Dexamethasone and risk of bleeding in children undergoing tonsillectomy

Does Celecoxib Prescription for Pain Management Affect Post-tonsillectomy Hemorrhage Requiring Surgery? A Retrospective Observational Cohort Study

BACKGROUND

Adenotonsillectomy and tonsillectomy (referred to as tonsillectomy hereafter) are common pediatric surgeries. Postoperative complications include hemorrhage requiring surgery (2 to 3% of cases) and pain. Although nonsteroidal anti-inflammatory drugs are commonly administered for postsurgical pain, controversy exists regarding bleeding risk with cyclooxygenase-1 inhibition and associated platelet dysfunction. Preliminary evidence suggests selective cyclooxygenase-2 inhibitors, for example celecoxib, effectively manage pain without adverse events including bleeding. Given the paucity of data for routine celecoxib use after tonsillectomy, this study was designed to investigate the association between postoperative celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery using chart-review data from the Children's Hospital of Eastern Ontario.

METHODS

After ethics approval, a retrospective single-center observational cohort study was performed in children less than 18 yr of age undergoing tonsillectomy from January 2007 to December 2017. Cases of adenoidectomy alone were excluded due to low bleed rates. The primary outcome was the proportion of patients with post-tonsillectomy hemorrhage requiring surgery. The association between a celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery was estimated using inverse probability of treatment weighting based on propensity scores and using generalized estimating equations to accommodate clustering by surgeon.

RESULTS

An initial patient cohort of 6,468 was identified, and 5,846 children with complete data were included in analyses. Median (interquartile range) age was 6.10 (4.40, 9.00) yr, and 46% were female. In the cohort, 28.1% (n = 1,644) were prescribed celecoxib. Among the 4,996 tonsillectomy patients, 1.7% (n = 86) experienced post-tonsillectomy hemorrhage requiring surgery. The proportion with post-tonsillectomy hemorrhage requiring surgery among patients who had a tonsillectomy and were or were not prescribed celecoxib was 1.94% (30 of 1,548; 95% CI, 1.36 to 2.75) and 1.62% (56 of 3,448; 95% CI, 1.25 to 2.10), respectively. Modeling did not identify an association between celecoxib prescription and increased odds of post-tonsillectomy hemorrhage requiring surgery (odds ratio = 1.4; 95% CI, 0.85 to 2.31; P = 0.20).

CONCLUSIONS

Celecoxib does not significantly increase the odds of post-tonsillectomy hemorrhage requiring surgery, after adjusting for covariates. This large pediatric cohort study of celecoxib administered after tonsillectomy provides compelling evidence for safety but requires confirmation with a multisite randomized controlled trial.

EDITOR’S PERSPECTIVE

Effect of a health system payment and quality improvement programme for tonsillectomy in Ontario, Canada: an interrupted time series analysis

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.

Unplanned intensive care unit readmission after surgical treatment in patients with newly diagnosed glioblastoma - forfeiture of surgically achieved advantages?

Postoperative intensive care unit (ICU) monitoring is an established option to ensure patient safety after resection of newly diagnosed glioblastoma. In contrast, secondary unplanned ICU readmission following complicating events during the initial postoperative course might be associated with severe morbidity and impair initially intended surgical benefit. In the present study, we assessed the prognostic impact of secondary ICU readmission and aimed to identify preoperatively ascertainable risk factors for the development of such adverse events in patients treated surgically for newly diagnosed glioblastoma. Between 2013 and 2018, 240 patients were surgically treated for newly diagnosed glioblastoma at the authors' neuro-oncological center. Secondary ICU readmission was defined as any unplanned admission to the ICU during initial hospital stay. A multivariable logistic regression analysis was performed to identify preoperatively measurable risk factors for unplanned ICU readmission. Nineteen of 240 glioblastoma patients (8%) were readmitted to the ICU. Median overall survival of patients with unplanned ICU readmission was 9 months compared to 17 months for patients without secondary ICU readmission (p=0.008). Multivariable analysis identified "preoperative administration of dexamethasone > 7 days" (p=0.002) as a significant and independent predictor of secondary unplanned ICU admission. Secondary ICU readmission following surgery for newly diagnosed glioblastoma is significantly associated with poor survival and thus may negate surgically achieved prerequisites for further treatment. This underlines the indispensability of precise patient selection as well as the importance of further scientific debate on these highly relevant aspects for patient safety.

