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Chen X, Liu W, Guo X, Zhou L, Liu W. Dexamethasone Decreased Postoperative Complications in Tonsillotomy. J Perianesth Nurs 2024; 39:79-81. [PMID: 37855764 DOI: 10.1016/j.jopan.2023.06.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE Tonsillotomy (TT) is a new and popular method with partial resection of the tonsils. Dexamethasone is often used during surgery for its anti-inflammatory, antiemetic, and analgesic properties. In this study, we aimed to explore the effect of systemic steroids use on postoperative vomiting, pain, and bleeding in TT. DESIGN A randomized controlled trial. METHODS We enrolled 240 children aged 2 to 18 years who had undergone TT or adenotonsillotomy at our center from July 2020 to July 2021. Dexamethasone or 0.9% normal saline was administered before the start of surgery. Postoperative hemorrhage, vomiting, and nausea were recorded and compared between groups. FINDINGS The dexamethasone group had a 2.5% (3/119) rate of postoperative bleeding, while the rate was 1.6% (2/119) in the control group. No patients required multiple operations for control of bleeding. The degree of postoperative pain (2.1 ± 0.5 vs 3.4 ± 0.9) and the occurrence of postoperative nausea (21% vs 31.9%), as well as vomiting (15% vs 24.4%) in the dexamethasone group, was significantly lower compared with the placebo group. CONCLUSIONS The rate of postoperative bleeding between the dexamethasone group and the control group had no significant difference, suggesting the high safety of dexamethasone use in TT. Dexamethasone use in TT improved postoperative pain, nausea, and vomiting significantly.
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Affiliation(s)
- Xi Chen
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenxing Liu
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiaohua Guo
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lifeng Zhou
- Department of Otolaryngology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenlong Liu
- Department of Otolaryngology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
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Mahant S, Guan J, Zhang J, Gandhi S, Propst EJ, Guttmann A. Effect of a health system payment and quality improvement programme for tonsillectomy in Ontario, Canada: an interrupted time series analysis. BMJ Qual Saf 2023; 32:526-535. [PMID: 34244328 DOI: 10.1136/bmjqs-2021-013110] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Tonsillectomy is among the most common and cumulatively expensive surgical procedures in children, with known variations in quality of care. However, evidence on health system interventions to improve quality of care is limited. The Quality-Based Procedures (QBP) programme in Ontario, Canada, introduced fixed episode hospital payment per tonsillectomy and disseminated a perioperative care pathway. We determined the association of this payment and quality improvement programme with tonsillectomy quality of care. METHODS Interrupted time series analysis of children undergoing elective tonsillectomy at community and children's hospitals in Ontario in the QBP period (1 April 2014 to 31 December 2018) and the pre-QBP period (1 January 2009 to 31 January 2014) using health administrative data. We compared the age-standardised and sex-standardised rates for all-cause tonsillectomy-related revisits within 30 days, opioid prescription fills within 30 days and index tonsillectomy inpatient admission. RESULTS 111 411 children underwent tonsillectomy: 51 967 in the QBP period and 59 444 in the pre-QBP period (annual median number of hospitals, 86 (range 77-93)). Following QBP programme implementation, revisit rates decreased for all-cause tonsillectomy-related revisits (0.48 to -0.18 revisits per 1000 tonsillectomies per month; difference -0.66 revisits per 1000 tonsillectomies per month (95% CI -0.97 to -0.34); p<0.0001). Codeine prescription fill rate continued to decrease but at a slower rate (-4.81 to -0.11 prescriptions per 1000 tonsillectomies per month; difference 4.69 (95% CI 3.60 to 5.79) prescriptions per 1000 tonsillectomies per month; p<0.0001). The index tonsillectomy inpatient admission rate decreased (1.12 to 0.23 admissions per 1000 tonsillectomies per month; difference -0.89 (95% CI -1.33 to -0.44) admissions per 1000 tonsillectomies per month; p<0.0001). CONCLUSIONS The payment and quality improvement programme was associated with several improvements in quality of care. These findings may inform jurisdictions planning health system interventions to improve quality of care for tonsillectomy and other paediatric procedures.
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Affiliation(s)
- Sanjay Mahant
- Department of Paediatrics, University of Toronto Termerty Faculty of Medicine, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Jun Guan
- Life Stage Program, ICES, Toronto, Ontario, Canada
| | - Jessie Zhang
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Sima Gandhi
- Life Stage Program, ICES, Toronto, Ontario, Canada
| | - Evan Jon Propst
- Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Otolaryngology-Head and Neck Surgery, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Department of Paediatrics, University of Toronto Termerty Faculty of Medicine, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Life Stage Program, ICES, Toronto, Ontario, Canada
- Leong Centre For Healthy Children, University of Toronto, Toronto, Ontario, Canada
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3
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[Postoperative nausea and vomiting-recommendations for its prevention and therapy in paediatric medicine]. DIE ANAESTHESIOLOGIE 2023; 72:37-47. [PMID: 36602557 DOI: 10.1007/s00101-022-01248-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Post-operative nausea and/or vomiting (PONV/POV) are among the biggest problems occurring in the paediatric recovery room and in the course of the following post-operative period. Apart from pain and emergence delirium, PONV is one of the main causes of post-operative discomfort in children. The DGAI Scientific Working Group on Paediatric Anaesthesia already worked out recommendations for the prevention and treatment of PONV in children years ago. These recommendations have now been revised by a team of experts, the current literature has been reviewed, and evidence-based core recommendations have been consented. Key elements of the new recommendations consist of effective individual measures for prevention and therapy, next to the implementation of a fixed dual prophylaxis in the clinical routine applicable to all children ≥ 3 years of age.
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Commesso EA, Osazuwa-Peters N, Frank-Ito DO, Einhorn L, Ji KSY, Greene NH, Eapen RJ, Raynor EM. Opioid and non-opioid analgesic prescribing practices for pediatric adenotonsillectomy in a tertiary care center. Int J Pediatr Otorhinolaryngol 2022; 163:111337. [PMID: 36302324 DOI: 10.1016/j.ijporl.2022.111337] [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: 04/21/2022] [Revised: 07/18/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
IMPORTANCE The U.S. is in an opioid epidemic with greater than 40,000 deaths annually. Pediatric adenotonsillectomy is one of the most common and painful otolaryngology surgeries performed, often associated with opioid prescriptions. OBJECTIVE To understand postoperative prescribing practices of adenotonsillectomy in a tertiary care institution and associated postoperative emergency department (ED) visits. DESIGN Descriptive analysis of retrospective cohort data. SETTING Tertiary academic healthcare institution. PARTICIPANTS Pediatric patients <18yo undergoing adenotonsillectomy between 2013 and 2016. INTERVENTIONS/EXPOSURES Postoperative analgesic regimens assessed including opioid and non-opioid analgesic prescriptions upon discharge from tonsillectomy surgery. MAIN OUTCOMES AND MEASURES Main outcomes included ED presentation within 30-days of surgery and reoperation. Secondary outcomes included reason for ED presentation and relation to prescribed analgesics. Data was analyzed between November 2021-February 2022. RESULTS 200 patients were included in the study with 69% prescribed opioids, and 51% prescribed non-opioid analgesics. Number of opioid doses ranged widely with a median of 37 (Q1, Q3: 0, 62). There were no demographic differences in patients prescribed opioids from those who were not. Of those patients who presented to the ED, 81% were not specifically prescribed acetaminophen (p < 0.001). Regression analysis models were not predictive of postoperative analgesic regimen or 30-day ED presentation (p > 0.05) CONCLUSIONS: Wide ranges of post tonsillectomy prescribing practices currently exist in our institution. Prescribing acetaminophen may help to reduce 30-day ED presentation rate. Larger prospective studies are needed to optimize pain control regimens and reduce variability of opioid prescribing practices. Standardization of postoperative pain medication doses may also reduce postoperative ED presentations.
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Affiliation(s)
- Emily A Commesso
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA
| | - Nosayaha Osazuwa-Peters
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA
| | - Dennis O Frank-Ito
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA
| | - Lisa Einhorn
- Duke University School of Medicine, Department of Anesthesiology, Division of Pediatrics, Durham, NC, 27710, USA
| | - Keven S Y Ji
- Oregon Health & Science University, Department of Otolaryngology-Head & Neck Surgery, Portland, OR, 97239, USA
| | - Nathaniel H Greene
- Legacy Emanuel Medical Center and Randall Children's Hospital, Portland, OR, 972272, USA
| | - Rose J Eapen
- South Bay Pediatric Otolaryngology, Manhattan Beach, CA, 90266, USA
| | - Eileen M Raynor
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC, 27710, USA.
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Practice patterns in transoral robotic surgery: results of an American head and neck society survey. J Robot Surg 2022; 17:549-556. [PMID: 35933632 DOI: 10.1007/s11701-022-01448-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/21/2022] [Indexed: 10/15/2022]
Abstract
To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed > 25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n = 28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n = 27, 71.1%) over fixed subunit-based resection (n = 11, 28.9%). Most surgeons (n = 29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n = 34) routinely ligated external carotid artery branches. A minority of institutions (n = 17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n = 21, 55.3%), and the most common duration being 24 h or less (n = 22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.
