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So V, Radhakrishnan D, MacCormick J, Webster RJ, Tsampalieros A, Zitikyte G, Ripley A, Murto K. Does Celecoxib Prescription for Pain Management Affect Post-tonsillectomy Hemorrhage Requiring Surgery? A Retrospective Observational Cohort Study. Anesthesiology 2024; 141:313-325. [PMID: 38684054 DOI: 10.1097/aln.0000000000005032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
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
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Affiliation(s)
- Vincent So
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dhenuka Radhakrishnan
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Johnna MacCormick
- Department of Otolaryngology Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard J Webster
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Allyson Ripley
- University of Western Ontario, Faculty of Medicine, London, Ontario, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Moroco AE, Friedman N, Jabbour C, Roy S, Schmidt R, Nardone HC. Current Pediatric Tertiary Care Practices Following Adenotonsillectomy: An Update. Laryngoscope 2024; 134:2931-2936. [PMID: 38073113 DOI: 10.1002/lary.31216] [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: 10/30/2023] [Revised: 11/08/2023] [Accepted: 11/17/2023] [Indexed: 05/09/2024]
Abstract
OBJECTIVE Adenotonsillectomy is a common procedure performed in children, and the practice patterns at academic centers have been evolving with the publication of updated societal guidelines. In this study, we assess perioperative practice patterns at tertiary care children's hospitals for children undergoing adenotonsillectomy. METHODS A cross-sectional 18-question survey distributed in July of 2022 recruited responses through August 25, 2022. The division chiefs of 70 pediatric otolaryngology groups at tertiary care children's hospitals across the United States and Canada were surveyed. Division chiefs submitted survey responses on behalf of the group practice patterns for children undergoing adenotonsillectomy. The main measure was survey responses from the division chiefs of pediatric otolaryngology reporting group practice. RESULTS The survey response rate was 46%. Eighty-eight percent of groups reported an official adenotonsillectomy admission policy. Commonly reported admission criteria included age (93%) and obesity (59%). Eighty-eight percent of groups defined severe obstructive sleep apnea as apnea-hypopnea index ≥10. Only 41% of groups required a child to be observed sleeping on room air prior to ambulatory discharge. Ninety-seven percent of groups reported routinely obtaining preoperative polysomnography in a variety of clinical settings. CONCLUSIONS Many children's hospitals report an official admission policy following adenotonsillectomy. Despite a decade passing since the initial publication of the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines, there remains great variability in the practice patterns for both preoperative polysomnography and postoperative monitoring and admission. These results highlight an opportunity for an improved unified approach to perioperative pediatric adenotonsillectomy practice. LEVEL OF EVIDENCE 5 Laryngoscope, 134:2931-2936, 2024.
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Affiliation(s)
- Annie E Moroco
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Norman Friedman
- Division of Pediatric Otolaryngology, Colorado Children's Hospital, Aurora, Colorado, U.S.A
| | - Christopher Jabbour
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Nemours Children's Health, Wilmington, Delaware, U.S.A
| | - Soham Roy
- Division of Pediatric Otolaryngology, Colorado Children's Hospital, Aurora, Colorado, U.S.A
| | - Richard Schmidt
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Nemours Children's Health, Wilmington, Delaware, U.S.A
| | - Heather C Nardone
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Nemours Children's Health, Wilmington, Delaware, U.S.A
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Yanai Milshtein N, Pres S, Derowe A, Rimon A. Diagnosis of Fever Source Following Tonsillectomy and Adenoidectomy in the Pediatric Emergency Department. Pediatr Emerg Care 2024; 40:459-462. [PMID: 38355105 DOI: 10.1097/pec.0000000000003122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
OBJECTIVES This study aimed to describe the epidemiology and diagnoses of children with postoperative fever (a temperature of 38°C or higher) during the week after tonsillectomy and/or adenoidectomy and to assess the yield of the laboratory tests and otolaryngologist consultations of these patients in the pediatric emergency department (ED). METHODS We conducted a retrospective cohort study that included all children who presented with fever to the pediatric ED of a tertiary university-affiliated medical center between May 2017 and April 2020 during the week after a tonsillectomy and/or adenoidectomy. RESULTS There were 94 patients who fulfilled study entry criteria during the 3-year study period, representing a 6% rate of postoperative fever for combined tonsillectomy and adenoidectomy and 3% for adenoidectomy alone. Only 9 patients (<10% of the total) were classified as having bacterial infection, whereas the most common cause for the fever was pneumonia diagnosed by chest radiography. None had surgical site infection. There was no significant difference in blood test findings of patients diagnosed with a bacterial infection and patients with a presumed viral infection or an inflammatory response to surgery. CONCLUSIONS The results of this investigation revealed that the source of fever of the overwhelming majority of children who were referred to the pediatric ED for fever after undergoing tonsillectomy and/or adenoidectomy was pneumonia as determined by chest radiography, which can be performed in an outpatient setting. Blood tests and otolaryngologist consultations were not contributory in classifying the source of fever, questioning the value of their routine use in these patients.