The Effect of Pre-Emptive Analgesia on the Postoperative Pain in Pediatric Otolaryngology: A Randomized, Controlled Trial

The aim of this randomized, controlled trial was to determine whether children undergoing otolaryngological procedures (adenoidectomy, adenotonsillotomy, or tonsillectomy) benefit from pre-emptive analgesia in the postoperative period. Methods: Fifty-five children were assessed for eligibility for the research. Four children refused to participate during the first stage of the study, leaving fifty-one (n = 51) to be randomly assigned either to receive pre-emptive analgesic acetaminophen (15 mg/kg; n = 26) or a placebo (n = 25) in addition to midazolam (0.5 mg/kg) as premedication. All children were anesthetized with sevoflurane, propofol (2−4 mg/kg), and fentanyl (2 mcg/kg). Postoperative pain was assessed using the Visual Analogue Scale (VAS), the Wong−Baker Faces Pain Rating Scale, and the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. The postoperative pain was measured 1, 2, 4, and 6 h after the surgery. Results: The clinical trial reported a statistically significant correlation between administering pre-emptive analgesia (acetaminophen) and reducing pain in children after otolaryngological procedures compared to placebo. The ratio of boys to girls and age were similar among the groups (p > 0.05), so the groups of children were not divided by gender or age. Conclusions: Standard pre-emptive analgesia reduced the severity of pain in the postoperative period after otolaryngological procedures in children. Acetaminophen given before surgery reduces postoperative pain in children undergoing otolaryngological procedures.

Impact of Oral Steroids on Tonsillectomy Postoperative Complications and Pain

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.

Dexamethasone and post-adenotonsillectomy pain in children: Double-blind, randomized controlled trial

OBJECTIVE

To assess the impact of intraoperative intravenous dexamethasone on the reduction of postoperative morbidity in children undergoing adenotonsillectomy.

METHODS

A double blind randomized controlled trial conducted among children undergoing adenotonsillectomy at a tertiary hospital in Korea from November 2018 to June 2019. Children were randomly assigned to receive dexamethasone (0.5 mg/kg, maximum dose 24 mg) or placebo intravenously after induction of anesthesia. The primary endpoint was the reduction of postoperative pain and postoperative nausea and vomiting (PONV); secondary endpoints were adverse effects like postoperative hemorrhage.

RESULTS

The study included 105 children, and 67 were male. Their mean age was 6.2 ± 2.1 years. There was no significant difference between the groups in terms of demographic data or the operation time. The pain scores of the dexamethasone group were lower than those of the control group, but no significant difference was found (all P > .05). The average pain visual analog scale (VAS) during the study period (day 0-7) was 3.67 ± 1.59 and 4.40 ± 2.01 in the dexamethasone group and control group, respectively (P-value = .107). When we compared early pain VAS (day 0-2) and late pain VAS (day 5-7), the dexamethasone group showed significantly lower early mean VAS compared to the control group (4.55 ± 1.78 vs 5.40 ± 2.05, P-value = .046). The mean VAS for PONV was significantly lower in the dexamethasone group than in the control group (1.89 ± 2.22 vs 3.00 ± 2.37, P value = .044).

CONCLUSION

In children undergoing adenotonsillectomy, dexamethasone decreased the early postoperative pain and PONV without increasing postoperative hemorrhage.

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

OBJECTIVE

To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database.

STUDY DESIGN

Retrospective cohort study.

SETTING

The study was conducted using the Pediatric Health Information System (PHIS) database.

METHODS

Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region.

RESULTS

Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735).

CONCLUSION

The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.

Effectiveness of intravenous lidocaine in preventing postoperative nausea and vomiting in pediatric patients: A systematic review and meta-analysis

BACKGROUND

Intravenous lidocaine in adults undergoing general anesthesia has been shown to reduce the incidence of postoperative nausea and vomiting (PONV). However, the anti-postoperative vomiting (POV) effect of lidocaine in pediatric patients remains unclear. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of intravenous lidocaine on prevention of POV/PONV.