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Jensen DR. Pharmacologic management of post-tonsillectomy pain in children. World J Otorhinolaryngol Head Neck Surg 2021; 7:186-193. [PMID: 34430826 PMCID: PMC8356107 DOI: 10.1016/j.wjorl.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/18/2021] [Indexed: 12/19/2022] Open
Abstract
Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.
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Affiliation(s)
- Daniel R. Jensen
- Division of Otolaryngology, Children's Mercy Hospital, Kansas City, MO, USA
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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7
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Kubala ME, Turner M, Gardner JR, Williamson A, Richter GT. Impact of Oral Steroids on Tonsillectomy Postoperative Complications and Pain. EAR, NOSE & THROAT JOURNAL 2021; 102:NP206-NP211. [PMID: 33734886 DOI: 10.1177/01455613211000832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To analyze the impact of steroids on postoperative tonsillectomy recovery and implement findings for improvement in postoperative management. METHODS Institutional review board approved prospective study with retrospective analysis of private practice setting tonsillectomy patients (November 2015 to January 2017). A questionnaire was provided postoperatively to patients undergoing tonsillectomy with or without adenoidectomy. The study population was separated into 2 groups: patients who received steroids (3 days of either dexamethasone or prednisolone), postoperative steroid (POS), versus patients who did not receive steroids (PONS). RESULTS The questionnaire had a return rate of 27.3% (254/931). Nine of the 254 responses were disqualified for lack of information; therefore, the total number of responses was 245. Of these, 115 were POS and 130 were PONS. The groups were similar in mean age (POS: 13.2 ± 10.4 years, PONS: 14.7 ± 12.1 years, P = .32) and sex (POS: Male 40.0%, PONS: Male 40.0%, P = .97). There was an overall decrease of pain and nausea/vomiting (N/V) in the steroid group (P = .0007). There was reduction in pain (P < .05) from postoperative day (POD) 2, 3, 4, and 6 in the POS group. Otherwise, there was no significant reduction in pain from POD 7 to 14, day-by-day rate of N/V, bleeding, or rate of emergency department (ED) or clinic visit (P > .05). CONCLUSION Postoperative steroid reduced overall pain and N/V, as well as daily pain on POD 2, 3, 4, and 6. Pain from POD 7 to 14, rate of ED or clinic visit, or daily N/V and bleeding rate were not significantly different between cohorts.
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Affiliation(s)
- Michael E Kubala
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Merit Turner
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James Reed Gardner
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adrian Williamson
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Arkansas Otolaryngology Centers, Little Rock, AR, USA
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, AR, USA
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8
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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.
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Affiliation(s)
- Anthony L Kovac
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 1034, Kansas City, KS, 66160, USA.
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9
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Mokhtari A, Yip O, Alain J, Berthelot S. Prophylactic Administration of Diphenhydramine to Reduce Neuroleptic Side Effects in the Acute Care Setting: A Systematic Review and Meta-Analysis. J Emerg Med 2020; 60:165-174. [PMID: 33131965 DOI: 10.1016/j.jemermed.2020.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/12/2020] [Accepted: 09/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neuroleptics are commonly prescribed drugs to treat acute conditions (e.g., migraines) in the emergency department, but can cause serious adverse effects. Using diphenhydramine to prevent these adverse effects is very common but remains controversial. OBJECTIVE We performed a systematic review to determine whether prophylactic administration of diphenhydramine reduces the incidence of neuroleptic adverse effects in patients with acute conditions. METHODS Medline, Embase, Cochrane, PsycInfo, and Web of Science were searched for randomized controlled trials evaluating any neuroleptic with diphenhydramine vs. the same neuroleptic with any inactive agent. Primary outcome was incidence of any extrapyramidal adverse effect. Secondary outcomes were akathisia, rescue medication, subjective restlessness, neuroleptic malignant syndrome, and sedation. Independent reviewers scanned identified citations, extracted data, and assessed risk of bias. Meta-analysis was performed using random effect models. RESULTS Of 1566 identified citations, nine studies (n = 1648 patients) met eligibility criteria. Four studies were specifically designed to compare the incidence of neuroleptic adverse effects with and without co-administration of diphenhydramine. Four studies were at high risk of bias. In primary analysis, diphenhydramine had no effect on the incidence of extrapyramidal symptoms (7 studies, n = 1393, risk ratio [RR] 0.75; 95% confidence interval [CI] 0.44-1.31) or akathisia (5 studies, n = 1094; RR 0.78; 95% CI 0.33-1.82) or any of the secondary outcomes. In subgroup analysis, diphenhydramine was associated with a significant decrease in extrapyramidal adverse effects compared with placebo (4 studies, n = 705; RR 0.61; 95% CI 0.41-0.90). Dosage analysis yielded no further information. CONCLUSIONS When compared with placebo, diphenhydramine was associated with a significant reduction of extrapyramidal adverse effects. Overall quality of evidence is low. Further studies are warranted.
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Affiliation(s)
- Akram Mokhtari
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
| | - Olivia Yip
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
| | - Judith Alain
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
| | - Simon Berthelot
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
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Abstract
Dexamethasone is a synthetic steroid that has been used for many years in the clinical routine due to its anti-inflammatory, anti-allergic and immunosuppressive properties. Furthermore, dexamethasone has been used for a long time for prophylaxis and treatment of chemotherapy-induced nausea and vomiting. In the meantime dexamethasone has been approved as standard for the prophylaxis and treatment of postoperative nausea and vomiting (PONV). This review article outlines the indications and side effects of the perioperative administration of dexamethasone.
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Affiliation(s)
- B Sinner
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93953, Regensburg, Deutschland.
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11
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Gostian AO, Loeser J, Tholen C, Wolber P, Otte M, Schwarz D, Heindl LM, Balk M, Gostian M. Postoperative pain after tonsillectomy - the value of standardized analgesic treatment protocols. Auris Nasus Larynx 2020; 47:1009-1017. [PMID: 32536501 DOI: 10.1016/j.anl.2020.05.011] [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] [Received: 12/15/2019] [Revised: 04/24/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To alleviate pain after tonsillectomy (TE) with escalating gradual treatment protocols in a prospective trial. MATERIALS & METHODS Following TE, 83 consecutive adult patients were treated with two different four-staged escalating analgesic protocols. Metamizole served as basic medication in protocol 1 (PT1; n = 44), whereas with protocol 2 (PT2; n = 39) ibuprofen was applied as baseline analgesic. Both protocols were escalated according to the patient´s needs to metamizole and ibuprofen vice versa and additional weak to strong opioids. The primary efficacy endpoint was defined as the minimum and maximum pain as well as pain on ambulation (NRS, 0-10). Secondary endpoints comprised analgesic score, patient satisfaction and treatment-related side-effects. RESULTS Both patient groups exhibited similar demographic characteristics (PT1: Ø 28.8 years; 64% ♀ and PT2: Ø 26.6 years; 56% ♀). Maximum pain (6.7 ± 1.9 vs. 7.6 ± 1.6, t(81) = -2.254, p = 0.027) and pain on ambulation (5.0 ± 1.8 vs. 5.8 ± 1.8, t(81) = -2.114, p = 0.038) were significantly higher with PT2. 68.2% of patients with PT1 needed an escalation of analgesic treatment compared to 100% with PT2 (p < 0.001). The opioid consumption was also significantly higher with PT2 (43.2% vs. 71.8%, p < 0.001). There were no significant differences regarding functional impairments, side-effects and patient satisfaction (7.0 ± 2.0 vs. 7.4 ± 2.4, t(79) = -0.897, p = 0.373). CONCLUSION Both treatment protocols yielded in a high degree of patient satisfaction but dissatisfactory pain relief following TE. Metamizole can be recommended as a basic medication allowing for improved pain relief. Reported pain intensities were independent of the amount of opioid intake. Further research is mandatory to standardize and improve analgesic treatment after TE.
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Affiliation(s)
- Antoniu-Oreste Gostian
- Department of ENT, Head and Neck Surgery, University of Erlangen-Nuremberg, Waldstrasse 1, 91054 Erlangen, Erlangen, Germany.
| | - Johannes Loeser
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Christian Tholen
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Philipp Wolber
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Martin Otte
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - David Schwarz
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | | | - Matthias Balk
- Department of ENT, Head and Neck Surgery, University of Erlangen-Nuremberg, Waldstrasse 1, 91054 Erlangen, Erlangen, Germany
| | - Magdalena Gostian
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
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12
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King A, Elmaraghy C, Lind M, Tobias JD. A review of dexamethasone as an adjunct to adenotonsillectomy in the pediatric population. J Anesth 2020; 34:445-452. [PMID: 32193715 DOI: 10.1007/s00540-020-02758-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/07/2020] [Indexed: 12/22/2022]
Abstract
Although one of the most commonly performed surgical procedures in children and frequently performed as outpatient surgery, the postoperative course following tonsillectomy may include nausea, vomiting, poor oral intake, and pain. These problems may last days into the postoperative course. Although opioids may be used to treat the pain, comorbid conditions such as obstructive sleep apnea may mandate limiting the dose and the frequency of administration. Adjunctive agents may improve the overall postoperative course of patients and limit the need for opioid analgesics. Dexamethasone is a frequently administered intraoperatively as an adjunctive agent to decrease inflammation and pain, limit the potential for postoperative nausea and vomiting, and improve the overall postoperative course. The following manuscript reviews the use of dexamethasone to improve outcomes following tonsillectomy or adenotonsillectomy, discusses the controversies regarding its potential association with perioperative bleeding, and investigates options for dosing regimens which may maintain the beneficial physiologic effects while limiting the potential for bleeding.
