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju.,Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju
| | - Yong Joo Yoon
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju
| |
Collapse
|
7
|
Konstantinopoulou S, Gallagher P, Elden L, Garetz SL, Mitchell RB, Redline S, Rosen CL, Katz ES, Chervin RD, Amin R, Arens R, Paruthi S, Marcus CL. Complications of adenotonsillectomy for obstructive sleep apnea in school-aged children. Int J Pediatr Otorhinolaryngol 2015; 79:240-5. [PMID: 25575425 PMCID: PMC4319650 DOI: 10.1016/j.ijporl.2014.12.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/14/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Adenotonsillectomy is the treatment of choice for most children with obstructive sleep apnea syndrome, but can lead to complications. Current guidelines recommend that high-risk children be hospitalized after adenotonsillectomy, but it is unclear which otherwise-healthy children will develop post-operative complications. We hypothesized that polysomnographic parameters would predict post-operative complications in children who participated in the Childhood AdenoTonsillectomy (CHAT) study. METHODS Children in the CHAT study aged 5-9 years with apnea hypopnea index 2-30/h or obstructive apnea index 1-20/h without comorbidities other than obesity/asthma underwent adenotonsillectomy. Associations between demographic variables and surgical complications were examined with Chi square and Fisher's exact tests. Polysomnographic parameters between subjects with/without complications were compared using Mann-Whitney tests. RESULTS Of the 221 children (median apnea hypopnea index 4.7/h, range 1.2-27.7/h; 31% obese), 16 (7%) children experienced complications. 3 (1.4%) children had respiratory complications including pulmonary edema, hypoxemia and bronchospasm. Thirteen (5.9%) had non-respiratory complications, including dehydration (4.5%), hemorrhage (2.3%) and fever (0.5%). There were no statistically significant associations between demographic parameters (gender, race, and obesity) or polysomnographic parameters (apnea hypopnea index, % total sleep time with SpO2<92%, SpO2 nadir, % sleep time with end-tidal CO2>50Torr) and complications. CONCLUSIONS This study showed a low risk of post-adenotonsillectomy complications in school-aged healthy children with obstructive apnea although many children met published criteria for admission due to obesity, or polysomnographic severity. In this specific population, none of the polysomnographic or demographic parameters predicted post-operative complications. Further research could identify the patients at greatest risk of post-operative complications.
Collapse
Affiliation(s)
- Sofia Konstantinopoulou
- Department of Pediatrics, Sleep Center, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States.
| | - Paul Gallagher
- Biostatistics Core, The Clinical and Translational Research Center, Children’s Hospital of Philadelphia; University of Pennsylvania, Philadelphia, PA
| | - Lisa Elden
- Department of Otolaryngology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Susan L. Garetz
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI
| | - Ron B. Mitchell
- Departments of Otolaryngology and Pediatrics, UT Southwestern Medical Center, Dallas, TX
| | - Susan Redline
- Department of Medicine, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Carol L. Rosen
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH
| | - Eliot S. Katz
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Ronald D. Chervin
- Departments of Pediatrics and Neurology, University of Michigan, Ann Arbor, MI
| | - Raouf Amin
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Raanan Arens
- Department of Pediatrics, Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Shalini Paruthi
- Department of Pediatrics and Internal Medicine, Cardinal Glennon Children’s Medical Center, Saint Louis University, St Louis, MO
| | - Carole L. Marcus
- Department of Pediatrics, Sleep Center, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
8
|
Thongyam A, Marcus CL, Lockman JL, Cornaglia MA, Caroff A, Gallagher PR, Shults J, Traylor JT, Rizzi MD, Elden L. Predictors of perioperative complications in higher risk children after adenotonsillectomy for obstructive sleep apnea: a prospective study. Otolaryngol Head Neck Surg 2014; 151:1046-54. [PMID: 25301788 DOI: 10.1177/0194599814552059] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Retrospective studies have limitations in predicting perioperative risk following adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS). Few prospective studies exist. We hypothesized that demographic and polysomnographic (PSG) variables would predict respiratory and general perioperative complications. STUDY DESIGN Prospective, observational cohort study. SETTING Pediatric tertiary center. SUBJECTS AND METHODS Consecutive children undergoing adenotonsillectomy for OSAS within 12 months of PSG were evaluated for complications occurring within 2 weeks of surgery. RESULTS There were 329 subjects, with 27% <3 years old, 24% obese, 16% preterm, and 29% with comorbidities. In this higher risk population, 28% had respiratory complications (major and/or minor), and 33% had nonrespiratory complications. Significant associations were found between PSG parameters and respiratory complications as follows: apnea hypopnea index (rank-biserial correlation coefficient [r] = 0.174, P = .017), SpO2 nadir (r = -0.332, P < .0005), sleep time with SpO2 <90% (r = 0.298, P < .0005), peak end-tidal CO2 (r = 0.354, P < .0005), and sleep time with end-tidal CO2 >50 mm Hg (r = 0.199, P = .006). Associations were also found between respiratory complications and age <3 years (r = -0.174, P = .003) or black race (r = 0.123, P = .039). No significant associations existed between PSG parameters and nonrespiratory complications. A model using age <3 years, SpO2 nadir, and peak CO2 predicted respiratory complications better than the American Academy of Pediatrics or American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines but was imperfect (area under the curve = 0.72). CONCLUSION Thus, PSG predicted perioperative respiratory, but not nonrespiratory, complications in children with OSAS. Age <3 years or black race are high-risk factors. Present guidelines have limitations in determining the need for postoperative admission.