METHODS

Six databases including trial registration sites were searched. Randomized clinical trials evaluating the incidence of POV/PONV after intravenous lidocaine compared with control were included. The primary outcome was the incidence of POV within 24 hours after general anesthesia. The incidence of POV was combined as a risk ratio with 95% confidence interval using a random-effect model. We used the I2 to assess heterogeneity. We evaluated the quality of trials using the Cochrane methodology, and we assessed quality of evidence using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events.

RESULTS AND DISCUSSION

Six trials with 849 patients were included, of whom 433 received intravenous lidocaine. Three trials evaluated the incidence of POV, and 3 evaluated the incidence of PONV. The overall incidence of POV within 24 hours after anesthesia was 45.9% in the lidocaine group and 63.4% in the control group (risk ratio, 0.73; 95% confidence interval, 0.53-1.00; I2 = 32%; p = 0.05). The incidence of PONV within 24 hours after anesthesia was 3.73% in the lidocaine group and 4.87% in the control group (RR, 0.76; 95% CI, 0.36-1.59; I2 = 0%; p = 0.47). The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, imprecision, and possible publication bias.

CONCLUSION

Our meta-analysis suggests that intravenous lidocaine infusion may reduce the incidence of POV, however, the evidence quality was "very low." Further trials with a low risk of bias are necessary.

Postoperative Nausea and Vomiting in Paediatric Anaesthesia

Postoperative nausea and vomiting (PONV) is a common complication in paediatric anaesthesia and is a source of significant morbidity. Various independent risk factors have been implicated in the development of paediatric PONV, including higher pain scores postoperatively, the use of opioids for pain management and the use of volatile anaesthetics for the maintenance of anaesthesia. This review of the current literature regarding the prevention and treatment of paediatric PONV is based on a search of the PubMed database, which identified published clinical trials, systematic reviews and meta-analyses. While the occurrence of PONV in many cases is difficult to avoid entirely, the risk can be mitigated by the use of multimodal nonopioid analgesic regimens, total intravenous drugs in favour of volatile anaesthetics and an appropriate regimen of prophylactic pharmacotherapy. Frequently administered drug classes for the prevention of PONV include corticosteroids, 5HT3 antagonists and anticholinergics. The clinical use of the findings in the literature may help to reduce the occurrence of PONV in children. In this review, we provide comprehensive and updated information on the risk factors contributing the occurrence of PONV in children, outline the current opinion on the drugs that are commonly used for management and provide an overview of the guidelines that are used to help establish the prophylaxis and treatment of paediatric PONV.

The effect of perioperative dexamethasone dosing on post-tonsillectomy hemorrhage risk

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.

Hemostasis in Tonsillectomy

Tonsillectomy is a commonly performed procedure with an accepted risk of posttonsillectomy hemorrhage (PTH) approaching 5%, but catastrophic effects of hemorrhage are exceedingly rare. A variety of surgical techniques and hemostatic agents have been used to reduce the rate of hemorrhage, although none eliminate the risk. Numerous patient, surgical, and postoperative care factors have been studied for an association with PTH. The most consistent risk factors for PTH seem to be patient age and coagulopathies. Surgeon skill and surgical technique are most consistently associated with primary PTH.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Specified data for tonsil surgery in Germany

Background: Tonsillectomy rates vary considerably among different states, regions, and times. This study was conducted to identify the prevalence of “chronic” tonsillitis, peritonsillar abscess, hypertrophy of the tonsils with and without adenoids in absolute and relative numbers in an 80 million people nation. Moreover, the number and rates of different surgical procedures to resolve either “chronic” tonsillitis, peritonsillar abscess, or upper airway obstruction due to (adeno)tonsillar hypertrophy over several years was evaluated in this study (tonsillectomy, adenotonsillectomy, tonsillotomy, abscess tonsillectomy, transoral incision and drainage). Finally, the post-tonsillectomy hemorrhage rate was calculated and analyzed in relation to age and gender.

Material and methods: Calculations were based on data as published by the Federal Institute of Statistics or on request, if needed. The latest data were provided for 2013.