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Affiliation(s)
- Adele King
- Department of Anesthesiology, Royal Hospital for Children, Glasgow, UK.,Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Charles Elmaraghy
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Meredith Lind
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA. .,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
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13
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Abdel-Ghaffar HS, Abdel-Wahab AH, Roushdy MM, Osman AMM. [Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial]. Rev Bras Anestesiol 2019; 69:350-357. [PMID: 31362882 DOI: 10.1016/j.bjan.2019.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/10/2019] [Accepted: 03/17/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2mg.kg-1) administered 30min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5mg.kg-1) and saline placebo. METHODS One hundred children aged (7-12) years were randomly allocated in four groups (n=25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5mg.kg-1 (Group K-IV), Nebulized Ketamine 1mg.kg-1 (Group K-N1) or 2mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24h postoperative. RESULTS The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9±60.5min, 95% CI 375.9-425.87) and K-N2 (455.5±44.6min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5±86.1min, 95% CI 282.9-354.1) and Group C (68.3±21.9min, 95% CI 59.5-77.1; p<0.001), with a significant difference between K-N1 and K-N2 Groups (p<0.001). The total consumption of IV paracetamol in the first 24h postoperative was reduced in Group K-IV (672.6±272.8mg, 95% CI 559.9-785.2), Group K-N1 (715.6±103.2mg, 95% CI 590.4-840.8) and Group K-N2 (696.6±133.3mg, 95% CI 558.8-834.4) compared with Control Group (1153.8±312.4mg, 95% CI 1024.8-1282.8; p<0.001). With no difference between intravenous and Nebulized Ketamine Groups (p=0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p<0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. CONCLUSION Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.
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Affiliation(s)
- Hala S Abdel-Ghaffar
- Assiut University, Faculty of Medicine, Department of Anesthesia and Intensive Care, Assiut, Egito
| | - Amani H Abdel-Wahab
- Assiut University, Faculty of Medicine, Department of Anesthesia and Intensive Care, Assiut, Egito.
| | - Mohammed M Roushdy
- Assiut University, Faculty of Medicine, Department of Ear, Nose and Throat, Assiut, Egito
| | - Amira M M Osman
- Assiut University, South Egypt Cancer Institute, Department of Pediatric Oncology, Assiut, Egito
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Abdel-Ghaffar HS, Abdel-Wahab AH, Roushdy MM, Osman AMM. Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31362882 PMCID: PMC9391877 DOI: 10.1016/j.bjane.2019.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objectives The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg−1) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg−1) and saline placebo. Methods One hundred children aged (7–12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg−1 (Group K-IV), Nebulized Ketamine 1 mg.kg−1 (Group K-N1) or 2 mg.kg−1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative. Results The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9 ± 60.5 min, 95% CI 375.9–425.87) and K-N2 (455.5 ± 44.6 min, 95% CI 437.1–473.9) groups compared with Group K-IV (318.5 ± 86.1 min, 95% CI 282.9–354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5–77.1; p < 0.001), with a significant difference between K-N1 and K-N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K-IV (672.6 ± 272.8 mg, 95% CI 559.9–785.2), Group K-N1 (715.6 ± 103.2 mg, 95% CI 590.4–840.8) and Group K-N2 (696.6 ± 133.3 mg, 95% CI 558.8–834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8–1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. Conclusion Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.
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Affiliation(s)
- Hala S Abdel-Ghaffar
- Assiut University, Faculty of Medicine, Department of Anesthesia and Intensive Care, Assiut, Egito
| | - Amani H Abdel-Wahab
- Assiut University, Faculty of Medicine, Department of Anesthesia and Intensive Care, Assiut, Egito.
| | - Mohammed M Roushdy
- Assiut University, Faculty of Medicine, Department of Ear, Nose and Throat, Assiut, Egito
| | - Amira M M Osman
- Assiut University, South Egypt Cancer Institute, Department of Pediatric Oncology, Assiut, Egito
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Tolska HK, Hamunen K, Takala A, Kontinen VK. Systematic review of analgesics and dexamethasone for post-tonsillectomy pain in adults. Br J Anaesth 2019; 123:e397-e411. [PMID: 31221427 DOI: 10.1016/j.bja.2019.04.063] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 03/22/2019] [Accepted: 04/05/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Intense pain can last several days after tonsillectomy. It is often undertreated and improved analgesic strategies that can be safely used at home are needed. METHODS We conducted a systematic review and meta-analysis on the effectiveness of systemic medications used for post-tonsillectomy pain in adult and adolescent (13 yr old) patients. Studies were identified from PubMed, the Cochrane Library, and by hand searching reference lists from studies and review articles. Randomised, double-blind, placebo-controlled studies reporting on pain intensity or use of rescue analgesia were included. RESULTS Twenty-nine randomised controlled trials representing 1816 subjects met the inclusion criteria. Follow-up time was ≤24 h in 15 studies, in which the majority were taking nonsteroidal anti-inflammatory drugs. Thirteen studies were suitable for meta-analysis. In pooled analysis, paracetamol, dexamethasone, and gabapentinoids reduced pain intensity on the day of operation. In individual studies, ketoprofen, ibuprofen, lornoxicam, parecoxib, rofecoxib, indomethacin and dextromethorphan reduced pain intensity, need for rescue analgesics, or both on the day of operation. Oral celecoxib for 2 postoperative weeks or i.v. ketamine on the day of operation were not effective at the studied doses. Dexamethasone in multiple doses provided analgesia beyond 1 postoperative day. Pain was moderate to strong in both study and control groups during the first postoperative week. CONCLUSIONS Single analgesics and dexamethasone provide only a weak to moderate effect for post-tonsillectomy pain on the day of operation and thus a multimodal analgesic strategy is recommended. Short follow-up times and clinical heterogeneity of studies limit the usefulness of results.
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Affiliation(s)
- H K Tolska
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - K Hamunen
- National Supervisory Authority for Welfare and Health, Helsinki, Finland
| | - A Takala
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; National Supervisory Authority for Welfare and Health, Helsinki, Finland
| | - V K Kontinen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Hanani T, Gadban H, Jahshan F, Ronen O. Tantum verde mouthwash for tonsillectomy: A prospective, double-blind, randomized control trial. Int J Pediatr Otorhinolaryngol 2019; 121:173-178. [PMID: 30917302 DOI: 10.1016/j.ijporl.2019.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Post-tonsillectomy pain control is still considered a challenge. Topical agents would seem to be an ideal, safe option. Our objective was to compare the efficacy of mouthwash preparation with anti-inflammatory, anesthetic, and analgesic properties (Tantum Verde®, 0.15% benzydamine hydrochloride) with that of placebo in improving post-tonsillectomy morbidity. METHODS A prospective, double blind, randomized clinical trial was performed. Patients older than 12-years-of-age who underwent tonsillectomy were recruited. Participants were randomized into 2 groups to receive either 0.15% benzydamine hydrochloride (TV) mouthwash solution (study arm) or a placebo solution. They were instructed to gargle the intervention they received 3 times a day for 7 days following surgery. Primary outcomes were intensity and duration of post-operative pain (using VAS visual analogue score) during a 2-week follow-up period. Secondary outcomes were pain medication demand, readmission, incidence of post-operative bleeding, hospital stay duration, and time to resume normal solid diet. RESULTS Thirty-nine patients completed the study, of whom 23 received TV and 16 received placebo. The mean age was 23.1 years. There was no significant difference between the groups in the primary or secondary outcomes. CONCLUSIONS The data suggest that topical treatment with TV mouthwash solution was not found to be superior to placebo in the management of post-tonsillectomy pain, bleeding, and return to a regular solid diet. Further research studies should be designed to investigate the ideal treatment for reducing post-tonsillectomy morbidity. CLINICAL TRIAL REGISTRATION NIH identifier: NCT02190762; IRB NHR002814.
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Affiliation(s)
- Tal Hanani
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Hussein Gadban
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Forsan Jahshan
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Ohad Ronen
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Israel.