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Affiliation(s)
- Nili Yanai Milshtein
- From the Pediatric Emergency Medicine, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shir Pres
- From the Pediatric Emergency Medicine, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Derowe
- Pediatric Otolaryngology Department, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Rimon
- From the Pediatric Emergency Medicine, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Foster AA, Hoffmann JA, Qayyum Z, Porter JJ, Monuteaux M, Hudgins J. Psychotropic Medication Administration in Pediatric Emergency Departments. Pediatrics 2024; 153:e2023063730. [PMID: 38487821 DOI: 10.1542/peds.2023-063730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Visits by youth to the emergency department (ED) with mental and behavioral health (MBH) conditions are increasing, yet use of psychotropic medications during visits has not been well described. We aimed to assess changes in psychotropic medication use over time, overall and by medication category, and variation in medication administration across hospitals. METHODS We conducted a retrospective cross-sectional study of ED encounters by youth aged 3-21 with MBH diagnoses using the Pediatric Health Information System, 2013-2022. Medication categories included psychotherapeutics, stimulants, anticonvulsants, antihistamines, antihypertensives, and other. We constructed regression models to examine trends in use over time, overall and by medication category, and variation by hospital. RESULTS Of 670 911 ED encounters by youth with a MBH diagnosis, 12.3% had psychotropic medication administered. The percentage of MBH encounters with psychotropic medication administered increased from 7.9% to16.3% from 2013-2022 with the odds of administration increasing each year (odds ratio, 1.09; 95% confidence interval, 1.05-1.13). Use of all medication categories except for antianxiety medications increased significantly over time. The proportion of encounters with psychotropic medication administered ranged from 4.2%-23.1% across hospitals (P < .001). The number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001). CONCLUSIONS Administration of psychotropic medications during MBH ED encounters is increasing over time and varies across hospitals. Inconsistent practice patterns indicate that opportunities are available to standardize ED management of pediatric MBH conditions to enhance quality of care.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Zheala Qayyum
- Department of Psychiatry and Behavioral Sciences
- Departments of Psychiatry
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joel Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Emergency Medicine
- Pediatrics, Harvard Medical School, Boston, Massachusetts
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Alsalamah S, Alraddadi J, Alsulaiman A, Alsalamah R, Alaraifi AK, Alsaab F. Incidence and predictors of readmission following tonsillectomy in pediatric population. Int J Pediatr Otorhinolaryngol 2024; 177:111859. [PMID: 38219296 DOI: 10.1016/j.ijporl.2024.111859] [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: 07/25/2023] [Revised: 11/18/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND Tonsillectomy is one of the most common surgical procedures performed in the pediatric population. This study aims to estimate the incidence rate of readmission post tonsillectomy in pediatrics and identify the causes and predictors contributing to the readmission post-surgery. METHODS A retrospective cohort study included 1280 pediatric patients (18 years or younger) who underwent tonsillectomy at a tertiary hospital in 2019 and 2020. The study sample was divided into two groups based on readmission and were compared using the appropriate statistical tests. Significant variables (p-value≤0.05) were included in the logistic regression model to determine the predictors of readmission following tonsillectomy in these patients. RESULTS The readmission rate following tonsillectomy was 6.3 % (95 % confidence interval 5.1-7.9). The causes of readmission included poor oral intake followed by bleeding and vomiting, 55.6 %,49.4 %, and 13.6 %, respectively. In the multivariable logistic regression model, the only significant predictor of post-tonsillectomy readmission was the use of a single postoperative analgesia (OR: 57.27, P = 0.000). CONCLUSION The readmission rate following tonsillectomy in this study was relatively high. The most common causes contributing to readmission post tonsillectomy were poor oral intake and hemorrhage. The study also revealed a significant association between the utilization of single postoperative analgesia and an increased likelihood of readmission.