Results: The total number of the aforementioned diseases (stratified by ICD-10) decreased from 142,574 (in 2000) to 87,624 in 2013 (38.5%). Tonsillectomy, with or without adenoidectomy, was performed in a total of 833,896 patients between 2006 and 2013 in Germany. The yearly number decreased continually from 120,993 in 2006 to 84,332 procedures in 2013 (30.3%). The most significant decrease was registered in patients younger than 20 years of age for this time period: 70.92 per 10,000 in 2010 to 58.68 per 10,000 in 2013. If all age groups were included, the rate decreased from 13.34 per 10,000 to 10.90 per 10,000. In contrast, an increasing number of tonsillotomies was observed between 2007 (4,659 procedures) and 2013 (11,493). The cumulated number of procedures was 59,049. A constant number of 15,000 cases with peritonsillar abscess were diagnosed per year in Germany (19 patients per 100,000). The prevalence increased significantly at an age of 15 years and there was a preponderance of female patients below that age. Compared to the transoral incision and drainage, a 2.8-fold greater number of abscess tonsillectomies were performed annually. Post-tonsillectomy hemorrhage was experienced in 5.98% of all patients after 245,721 procedures in 2010 and 2013 (all indications, except tonsillotomy). Bleeding complications had occurred less frequently in female patients (5.06% vs. 7.02%). Finally, a considerable increase of post-tonsillectomy hemorrhage in patients older than 10 years of age was registered in male patients only.

Conclusion: Chronic tonsillitis was less frequently diagnosed and surgically treated in terms of tonsillectomy (with or without adenoidectomy), particularly in female patients. In contrast, the number of tonsillotomies increased continually, particularly in male patients. Peritonsillar abscess was diagnosed and surgically treated in a constant number of patients in the yearly comparison. Most of these patients were scheduled for abscess tonsillectomy, and only a 2.8-fold smaller number for transoral incision and drainage. Independent from the indication for surgery, post-tonsillectomy hemorrhage was clearly associated with male gender and age (>10 years). The study reveals a dramatic change mandating further surveillance in insurance companies and authorities in the national health system of an 80 million people nation. (Tab. 1)

Does topical use of autologous serum help to reduce post-tonsillectomy morbidity? A prospective, controlled preliminary study

BACKGROUND

To evaluate the effects of autologous serum usage on throat pain, haemorrhage and tonsillar fossa epithelisation in patients after tonsillectomy.

METHODS

Thirty-two patients (aged 4-15 years) were included in the study. Tonsillectomy was performed and autologous serum was administered topically to the right tonsillar fossa during the operation, and at 8 and 24 hours post-operatively. The left side served as the control. A visual analogue scale was used to record the patient's pain every day. Each patient's oropharynx was observed on the 5th and 10th post-operative days to examine bleeding and epithelisation.

RESULTS

The pain scores for the side administered autologous serum were significantly lower than those for the control side, on the night following the operation and on the 1st, 2nd, 5th and 6th post-operative days. Tonsillar fossa epithelisation was significantly accelerated on the study side compared with the control side on the 5th and 10th post-operative days.

CONCLUSION

In tonsillectomy patients, topically administered autologous serum contributed to throat pain relief and tonsillar fossa epithelisation during the post-operative period.

Causes, costs, and risk factors for unplanned return visits after adenotonsillectomy in children

OBJECTIVE

To review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A).

METHODS

Review of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1-18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits.

RESULTS

Data from 39,906 children aged 1-18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR=1.64 95% CI 1.47-1.84), Hispanic race (OR=1.36 95% CI 1.13-1.64), and increased severity of illness (SOI) (OR=11.29 95% CI 2.69-47.4 for SOI=3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU (p<0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage.

CONCLUSION

Children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage.

Anaesthesia for the paediatric outpatient

PURPOSE OF REVIEW

The aim of this review was to discuss recent developments in paediatric anaesthesia, which are particularly relevant to the practitioner involved in paediatric outpatient anaesthesia.