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Kim MG, Kwak A, Choi B, Ji E, Oh JM, Kim K. Effect of glutathione S-transferase genetic polymorphisms on busulfan pharmacokinetics and veno-occlusive disease in hematopoietic stem cell transplantation: A meta-analysis. Basic Clin Pharmacol Toxicol 2018; 124:691-703. [PMID: 30511436 DOI: 10.1111/bcpt.13185] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/28/2018] [Indexed: 12/25/2022]
Abstract
This meta-analysis was conducted to derive an integrated conclusion about the influence of glutathione S-transferase (GST) genetic polymorphisms on busulfan pharmacokinetic (PK) parameters and veno-occlusive disease (VOD). Studies which analysed the effect of GST genetic polymorphisms on area under the curve (AUC), clearance (CL) or VOD were searched for and selected. A pooled analysis was conducted using Comprehensive Meta-Analysis programme. Nineteen studies were included in this meta-analysis. GSTA1*B and GSTM1 null genotypes significantly decreased CLIV of busulfan (standardized difference in means (SDM) = -1.103; P = 0.019 and SDM = -0.418; P = 0.002, respectively). GSTA1*B significantly increased AUCIV of busulfan (SDM = 0.832; P = 0.046), whereas GSTM1 did not (SDM = 0.155; P = 0.478). The PK parameters of oral busulfan did not differ according to GST genotype. GSTA1, GSTM1 and GSTP1 were not significantly associated with VOD occurrence. GSTA1 and GSTM1 genotypes affected CLIV of busulfan, but only GSTA1 affected AUCIV . There was no significant difference in the PK parameters of oral busulfan (CLPO and AUCPO ) and VOD when only GST genotypes were considered.
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Affiliation(s)
- Myeong Gyu Kim
- Graduate School of Clinical Pharmacy, CHA University, Pocheon, Korea
| | - Arim Kwak
- College of Pharmacy, Korea University, Sejong, Korea
| | - Boyoon Choi
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Korea
| | - Eunhee Ji
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Gachon University, Incheon, Korea
| | - Jung Mi Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Korea
| | - Kyungim Kim
- College of Pharmacy, Korea University, Sejong, Korea
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Frelich M, Divák J, Vodička V, Masárová M, Jor O, Gál R. Dexamethasone Reduces the Incidence of Postoperative Nausea and Vomiting in Children Undergoing Endoscopic Adenoidectomy under General Anesthesia Without Increasing the Risk of Postoperative Hemorrhage. Med Sci Monit 2018; 24:8430-8438. [PMID: 30465722 PMCID: PMC6263352 DOI: 10.12659/msm.911231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Postoperative nausea and vomiting (PONV) is a common complication of pediatric anesthesia, but the overall incidence of PONV in patients undergoing adenoidectomy is unknown. The aim of this controlled study was to compare the effect of dexamethasone administration with placebo to reduce PONV in children undergoing endoscopic adenoidectomy under general anesthesia. Material/Methods A randomized placebo-controlled study included 118 pediatric patients who underwent elective endoscopic adenoidectomy under general anesthesia. A dexamethasone-treated (0.15 mg/kg) group (Group D) (n=56) and a placebo group (Group C) (n=62) were randomly assigned. The incidence of nausea and vomiting was recorded on the day of surgery. Postoperative nausea was assessed according to illustrated Baxter Animated Retching Faces (BARF) scale. The Face, Legs, Activity, Cry, and Consolability (FLACC) scale (scores between 0–10) was used to assess pain. Follow-up was performed on the 14th postoperative day by a telephone call. Results Overall prevalence of postoperative nausea was 25% (30/118) and postoperative vomiting was 14% (17/118). In the first 24 hours following surgery, in Group D, the incidence of nausea and vomiting was 13% and 7%, respectively; in Group C, without pharmacological prophylaxis, the incidence of postoperative nausea and vomiting was 37%, and 21%, respectively. Conclusions A prospective controlled study in children undergoing endoscopic adenoidectomy under general anesthesia showed that dexamethasone (0.15 mg/kg) significantly reduced the incidence of PONV without increasing the risk of postoperative hemorrhage. Dexamethasone is a safe method for the prevention of PONV that may be recommended in pediatric anesthesiology.
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Affiliation(s)
- Michal Frelich
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Jan Divák
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Vojtěch Vodička
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Michaela Masárová
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Ondřej Jor
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Roman Gál
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Brno, Brno, Czech Republic
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The use of steroids to reduce complications after tonsillectomy: a systematic review and meta-analysis of randomized controlled studies. Eur Arch Otorhinolaryngol 2018; 276:585-604. [DOI: 10.1007/s00405-018-5202-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
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Hsueh WY, Hsu WC, Ko JY, Yeh TH, Lee CH, Kang KT. Postoperative hemorrhage following tonsillectomy in adults: Analysis of population-based inpatient cohort in Taiwan. Auris Nasus Larynx 2018; 46:397-406. [PMID: 30392979 DOI: 10.1016/j.anl.2018.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/18/2018] [Accepted: 10/17/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Because of the lack of population-based analyses, this study elucidated the epidemiology and 30-day postoperative complications of inpatient adult tonsillectomies in Taiwan. METHODS Using the Taiwan National Health Insurance Research Database, we identified all inpatient adult tonsillectomies (age>20years) in Taiwan during 1997-2012 through International Codes of Diseases, 9th Revision. Trend of the inpatient tonsillectomy in adult during the study period was explored. Major complications of readmission, reoperation, and mortality within 30days after tonsillectomies were identified. Factors associated with major complications were analyzed using multivariate logistic model. RESULTS In total, 27,365 adults received inpatient tonsillectomies (mean age, 38.4±13.0years; 57.2% male). The overall incidence was 10.2 per 100,000 population per year among adults. Incidence rates increased from 1997 (8.2/100,000 adults) to 2012 (11.2/100,000 adults) (P trend<0.001). The rate of readmission for any reason, readmission for bleeding, reoperation for bleeding, and mortality were 4.9%, 2.2%, 1%, and 0.1%, respectively. Young age increased the risk of bleeding-related readmission and reoperation, whereas old age increased the risk of readmission for any reason and mortality. Male gender increased the risk of all major complications. Hypertension was associated with an increased risk of bleeding-related readmission (odds ratio [OR]=2.21; 95% confidence interval [CI] 1.68-2.92) and reoperation (OR=2.17; 95% CI 1.44-3.27). Existing catastrophic illness increased the risk of readmission (OR=4.28; 95% CI 3.60-5.08) for any reason and mortality (OR=3.24; 95% CI 1.37-7.65). Nonsteroidal anti-inflammatory drugs and steroids were associated with an increased risk of readmission or reoperation for bleeding. CONCLUSION Incidence rates of inpatient adult tonsillectomy increased during 1997-2012 in Taiwan. Age, gender, comorbidity, and drug administration characteristics were associated with major complications of adult tonsillectomies in this cohort.
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Affiliation(s)
- Wan-Yi Hsueh
- Department of Otolaryngology, Hsinchu Cathay General Hospital, Hsinchu, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, College of Medicine, National Taiwan University, Taiwan
| | - Jenq-Yuh Ko
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, College of Medicine, National Taiwan University, Taiwan
| | - Te-Huei Yeh
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, College of Medicine, National Taiwan University, Taiwan
| | - Chia-Hsuan Lee
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan; Department of Nursing, Hsin Sheng Junior College of Medical Care and Management, Taoyuan, Taiwan.
| | - Kun-Tai Kang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan.
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Attia TM. Effect of paracetamol/prednisolone versus paracetamol/ibuprofen on post-operative recovery after adult tonsillectomy. Am J Otolaryngol 2018; 39:476-480. [PMID: 29805060 DOI: 10.1016/j.amjoto.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 05/09/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare the effect of Paracetamol/Prednisolone versus Paracetamol/Ibuprofen on post-operative recovery after adult tonsillectomy. BACKGROUND Various analgesic protocols have been proposed for the control of post-tonsillectomy morbidity with need for better control in adult population for having higher severity of post-operative pain and risk of secondary post-tonsillectomy bleeding. METHODS This is a prospective cohort study conducted on 248 patients with age of 12 years or older distributed as two equal groups; the first one receiving Paracetamol/Prednisolone and the second one receiving Paracetamol/Ibuprofen. Both groups were compared at 7 days post-operative regarding pain at rest, tiredness of speech, dietary intake, and decrease in sleep duration. Both groups were compared regarding incidence of nausea and vomiting at 2 days post-operative. The incidence and severity of secondary post-tonsillectomy hemorrhage was compared between the two groups. RESULTS Pain at rest (no swallowing - no talking) was less in group I but not reaching statistical significance (p = 0.36). In addition, dietary intake was better in group I but not reaching statistical significance (P = 0.17). However, talking ability was better with statistically significant difference (P = 0.03) in group I. Impairment of sleep was less with group II but not reaching statistical significance (p = 0.31). The incidence of vomiting at second post-operative day was less in group I with statistical significance (p = 0.049). The incidence of secondary post-tonsillectomy bleeding was significantly higher in group II with statistical significance (p = 0.046). The severity of bleeding episodes was also significantly higher in group II (p = 0.045). CONCLUSION Both ibuprofen and prednisolone were effective as a part of post-operative medication regimen after adult tonsillectomy. However, prednisolone was superior to ibuprofen regarding improvement of pain at rest, dietary intake, tiredness of speech and post-operative nausea and vomiting. However, ibuprofen had a better impact on sleep. The incidence and severity of secondary post-tonsillectomy hemorrhage were significantly higher with ibuprofen favoring the selection of prednisolone to be combined with paracetamol in the post-operative medication protocol following tonsillectomy.