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Affiliation(s)
- Shmokh Alsalamah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Jumanah Alraddadi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Azouf Alsulaiman
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Raghad Alsalamah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulaziz K Alaraifi
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Fahad Alsaab
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Wentzel S, Craft A, Onwuka A, Lind M. Racial, ethnic and language disparities in healthcare utilization in pediatric patients following tonsillectomy. Int J Pediatr Otorhinolaryngol 2024; 176:111805. [PMID: 38043184 DOI: 10.1016/j.ijporl.2023.111805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 12/05/2023]
Abstract
IMPORTANCE Tonsillectomy is one of the most common surgical procedures performed in the United States. However, there is little known about the intersectionality of race, ethnicity, and language and how these factors influence post-tonsillectomy outcomes such as ED utilization and hospital readmission rates. OBJECTIVE To examine disparities in emergency department (ED) utilization and hospital readmissions for post-tonsillectomy complications based on insurance status, patient race, ethnicity and language spoken. DESIGN This was retrospective cohort over four years. SETTING Tertiary Care Children's Hospital. PARTICIPANTS All children (n = 10,215) who underwent tonsillectomy or adenotonsillectomy at a tertiary children's hospital from January 2015 to December 2018 were identified and included. There were no exclusion criteria. EXPOSURE The exposure of interest was tonsillectomy. MAIN OUTCOMES AND MEASURES Outcomes and variables of interest were defined prior to data collection. The primary outcome of this study was emergency department (ED) utilization defined as any ED or urgent care visit within 21 days of the tonsillectomy for surgery-related concerns. The secondary outcome of this study was readmissions following tonsillectomy. RESULTS A total of 10215 pediatric patients (median age, 6 years; 5096 [50 %] male) who underwent tonsillectomy were included in the analysis. 13 % of patients presented to the ED with surgery-related complaints. Among English proficient patients, multi-racial patients were the only group with an elevated odds of ED utilization (OR:1.5, 95 % CI: 1.2, 1.9). Non-English language preference (NELP) patients of Black, Hispanic, Asian, and American Indian/Alaskan Native race/ethnicity also had elevated odds of ED use post-tonsillectomy compared to non-Hispanic White English proficient patients. Six percent of all patients had an unplanned hospital readmission. Asian patients with non-English language preference had 2.1 times the odds of readmission (95 % CI: 1.2, 3.6); and were disproportionately admitted for post-tonsillectomy hemorrhage. CONCLUSIONS and Relevance: Language disparities in ED use and readmission persist after adjusting for risk factors. Non-English language preference populations have a higher rate of ED utilization, especially for minor complications. Disparities may result from differential health literacy or predispositions to complications. Future directions include additional research on mechanisms and targeted interventions to increase education and access to language-appropriate resources.
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Affiliation(s)
- Stephanie Wentzel
- Medical Student Research Program, The Ohio State University College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aaron Craft
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Meredith Lind
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA; Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Tamraz R, Austin R, Falcon R, Kraai T, Lock R, Petersen TR, Soneru C. Management of a Large Post-tonsillectomy Thrombus Obstructing the Laryngeal View: A Case Report. Cureus 2023; 15:e46763. [PMID: 37954797 PMCID: PMC10632186 DOI: 10.7759/cureus.46763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 11/14/2023] Open
Abstract
Anesthetic management of children with a post-tonsillectomy hemorrhage can be challenging. The patients may be anemic and hypovolemic and are at increased risk of having a difficult airway due to active bleeding, vomiting, and anatomical issues. A clot may also interfere with viewing the larynx, further exacerbating the difficulty of intubation. We describe a pediatric post-tonsillectomy hemorrhage case complicated by a large obstructing clot that was removed with Magill forceps after the airway was successfully secured with an endotracheal tube during rapid sequence induction.
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Affiliation(s)
- Rana Tamraz
- Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Roman Austin
- Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Ricardo Falcon
- Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Tania Kraai
- Otolaryngology - Head and Neck Surgery, University of New Mexico School of Medicine, Albuquerque, USA
| | - Richard Lock
- Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Timothy R Petersen
- Office of Graduate Medical Education, University of New Mexico School of Medicine, Albuquerque, USA
- Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Codruta Soneru
- Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, USA
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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: 0] [Impact Index Per Article: 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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Johnson RF, Beams DR, Zaniletti I, Chorney SR, Kou YF, Lenes-Voit F, Ulualp S, Liu C, Mitchell RB. Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children. JAMA Otolaryngol Head Neck Surg 2023; 149:431-438. [PMID: 36995688 PMCID: PMC10064285 DOI: 10.1001/jamaoto.2023.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/06/2023] [Indexed: 03/31/2023]
Abstract
Importance The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored. Objective To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event. Design, Settings, and Participants This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023. Main Outcomes and Measures Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy. Results Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%. Conclusions and Relevance This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.