RECENT FINDINGS

The use of a pharmacological premedication is still a matter of debate. Several publications are focussing on nasal dexmedetomidine; however, its exact place has not yet been defined. Both inhalational and intravenous anaesthesia techniques still have their advocates; for diagnostic imaging, however, propofol is emerging as the agent of choice. The disappearance of codeine has left a breach for an oral opioid and has probably worsened postoperative analgesia following tonsillectomy. In recent years, a large body of evidence for the prevention of postoperative agitation has appeared. Alpha-2-agonists as well as the transition to propofol play an important role. There is now some consensus that for reasons of practicability prophylactic antiemetics should be administered to all and not only to selected high-risk patients.

SUMMARY

Perfect organization of the whole process is a prerequisite for successful paediatric outpatient anaesthesia. In addition, the skilled practitioner is able to provide a smooth anaesthetic, minimizing complications, and, finally, he has a clear concept for avoiding postoperative pain, agitation and vomiting.

The efficacy of TachoComb on reducing postoperative complications after tonsillectomy in children

OBJECTIVE

A fibrinogen/thrombin-based collagen fleece (TachoComb) is a powerful topical hemostatic agent that has been widely used in various surgical specialties with a favorable outcome. The purpose of this study was to investigate the effect of TachoComb application on postoperative complications after tonsillectomy.

MATERIALS AND METHODS

A total of 1633 children had undergone tonsillectomy with or without adenoidectomy were included in this study. After removal of both tonsils, 1057 patients (64.7%) were treated with TachoComb on the tonsillectomy site and 576 without TachoComb. Post-tonsillectomy pain, hemorrhage rates, re-admission rates, and emergency surgery rates for post-tonsillectomy hemorrhage were evaluated between patients who received TachoComb and those who did not.

RESULTS

TachoComb treatment significantly reduced post-tonsillectomy pain and emergency surgery rates for post-tonsillectomy hemorrhage. However, postoperative hemorrhage rate and re-admission rates for post-tonsillectomy hemorrhage were not statistically significant between TachoComb treatment group and control group. No patients had complications or adverse reactions after TachoComb treatment.

CONCLUSIONS

The use of TachoComb after tonsillectomy significantly reduces pain and emergency surgery for severe post-tonsillectomy hemorrhage without an apparent adverse effect. Therefore, TachoComb may be a useful adjuvant in terms of efficacy and safety after tonsillectomy.

Association of National Guidelines With Tonsillectomy Perioperative Care and Outcomes

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.

Causes and Costs for ED Visits after Pediatric Adenotonsillectomy

Objective

(1) Review the reasons, timing, and costs for children presenting to the emergency department (ED) after adenotonsillectomy (T&A).

Study Design

Case series with chart review.

Setting

Tertiary care children’s hospital.

Subjects and Methods

A standardized activity-based hospital accounting system was used to identify 437 children from an academic pediatric otolaryngology practice presenting to the ED after T&A from 2009 to 2012. The reason for presentation, timing after surgery, and facility costs were recorded.

Results

The study cohort represented 13.3% of the 3198 patients who underwent T&A during that time period. Overall, 133 (4.2%) presented for dehydration, 106 (3.3%) presented for post-tonsillectomy hemorrhage, 65 (2.0%) for poorly controlled pain, 42 (1.3%) for fever, 29 (1.0%) for vomiting/nausea/GI discomfort, 22 (0.7%) for respiratory complications, and 12 (0.4%) for miscellaneous reasons related to the operation; 28 (0.8%) were unrelated to the T&A and excluded. Mean postoperative day at the time of ED presentation was 4.4 (95% CI, 4.1-4.7). The mean cost per patient presenting to the ED was $1420 (95% CI, $1104-$1737), the most costly subgroups being those presenting with respiratory complications ($2855; 95% CI, $1434-$4277), hemorrhage ($1502; 95% CI, $1216-$1787), and dehydration ($1372; 95% CI, $995-$1750). The least costly subgroup was acute postoperative pain ($781; 95% CI, $282-$1200).

Conclusion

A significant portion of children present to the ED after T&A for poorly controlled pain, dehydration, or fever. The costs from these visits are significant. Accounting for these costs in the global care for pediatric T&A could assist in calculating appropriate reimbursement for bundled payments in this climate of health care reform.