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Affiliation(s)
- Tamer M Attia
- Lecturer at Otolaryngology Department, Faculty of Medicine, Menoufia University, Egypt; Consultant at Otolaryngology, Head & Neck Surgery Department, Specialized Medical Care Hospital, Al Ain, United Arab Emirates.
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Ferster APO, Schaefer E, Schubart JR, Carr MM. Ancillary Medications and Outcomes in Post-Tonsillectomy Patients. EAR, NOSE & THROAT JOURNAL 2018. [DOI: 10.1177/014556131809700804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To investigate the impact of medications on outcomes after tonsillectomy, a retrospective review using the Market Scan database was performed. A total of 306,536 privately insured children and adolescents (1 to 17 years old) who underwent tonsillectomy/adenoidectomy were identified from 2008 to 2012. Pharmaceutical claims identified patients who received outpatient prescriptions for ibuprofen, steroids, or topical anesthetics until discharge and for medications for the treatment of attention deficit hyperactivity disorder (ADHD) or montelukast up to 14 days postoperatively. Logistic regression compared prescription claims to outcomes, including postoperative bleeding, dehydration, emergency department visits, and readmissions. Ibuprofen was the only medication associated with increased odds of postoperative bleeding (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.07 to 1.95). Patients receiving steroids had lower odds of dehydration (OR: 0.74, 95% CI: 0.65 to 0.84) and emergency department visits (OR: 0.82, 95% CI: 0.76 to 0.88). Odds of dehydration were highest in patients taking ADHD medications (OR: 1.38, 95% CI: 1.15 to 1.66) and topical anesthetics (OR: 1.32, 95% CI: 1.10 to 1.59). Although causality cannot be assumed in observational studies, steroids and ibuprofen should be used judiciously.
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Affiliation(s)
- Ashley P. O'Connell Ferster
- From the Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, The Pennsylvania State University College of Medicine, Hershey, Penn
| | - Eric Schaefer
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Penn
| | - Jane R. Schubart
- From the Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, The Pennsylvania State University College of Medicine, Hershey, Penn
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Penn
| | - Michele M. Carr
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University
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Cull F, Choo S, Milner T, Kontorinis G, Marshall J. A comprehensive analysis of all patients (n = 509) undergoing tonsillectomy during 1 year in a large centralised service. Clin Otolaryngol 2018; 43:1383-1387. [DOI: 10.1111/coa.13148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
- F. Cull
- Department of Otolaryngology, Head and Neck Surgery; Queen Elizabeth University Hospital; Glasgow UK
| | - S. Choo
- University of Glasgow; Glasgow UK
| | - T.D. Milner
- Department of Otolaryngology, Head and Neck Surgery; Queen Elizabeth University Hospital; Glasgow UK
- University of Glasgow; Glasgow UK
| | - G. Kontorinis
- Department of Otolaryngology, Head and Neck Surgery; Queen Elizabeth University Hospital; Glasgow UK
| | - J. Marshall
- Department of Otolaryngology, Head and Neck Surgery; Queen Elizabeth University Hospital; Glasgow UK
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Hsueh WY, Hsu WC, Ko JY, Yeh TH, Lee CH, Kang KT. Population-based survey of inpatient pediatric tonsillectomy and postoperative hemorrhage in Taiwan, 1997-2012. Int J Pediatr Otorhinolaryngol 2018; 108:55-62. [PMID: 29605366 DOI: 10.1016/j.ijporl.2018.02.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/11/2018] [Accepted: 02/12/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Tonsil surgery in children is a common surgical procedure, and is mostly performed as an inpatient procedure in Taiwan. This study elucidates the epidemiology and postoperative hemorrhage of inpatient tonsillectomies in Taiwanese children. METHODS This study used the Taiwan National Health Insurance Research Database for analysis. From 1997 to 2012, all in-hospital children (aged <18 years) who underwent tonsillectomies were identified through the International Codes of Diseases (9th Revision). Incidence rates and trends of inpatient pediatric tonsillectomies during the study period were identified. Major complications, including readmission, reoperation, and mortality were identified. The factors associated with major complications were analyzed. RESULTS From 1997 to 2012, 17326 children received inpatient tonsillectomies (mean age, 8.6 ± 3.8 y; 65% boys). The overall incidence rate was 20.6 per 100,000 children. The incidence rate was highest in children who were 6-8 years of age, and boys exhibited a higher rate than girls (P < 0.001). Longitudinal data indicated that the incidence rate increased from 1997 (15.7/100,000 children) to 2012 (19.2/100,000 children) (P trend < 0.001). The proportions of readmission for any reason, readmission for bleeding, and reoperation were 1.8%, 0.9%, and 0.3%, respectively. No mortality occurred within 30 days of the tonsillectomy. A multivariable logistic model indicated that toddlers were associated with an increased risk of readmission for any reason (OR, 2.70; 95% CI 1.60-4.56), and adolescents were at risk of bleeding-related readmission (OR, 2.81; 95% CI 1.91-4.14) and reoperation (OR, 2.86; 95% CI 1.47-5.55). Children with comorbidities (OR, 3.14; 95% CI 1.93-5.09) or a surgical indication of tumor (OR, 11.73; 95% CI 4.93-27.91) had a higher risk of readmission. The use of nonsteroidal anti-inflammatory drugs or steroids is associated with an increased risk of readmission or reoperation. Moreover, concurrent procedures (i.e., adenoidectomy, ear surgery, or nasal surgery) did not increase the risk of readmission or reoperation. CONCLUSIONS The incidence rate and indications of obstructive sleep disorders for inpatient pediatric tonsillectomy increased during 1997-2012 in Taiwan. Postoperative readmission and reoperation were rare. Age, surgical indication, comorbidities, and drug administration were associated with readmission or reoperation in this study cohort.
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Affiliation(s)
- Wan-Yi Hsueh
- Department of Otolaryngology, Hsinchu Cathay General Hospital, Hsinchu, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University, College of Medicine, Taiwan
| | - Jenq-Yuh Ko
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University, College of Medicine, Taiwan
| | - Te-Huei Yeh
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University, College of Medicine, Taiwan
| | - Chia-Hsuan Lee
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan; Department of Nursing, Hsin Sheng Junior College of Medical Care and Management, Taoyuan, Taiwan.
| | - Kun-Tai Kang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan.
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Miyamoto Y, Shinzawa M, Tanaka S, Tanaka-Mizuno S, Kawakami K. Perioperative Steroid Use for Tonsillectomy and Its Association With Reoperation for Posttonsillectomy Hemorrhage. Anesth Analg 2018; 126:806-814. [DOI: 10.1213/ane.0000000000002681] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Post-tonsillectomy hemorrhage: Underlying factors and prevention. Am J Otolaryngol 2018; 39:230-231. [PMID: 29305220 DOI: 10.1016/j.amjoto.2017.12.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/27/2017] [Indexed: 01/06/2023]
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Clayburgh D, Stott W, Bolognone R, Palmer A, Achim V, Troob S, Li R, Brickman D, Graville D, Andersen P, Gross ND. A randomized controlled trial of corticosteroids for pain after transoral robotic surgery. Laryngoscope 2017; 127:2558-2564. [DOI: 10.1002/lary.26625] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/14/2017] [Accepted: 03/23/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Clayburgh
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Will Stott
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Rachel Bolognone
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Andrew Palmer
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Virginie Achim
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Scott Troob
- Department of Otolaryngology-Head and Neck Surgery; Columbia University Medical Center; New York New York
| | - Ryan Li
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Daniel Brickman
- Levine Cancer Institute, Carolinas Health System; Charlotte North Carolina
| | - Donna Graville
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Peter Andersen
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Neil D. Gross
- Department of Otolaryngology-Head and Neck Surgery; MD Anderson Cancer Center; Houston Texas U.S.A
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The effect of perioperative dexamethasone dosing on post-tonsillectomy hemorrhage risk. Int J Pediatr Otorhinolaryngol 2017; 98:19-24. [PMID: 28583496 DOI: 10.1016/j.ijporl.2017.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/19/2017] [Accepted: 04/21/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Dexamethasone is currently recommended for routine prophylaxis against postoperative nausea and vomiting after tonsillectomy procedures. However, some studies have raised concern that dexamethasone use may lead to higher rates of post-tonsillectomy hemorrhage. Our objective was to determine whether higher doses of dexamethasone administered perioperatively during tonsillectomy procedures are associated with an increased risk of secondary post-tonsillectomy hemorrhage. METHODS We conducted a retrospective review of 9843 patients who underwent tonsillectomy and received dexamethasone at our institution from January 2010 to October 2014. We compared the dose of dexamethasone administered to patients who did and did not develop secondary post-tonsillectomy hemorrhage using Mann Whitney U tests. Multivariable logistic regression models were used to evaluate the association between dexamethasone dose and post-tonsillectomy hemorrhage after adjustment for demographic and clinical characteristics. RESULTS A total of 280 (2.8%) patients developed secondary post-tonsillectomy hemorrhage. Patients who developed hemorrhage tended to be older (median (interquartile range) 7 (4-11) vs. 5 (3-8) years), p < 0.001) and had undergone tonsillectomy more often for chronic tonsillitis but less often for tonsillar or adenotonsillar hypertrophy or sleep disturbances. Dexamethasone dose was significantly lower on average in patients who experienced secondary post-tonsillectomy hemorrhage (median (interquartile range) 0.19 (0.14, 0.23) mg/kg vs. 0.21 (0.17, 0.30), p < 0.001). Multivariable modeling demonstrated that the dose of dexamethasone was not significantly associated with post-tonsillectomy hemorrhage after adjustment for age. CONCLUSIONS There does not appear to be a dose-related increase in the risk of post-tonsillectomy hemorrhage for patients receiving dexamethasone during tonsillectomy procedures.