Collapse
Affiliation(s)
- Anchana Thongyam
- Sleep Center, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA Bangkok Pattaya Hospital, Chonburi, Thailand Sleep Disorder Center, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Carole L Marcus
- Sleep Center, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Justin L Lockman
- Anesthesia and Critical Care Medicine Department, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mary Anne Cornaglia
- Sleep Center, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Aviva Caroff
- Division of Otolaryngology, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Paul R Gallagher
- Clinical and Translational Research Center, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Clinical and Translational Research Center, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joel T Traylor
- Sleep Center, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark D Rizzi
- Division of Otolaryngology, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lisa Elden
- Division of Otolaryngology, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Bellis JR, Pirmohamed M, Nunn AJ, Loke YK, De S, Golder S, Kirkham JJ. Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis. Br J Anaesth 2014; 113:23-42. [PMID: 24942713 DOI: 10.1093/bja/aeu152] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Summary In children undergoing tonsillectomy, dexamethasone is recommended to reduce the risk of postoperative nausea and vomiting while non-steroidal anti-inflammatory drugs (NSAIDs) are used for pain relief. We aimed to determine whether children who receive dexamethasone or dexamethasone with NSAID are more likely to experience haemorrhage post-tonsillectomy. Randomized and non-randomized studies in which children undergoing tonsillectomy received dexamethasone or dexamethasone and NSAID were sought within bibliographic databases and selected tertiary sources. The risk of bias assessment and evaluation of haemorrhage rate data collection and reporting were assessed using the Cochrane Risk of Bias Tool and McHarm tool. Synthesis methods comprised pooled estimate of the effect of dexamethasone on the risk of haemorrhage rate using the Peto odds ratio (OR) method. The pooled estimate for haemorrhage rate in children who received dexamethasone was 6.2%, OR 1.41 (95% confidence interval 0.89-2.25, P=0.15). There was risk of bias and inconsistent data collection and reporting rates of haemorrhage in many of the included studies. Clinical heterogeneity was observed between studies. The pooled analysis did not demonstrate a statistically significant increase in the risk of post-tonsillectomy haemorrhage with dexamethasone with/without NSAID use in children. However, the majority of the included studies were not designed to investigate this endpoint, and thus large studies which are specifically designed to collect data on haemorrhage rate are needed.
Collapse
Affiliation(s)
- J R Bellis
- Research and Development, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - M Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Ashton Street, Liverpool L69 3GE, UK
| | - A J Nunn
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Y K Loke
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich NR4 7TJ, UK
| | - S De
- Department of Paediatric Otolaryngology, Head and Neck Surgery, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - S Golder
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK
| | - J J Kirkham
- Department of Biostatistics, University of Liverpool, Shelley's Cottage, Brownlow Street, Liverpool L69 3GS, UK
| |
Collapse
|
10
|
Tranexamic acid – a useful drug in ENT surgery? The Journal of Laryngology & Otology 2014; 128:574-9. [DOI: 10.1017/s0022215114001285] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Tranexamic acid is a synthetic antifibrinolytic drug. It has been widely available for over 40 years, but only recently has it started to be used routinely in many surgical disciplines. For ENT surgeons, epistaxis and post-tonsillectomy bleeding contribute a significant proportion of the morbidity and emergency workload in a general ENT department. Published evidence indicates a potentially helpful role for tranexamic acid in managing epistaxis.Results and conclusion:To date, the benefits of tranexamic acid as a prophylactic treatment to reduce the rate and severity of post-tonsillectomy bleeding are less certain. Two recently published pilot studies looking at primary haemorrhage in children and secondary haemorrhage in adults following tonsillectomy suggest that further large, randomised trials should explore the efficacy of tranexamic acid in routine ENT surgery. There are potential reductions in patient morbidity and cost savings if tranexamic acid is found to be efficacious in larger trials.
Collapse
|
11
|
Robb PJ, Thorning G. Perioperative tranexamic acid in day-case paediatric tonsillectomy. Ann R Coll Surg Engl 2014; 96:127-9. [PMID: 24780670 DOI: 10.1308/003588414x13814021676477] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Tranexamic acid has been used for many years to minimise blood loss during surgery and, more recently, to reduce morbidity after major trauma. While small studies have confirmed reduction in blood loss during tonsillectomy with its use, the rate of primary haemorrhage following tonsillectomy has not been reported. In the UK, less than 50% of children having a tonsillectomy are managed as day cases, partly because of concerns about bleeding during the initial 24 hours following surgery. METHODS A retrospective review of clinical records between January 2007 and January 2013 produced 476 children between the ages of 3 and 16 years who underwent Coblation™ tonsillectomy, with or without adenoidectomy and/or insertion of ventilation tubes. All children were ASA (American Society of Anesthesiologists) grade 1 or 2 and anaesthetised using a standard day surgery protocol. Following induction of anaesthesia, all received intravenous tranexamic acid at a dose of 10-15 mg/kg. RESULTS Two children (0.4%) had minor bleeding within two hours of surgery. Both returned to theatre for haemostasis and were discharged home later the same day with no further complications. The expected rate for primary haemorrhage in the UK using this technique for tonsillectomy is 1%. CONCLUSIONS Perioperative tranexamic acid in a single, parenteral dose might reduce the incidence of primary haemorrhage following paediatric tonsillectomy, facilitating discharge on the day of surgery. The results from this observational study indicate a potential benefit and need for a large, prospective, multicentre, randomised controlled trial.
Collapse
Affiliation(s)
- P J Robb
- Epsom and St Helier University Hospitals NHS Trust, UK
| | | |
Collapse
|