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Outcomes after major surgery in patients with myasthenia gravis: A nationwide matched cohort study. PLoS One 2017; 12:e0180433. [PMID: 28666024 PMCID: PMC5493398 DOI: 10.1371/journal.pone.0180433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 05/24/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To validate the comprehensive features of adverse outcomes after surgery for patients with myasthenia gravis. Methods Using reimbursement claims from Taiwan’s National Health Insurance Research Database, we analyzed 2290 patients who received major surgery between 2004 and 2010 and were diagnosed with myasthenia gravis preoperatively. Surgical patients without myasthenia gravis (n = 22,900) were randomly selected by matching procedure with propensity score for comparison. The adjusted odds ratios and 95% confidence intervals of postoperative adverse events associated with preoperative myasthenia gravis were calculated under the multiple logistic regressions. Results Compared with surgical patients without myasthenia gravis, surgical patients with myasthenia gravis had higher risks of postoperative pneumonia (OR = 2.09; 95% CI: 1.65–2.65), septicemia (OR = 1.31; 95% CI: 1.05–1.64), postoperative bleeding (OR = 1.71; 95% CI: 1.07–2.72), and overall complications (OR = 1.70; 95% CI: 1.44–2.00). The ORs of postoperative adverse events for patients with myasthenia gravis who had symptomatic therapy, chronic immunotherapy, and short-term immunotherapy were 1.76 (95% CI 1.50–2.08), 1.70 (95% CI 1.36–2.11), and 4.36 (95% CI 2.11–9.04), respectively. Conclusions Patients with myasthenia gravis had increased risks of postoperative adverse events, particularly those experiencing emergency care, hospitalization, and thymectomy for care of myasthenia gravis. Our findings suggest the urgency of revising protocols for perioperative care for these populations.
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Somov P, Chan BKY, Wilde C, Corbett H. Bleeding after circumcision is more likely in children with lichen sclerosus (balanitis xerotica obliterans). J Pediatr Urol 2017; 13:208.e1-208.e4. [PMID: 28043767 DOI: 10.1016/j.jpurol.2016.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/26/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Over 27,000 circumcisions were performed in England in 2012-13. The complication rate is generally perceived to be low, although published figures vary widely. Balanitis xerotica obliterans, more correctly termed Lichen Sclerosus et atrophicus (LS), is one of the commonest indications for medical circumcision. To test the hypothesis that children undergoing circumcision for LS have a higher rate of postoperative bleeding than those undergoing the procedure for other reasons, we retrospectively reviewed records for patients undergoing circumcision. METHODS The disease and procedure coding system was used to identify patients who underwent circumcision (ICD10 code N303) between 2000-2010. Cases with a diagnosis unrelated to circumcision and children circumcised during hypospadias repair were excluded. Bleeding which required return to theatre for surgical arrest was considered significant. Cases were identified by review of medical records if there was: a second procedure during the same admission, or readmission coded for circumcision within 2 weeks. Only cases with histologically confirmed LS were included in the LS cohort. GraphPad online calculator was used for statistical analysis (two tailed Fisher's exact test. RESULTS 2385 boys with a median age of 4 years (range 0-16) were included in the study. Indication for circumcision included religious (1305, 54.7%), phimosis or redundant prepuce (512, 21.5%), suspected LS (366, 15.4%) and balanoposthitis (202, 8.5%). LS was histologically confirmed in 262 (10.9%) boys. Fourteen (0.6%) patients returned to theatre for surgical arrest of bleeding following circumcision; 6 had LS and 8 did not (Table 1). The bleeding rate was higher in those with LS (2.3%) than in those without (0.3%), P = 0.0003 with a relative risk of 6.08. CONCLUSION Post-operative complications are distressing, especially if further surgery is required. Published figures for complications following circumcision vary widely making counseling regarding risk difficult. Since LS includes an inflammatory element and circumcision in widespread LS can be challenging, the observation of more post-operative bleeding in patients with histologically confirmed LS during a previous audit prompted the hypothesis that this may be a significant finding. Thus we reviewed all patients requiring return to theatre within 2 weeks of circumcision, finding that whilst the overall bleeding rate was low, circumcision for LS significantly increased the risk. Although factors such as the severity of LS and surgical technique were not assessed, this is still a notable finding which should be reflected during pre-operative counseling.
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Affiliation(s)
- P Somov
- Alder Hey Children's NHS Foundation Trust, Department of Paediatric Surgery, E Prescot Rd, Liverpool, L14 5AB, UK.
| | - B K Y Chan
- Alder Hey Children's NHS Foundation Trust, Department of Paediatric Surgery, E Prescot Rd, Liverpool, L14 5AB, UK
| | - C Wilde
- Alder Hey Children's NHS Foundation Trust, Department of Paediatric Surgery, E Prescot Rd, Liverpool, L14 5AB, UK
| | - H Corbett
- Alder Hey Children's NHS Foundation Trust, Department of Paediatric Surgery, E Prescot Rd, Liverpool, L14 5AB, UK
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Cayer ME. Pediatric Tonsillectomy and Adenoidectomy. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abdel-Ghaffar HS, Abdel-Azeem HG, Roushdy MM. Safety and efficacy of pre-incisional peritonsillar lornoxicam in paediatric post-tonsillectomy pain: a prospective double-blind, placebo-controlled, split-body clinical study. Clin Otolaryngol 2016; 40:219-26. [PMID: 25404551 DOI: 10.1111/coa.12351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the risk of peri-operative bleeding and re-intervention with peritonsillar lornoxicam infiltration in paediatric tonsillectomy. DESIGN Prospective, randomised, double-blinded, placebo-controlled, split-body study. SETTING University hospital. PARTICIPANTS A total of 68 patients (7-15 years), ASA I-II, scheduled for tonsillectomy divided into two groups (n = 34) to receive bilateral peritonsillar saline infiltration (placebo group) or peritonsillar saline infiltration in one tonsil (placebo side) and 8 mg lornoxicam in the other tonsil (intervention side; study group). Drugs were administered after induction of anaesthesia and before start of surgery. MAIN OUTCOME MEASURES Intra-operative and postoperative bleeding score, platelet aggregometry before and 30 min after study drug administration, the verbal rating pain scale, time to first postoperative analgesic request, total analgesic consumption during 1st 24 h postoperative and adverse effects were evaluated. RESULTS The difference in bleeding score between groups did not reach our definition of statistical significance (P < 0.05). Platelet aggregometry tests did not change significantly with time between groups. Lower postoperative pain scores, longer time to first analgesic request (372.76 ± 82.15 versus 64.89 ± 25.76 min P < 0.001) and lower paracetamol consumption (421.76 ± 125.63 versus 690.29 ± 141.47 mg, P < 0.001) were recorded in study group compared with control group. No patient required hospital re-admission or re-operation because of postoperative tonsillar bed bleeding. CONCLUSIONS The lack of significant complications suggests that pre-incisional peritonsillar lornoxicam followed by intravenous paracetamol rescue analgesia may be safe for tonsillectomy in children. To avoid conflict with intra-operative bleeding, postoperative infiltration of lornoxicam is recommended.
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Affiliation(s)
- H S Abdel-Ghaffar
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - H G Abdel-Azeem
- Clinical Pathology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - M M Roushdy
- Otorhinolaryngology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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Aveline C, Le Hetet H, Le Roux A, Bonnet F. A survey of the administration of prednisolone versus ibuprofen analgesic protocols after ambulatory tonsillectomy. Anaesth Crit Care Pain Med 2015; 34:281-7. [DOI: 10.1016/j.accpm.2014.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 11/10/2014] [Indexed: 10/22/2022]
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Janiaud P, Lajoinie A, Cour-Andlauer F, Cornu C, Cochat P, Cucherat M, Gueyffier F, Kassai B. Different treatment benefits were estimated by clinical trials performed in adults compared with those performed in children. J Clin Epidemiol 2015; 68:1221-31. [PMID: 26164751 DOI: 10.1016/j.jclinepi.2015.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 12/20/2014] [Accepted: 06/29/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Our main objective was to see whether the therapeutic benefit observed in placebo controlled randomized controlled trials (RCTs) is different between adults and children. STUDY DESIGN AND SETTING We searched three electronic databases for meta-analyses that included double-blind, placebo-controlled RCTs with separate results for adults and children. The selected reviews were classified according to disease and drug used. The heterogeneity of treatment response between adults and children was measured using ratio of odds ratios (RORs). RESULTS We selected 89 meta-analyses and calculated RORs for 124 drugs. Heterogeneity in the direction of the treatment effect was observed in one drug and heterogeneity in the quantity of the treatment effect for 13 drugs, indicating significantly different treatment effect in adults when compared with children. RORs were not significantly different from 1 for 110 drugs. For 36 of these drugs, the treatment effect was confirmed in both populations. CONCLUSION We found different treatment benefits estimated by clinical trials performed in adults compared with those performed in children for 14 of 124 drugs. Data on dose adjustment and child age groups from RCTs were not adequately reported to investigate their influence on the treatment benefit dissimilarities.
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Affiliation(s)
| | - Audrey Lajoinie
- Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France
| | - Fleur Cour-Andlauer
- Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France
| | - Catherine Cornu
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France; Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France
| | - Pierre Cochat
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Department of Pediatric Nephrology, Hopital Femme Mere Enfant, Lyon, France
| | - Michel Cucherat
- Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France
| | - François Gueyffier
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France
| | - Behrouz Kassai
- UMR 5558 CRNS Lyon, University of Lyon 1, France; Clinical Investigation Center, EPICIME, INSERM CIC 1407/UMR 5558 CNRS, Bron, France; Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France.
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Mahant S, Hall M, Ishman SL, Morse R, Mittal V, Mussman GM, Gold J, Montalbano A, Srivastava R, Wilson KM, Shah SS. Association of National Guidelines With Tonsillectomy Perioperative Care and Outcomes. Pediatrics 2015; 136:53-60. [PMID: 26101361 DOI: 10.1542/peds.2015-0127] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy. METHODS We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits). We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series. RESULTS Of 111,813 children who underwent tonsillectomy, 54,043 and 57,770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P < .001) in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, -0.02% to 0.29%; P < .001). Antibiotic use decreased from 34.7% to 21.8% (P < .001), as did its rate of change in use (percentage change per month, -0.17% to -0.56%; P < .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% (P < .001) because of an increase in revisits for pain. Hospital-level results were similar. CONCLUSIONS The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain.
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Affiliation(s)
- Sanjay Mahant
- Division of Pediatric Medicine, Pediatric Outcomes Research Team (PORT), Department of Pediatrics, Institute of Health Policy, Management and Evaluation, University of Toronto, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada;
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Stacey L Ishman
- Division of Otolaryngology, Head & Neck Surgery, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, and Department of Otolaryngology, Head & Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rustin Morse
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vineeta Mittal
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Jessica Gold
- New York-Presbyterian Morgan Stanley Children's Hospital and Columbia University Medical Center, New York, New York
| | - Amanda Montalbano
- Children's Mercy Hospitals and Clinics and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Rajendu Srivastava
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah Health Sciences Center, Institute for Healthcare Delivery Research, Intermountain Healthcare Inc., Salt Lake City, Utah; and
| | - Karen M Wilson
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Corcoran TB, Edwards T. A survey of antiemetic dexamethasone administration-frequency of use and perceptions of benefits and risks. Anaesth Intensive Care 2015; 43:167-74. [PMID: 25735681 DOI: 10.1177/0310057x1504300205] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Postoperative nausea and vomiting (PONV) is a significant concern for anaesthetists. There are many agents from different classes that are effective in both preventing and treating PONV. Dexamethasone is a very effective antiemetic, but there are concerns regarding its safety. We performed an anonymous survey of a random selection of the fellows of the Australian and New Zealand College of Anaesthetists to ascertain patterns of practice in relation to PONV prophylaxis and treatment and also to determine awareness of the risks and benefits of perioperative dexamethasone administration. The response rate was 33%. From the responses, 71.2% of all patients undergoing general anaesthesia in the respondents' institutions receive PONV prophylaxis in total and 46.6% receive dexamethasone. No respondent gives more than a single dose of dexamethasone and there was an almost equal split between those who administer 4 and 8 mg, with a smaller number dosing on a weight basis. 5HT-3 receptor antagonists and dexamethasone are the preferred first-line PONV prophylactic agents and 5HT-3 receptor antagonists and droperidol are the preferred first-line PONV therapeutic agents. Concerns relating to the safety of dexamethasone were expressed by 80% of respondents. From this survey, we concluded that the PONV practice of the respondents is largely compliant with recent consensus guidelines, although PONV prophylaxis appears to be given more routinely. It also appears that more education is required on issues regarding dexamethasone safety.
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Affiliation(s)
- T B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital and Clinical Professor, School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - T Edwards
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia
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Abstract
PURPOSE OF REVIEW Postoperative nausea and vomiting (PONV) has a high incidence in children and requires prophylactic and therapeutic strategies. RECENT FINDINGS PONV can be reduced by the avoidance of nitrous oxide, volatile anesthetics, and the reduction of postoperative opioids. The use of dexamethasone, 5-HT3 antagonists, or droperidol alone is potent, but combinations are even more effective to reduce PONV. Droperidol has a Food and Drug Administration warning. Hence, dexamethasone and 5-HT3 antagonists should be preferred as prophylactic drugs. It is further reasonable to adapt PONV prophylaxis to different risk levels. Prolonged surgery time, inpatients, types of surgery (e.g. strabismus and ear-nose-throat surgery), and patients with PONV in history should be treated as high risk, whereas short procedures and outpatients are to be treated as low risk. SUMMARY Concluding from the existing guidelines and data on the handling of PONV in children at least 3 years, the following recommendations are given: outpatients undergoing small procedures should receive a single prophylaxis, outpatients at high risk a double prophylaxis, inpatients with surgery time of more than 30 min and use of postoperative opioids should get double prophylaxis, and inpatients receiving a high-risk surgical procedure or with other risk factors a triple prophylaxis (two drugs and total intravenous anesthesia). Dimenhydrinate can be used as a second choice, whereas droperidol and metoclopramide can only be recommended as rescue therapy.
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Mattos JL, Robison JG, Greenberg J, Yellon RF. Acetaminophen plus ibuprofen versus opioids for treatment of post-tonsillectomy pain in children. Int J Pediatr Otorhinolaryngol 2014; 78:1671-6. [PMID: 25128450 DOI: 10.1016/j.ijporl.2014.07.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/11/2014] [Accepted: 07/14/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of acetaminophen plus ibuprofen in treatment of post-tonsillectomy pain compared to acetaminophen plus opioids in children. STUDY DESIGN Retrospective medical record review. SETTING Tertiary-care children's hospital between September 2012 and March 2013. SUBJECTS AND METHODS All children undergoing total tonsillectomy (n=1065). Analysis included descriptive analysis, chi-square testing, and logistic regression controlling for age, diagnosis, trainee involvement, concurrent surgical procedures, and Coblator use for differences of outcomes: (1) post-operative bleeding, (2) emergency department (ED) visits for pain, dehydration, or bleeding, and (3) nurse phone calls from families. RESULTS All patients received acetaminophen. Seventy-four percent received ibuprofen (n=783) and 26.5% did not receive ibuprofen (n=282). In the ibuprofen group, 32.2% received opioids (n=252). Over eight percent of children had post-operative hemorrhage of any amount reported (n=89). Forty-eight percent of these required operative intervention (n=43). Ibuprofen prescription did not impact post-operative bleeding; operative intervention for bleeding, ED visits, or nurse phone calls either on chi-squared or logistic regression testing. Increasing age was found to increase bleeding risk as well as the likelihood of visiting the ED or calling the clinic nurses. All patients with multiple bleeding episodes were in the ibuprofen group. CONCLUSION Prescription of ibuprofen did not increase the risk of bleeding and did not increase the likelihood of a post-operative ED visit or nurse phone call. Ibuprofen prescription may possibly increase the risk of multiple bleeding episodes, but further prospective studies are needed. Increased age increases the risk of bleeding, ED visits, and nurse phone calls.
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Affiliation(s)
- Jose L Mattos
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Jacob G Robison
- Division of Pediatric Otolaryngology, St. Luke's Children's Hospital, Boise, ID 83712, USA
| | - Jesse Greenberg
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Robert F Yellon
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA.
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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.
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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
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Yellon RF, Kenna MA, Cladis FP, Mcghee W, Davis PJ. What is the best non-codeine postadenotonsillectomy pain management for children? Laryngoscope 2014; 124:1737-8. [DOI: 10.1002/lary.24599] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 12/27/2013] [Accepted: 01/13/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Robert F. Yellon
- Division of Pediatric Otolaryngology; Children-s Hospital of Pittsburgh of UPMC; Pittsburgh Pennsylvania U.S.A
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
| | - Margaret A. Kenna
- Department of Otology and Laryngology; Harvard Medical School; U.S.A
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Franklyn P. Cladis
- Department of Anesthesiology; Children-s Hospital of Pittsburgh of UPMC; Pittsburgh Pennsylvania U.S.A
| | - William Mcghee
- Clinical Pharmacy Specialist; Children-s Hospital of Pittsburgh of UPMC; Pittsburgh Pennsylvania U.S.A
- Department of Anesthesia and Pediatrics; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
| | - Peter J. Davis
- University of Pittsburgh School of Pharmacy; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
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Nguyen TBV, Chin RY, Paramaesvaran S, Eslick GD. Routine tonsillar bed oversew after diathermy tonsillectomy: does it reduce secondary tonsillar haemorrhage? Eur Arch Otorhinolaryngol 2014; 271:3005-10. [PMID: 24792067 DOI: 10.1007/s00405-014-3075-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
Tonsillectomy is a common otolaryngological procedure and is associated with a small risk of postoperative pharyngeal haemorrhage. This study compares secondary post tonsillectomy haemorrhage rates between two operative techniques: diathermy tonsillectomy and diathermy tonsillectomy with tonsillar bed oversew. A total of 424 patients underwent tonsillectomies with or without other procedures such as adenoidectomy and grommet insertion by two ears, nose and throat surgeons at three hospitals from May 2012 to July 2013. A diathermy tonsillectomy was performed in 266 patients, while a diathermy tonsillectomy with tonsillar bed oversew was performed in 158 patients. All patients were followed up within 2-4 weeks of surgery. Primary haemorrhage did not occur in either surgical technique groups. Secondary haemorrhage occurred in 20 patients (7.52 %) in the diathermy tonsillectomy group and in 9 patients (5.70 %) in the diathermy with tonsillar bed oversew group. This result was not significantly different (OR = 0.74, 95 % CI 0.33-1.67, p = 0.47). Sex, age, indication for surgery and whether or not a tonsillectomy was performed alone or with other procedures were not significant factors for secondary haemorrhage. In summary, routine tonsillar bed oversew after diathermy tonsillectomy does not reduce the risk of secondary tonsillar haemorrhage.
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Affiliation(s)
- Thomas B V Nguyen
- Department of Otolaryngology, Head and Neck Surgery, Nepean Hospital, Derby St, Kingswood, Sydney, NSW, 2750, Australia,
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Comparison of Two Analgesic Protocols for Post-tonsillectomy Pain Control in Outpatient Adults. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.otoeng.2013.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Comparación de 2 protocolos analgésicos en el control del dolor postamigdalectomía en pacientes adultos ambulatorios. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2014; 65:102-8. [DOI: 10.1016/j.otorri.2013.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 10/29/2013] [Indexed: 11/18/2022]
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Abstract
The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.
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Mahant S, Keren R, Localio R, Luan X, Song L, Shah SS, Tieder JS, Wilson KM, Elden L, Srivastava R. Dexamethasone and risk of bleeding in children undergoing tonsillectomy. Otolaryngol Head Neck Surg 2014; 150:872-9. [PMID: 24493786 DOI: 10.1177/0194599814521555] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether dexamethasone use in children undergoing tonsillectomy is associated with increased risk of postoperative bleeding. STUDY DESIGN Retrospective cohort study using a multihospital administrative database. SETTING Thirty-six US children's hospitals. SUBJECTS Children undergoing same-day tonsillectomy between the years 2004 and 2010. METHODS We used discrete time failure models to estimate the daily hazards of revisits for bleeding (emergency department or hospital admission) up to 30 days after surgery as a function of dexamethasone use. Revisits were standardized for patient characteristics, antibiotic use, year of surgery, and hospital. RESULTS Of 139,715 children who underwent same-day tonsillectomy, 97,242 (69.6%) received dexamethasone and 4182 (3.0%) had a 30-day revisit for bleeding. The 30-day cumulative standardized risk of revisits for bleeding was greater with dexamethasone use (3.11% vs 2.71%; standardized difference 0.40% [95% confidence interval, 0.13%-0.67%]; P = .003), and the increased risk was observed across all age strata. Dexamethasone use was associated with a higher standardized rate of revisits for bleeding in the postdischarge time periods of days 1 through 5 but not during the peak period for secondary bleeding, days 6 and 7. CONCLUSIONS In a real-world practice setting, dexamethasone use was associated with a small absolute increased risk of revisits for bleeding. However, the upper bound of this risk increase does not cross published thresholds for a minimal clinically important difference. Given the benefits of dexamethasone in reducing postoperative nausea and vomiting and the larger body of evidence from trials, these results support guideline recommendations for the routine use of dexamethasone.
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Affiliation(s)
- Sanjay Mahant
- Division of Pediatric Medicine, Pediatric Outcomes Research Team (PORT), Department of Pediatrics, Institute of Health Policy, Evaluation and Management, University of Toronto, Toronto, Canada
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Riggin L, Ramakrishna J, Sommer DD, Koren G. A 2013 updated systematic review & meta-analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy. Clin Otolaryngol 2013; 38:115-29. [PMID: 23448586 DOI: 10.1111/coa.12106] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND Although the literature suggests that non-steroidal anti-inflammatory drugs (NSAIDs) are effective in controlling post-operative pain in the paediatric population, physicians have been reluctant to utilise these medications after tonsillectomy due to concerns of increased bleeding rates. While many surgeons prescribe opioid analgesics postoperatively, these are associated with a number of potential adverse side-effects including nausea, vomiting, constipation, excessive sedation and respiratory compromise. OBJECTIVE OF REVIEW To compare bleeding rates and severity between recipients of NSAIDs versus placebo or opioid analgesics for tonsillectomy. SEARCH STRATEGY Two authors independently searched electronic databases including PubMed, OVID, EMBASE and Cochrane Review from inception to July 2012. The keywords used included: Adenotonsillectomy, Tonsillectomy, Analgesia, Bleeding, Perioperative and Postoperative. These were then combined in various combinations with specific NSAIDs. EVALUATION METHOD A systematic review and meta-analysis of all randomised control trials comparing bleeding rates and severity between NSAIDs versus placebo or opioids post-tonsillectomy. RESULTS A total of 36 studies met our inclusion criteria including 1747 children and 1446 adults. When all of the studies were combined in a meta-analysis using the most severe outcome, there was no increased risk of bleeding in those using NSAIDs after tonsillectomy. Use of NSAIDs in general [1.30 (0.90-1.88)] or in children [1.06 (0.65-1.74)] was not associated with increased risk of bleeding in general, most severe bleeding, secondary haemorrhage, readmission or need of reoperation due to bleeding. Similarly, there was no increased bleeding risk for specific NSAIDs in adults. In the studies looking at paediatric subjects, the overall odds ratio of bleeding was even lower than in the general population and not significant. This result is based on 18 studies, six of which had zero outcomes in either treatment arm. Similar to the general population analysis, there was no significant difference in any of the subanalyses: bleeds treated with reoperation, readmission or bleeds in children that could be managed conservatively. There were also no significant differences in the subanalyses of individual NSAIDs. Similarly, there was no significant difference in rates of bleeding in the subanalysis of studies that gave NSAIDs multiple times, for instance, both before and after surgery. CONCLUSIONS These results suggest that NSAIDs can be considered as a safe method of analgesia among children undergoing tonsillectomy.
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Affiliation(s)
- L Riggin
- Western University Schulich School of Medicine & Dentistry, London, ON, Canada
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Czarnetzki C, Tramèr M. How to make tonsillectomy a safer procedure: the anaesthetist's view. ORL J Otorhinolaryngol Relat Spec 2013; 75:144-51. [PMID: 23978799 DOI: 10.1159/000343706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Anaesthetists use specific drugs peri-operatively to try to decrease the incidence and severity of postoperative pain and of postoperative nausea and vomiting. These drugs are usually administered pre-operatively with the premedication, or intra-operatively when the patient is still anaesthetised. The aim of this approach is to prevent the occurrence of intolerable pain or to avoid any nausea or vomiting symptoms which may be clearly unpleasant for the patient and which interfere with the patient's well-being, recovery and satisfaction. However, since most of these drugs are given prophylactically, and since not all patients will actually be suffering from intolerable pain or severe nausea and vomiting symptoms postoperatively, many patients will receive these drugs unnecessarily. Thus, for the individual patient, the risk of suffering from drug-related adverse reactions without profiting from any benefit may be relevant. Perhaps a 'wait-and-see' approach should be considered; especially non-steroidal anti-inflammatory drugs or dexamethasone should not be given pre-operatively to all patients but should be provided exclusively to those in whom alternative analgesics (for instance, paracetamol combined with a weak opioid) or alternative anti-emetics (for instance, a setron or droperidol) have failed or are associated with unacceptable adverse effects. There is no evidence that prophylactic administration of an analgesic or an anti-emetic is more efficacious than the therapeutic administration. An interesting alternative to achieve satisfactory posttonsillectomy analgesia may be with local anaesthesia swabs that are applied onto the wound.
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Kakodkar PS. Routine use of dexamethasone for postoperative nausea and vomiting: the case for. Anaesthesia 2013; 68:889-91. [DOI: 10.1111/anae.12308] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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