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Affiliation(s)
- Romaine F. Johnson
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Dylan R. Beams
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
| | | | - Stephen R. Chorney
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Yann-Fuu Kou
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Felicity Lenes-Voit
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Seckin Ulualp
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Christopher Liu
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Ron B. Mitchell
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
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Karatas HA. Readmission after OSA surgery in pediatric patients. Eur Arch Otorhinolaryngol 2023; 280:879-884. [PMID: 36149489 DOI: 10.1007/s00405-022-07657-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 09/12/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVES This study aimed to determine the readmission rate after adenotonsillectomy with the diagnosis of obstructive sleep apnea (OSA) and analyze the factors associated with readmission. METHODS It was planned as a retrospective study conducted in a single institution that included pediatric patients who underwent adenotonsillectomy with OSA diagnosis between December 2018 and March 2021. Patients who were readmitted for bleeding or pain/dehydration were compared with those who did not require readmission. RESULTS The mean postoperative admission time was 7.27 ± 3.49 days in patients with bleeding and 3.5 ± 2.27 days in patients with pain or dehydration. The mean length of stay in the hospital was 2.6 ± 1.6 days in patients with bleeding and 3.13 ± 2.03 days in patients with pain or dehydration. The postoperative admission time was 5.96 ± 3.57 days, and the hospital stay after readmission was 2.78 ± 1.73 days. No statistically significant correlation was found in terms of age, gender, surgeon's experience, use of electrocautery and seasonality factors, and readmission rates. CONCLUSIONS In children who underwent adenotonsillectomy for OSA, the hospitalization period of patients hospitalized due to pain/dehydration is much longer than patients admitted with bleeding. Therefore, measures to reduce pain or dehydration have the most significant potential to reduce the readmission rate and length of stay.
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Affiliation(s)
- Halil Altin Karatas
- Konya Numune Hospital, Ferhuniye Mahallesi Hastane Caddesi No:22, 42060, Selçuklu, Konya, Turkey.
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11
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De Ravin E, Banik GL, Buzi A. Effect of ibuprofen on severity of surgically-managed pediatric post-tonsillectomy hemorrhage. Int J Pediatr Otorhinolaryngol 2023; 164:111422. [PMID: 36549016 DOI: 10.1016/j.ijporl.2022.111422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/08/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The association between ibuprofen use and severity of post-tonsillectomy hemorrhage (PTH) remains unclear. We aimed to compare PTH severity in patients who did or did not receive ibuprofen. METHODS A retrospective cohort study of pediatric patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 was performed. PTH severity was assessed using pre-tonsillectomy and post-hemorrhage hemoglobin and hematocrit values, estimated intraoperative blood loss, estimated hemorrhage flow rate, and need for transfusion. Differences in hemorrhage severity markers between the two cohorts were compared. RESULTS A total of 168 consecutive patients were included in this study. The mean age was 8.8 years, and 55.4% of patients were male. Sixty-five patients (38.7%) received ibuprofen postoperatively. There was no statistically significant difference in the mean change in hemoglobin (1.1 vs. 1.1, P = 0.85) or hematocrit (3.1 vs. 3.2, P = 0.97) between patients who received ibuprofen compared to those who did not. Similarly, there were no significant differences in need for transfusion (3.1% vs. 3.9%, P = 1.00) or occurrence of high-flow (arterial) blood loss (33.8% vs. 40.8%, P = 0.42) between the two groups. CONCLUSION Postoperative ibuprofen use does not appear to significantly increase PTH severity, as measured by change in hemoglobin and hematocrit values, need for transfusion, or presence of high-flow blood loss. This study introduces previously unexplored markers to assess PTH severity and supports further prospective studies to determine the effect of ibuprofen on PTH severity.
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Affiliation(s)
- Emma De Ravin
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Grace L Banik
- Division of Otolaryngology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Adva Buzi
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA; Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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12
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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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Wozney L, Vakili N, Chorney J, Clark A, Hong P. The Impact of a Text Messaging Service (Tonsil-Text-To-Me) on Pediatric Perioperative Tonsillectomy Outcomes: Cohort Study With a Historical Control Group. JMIR Perioper Med 2022; 5:e39617. [PMID: 36125849 PMCID: PMC9533209 DOI: 10.2196/39617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background Tonsillectomy is a common pediatric surgical procedure performed in North America. Caregivers experience complex challenges in preparing for their child’s surgery and coordinating care at home and, consequently, could benefit from access to educational resources. A previous feasibility study of Tonsil-Text-To-Me, an automated SMS text messaging service that sends 15 time-sensitive activity reminders, links to nutrition and hydration tips, pain management strategies, and guidance on monitoring for complications, showed promising results, with high levels of caregiver satisfaction and engagement. Objective This study aimed to pilot-test Tonsil-Text-To-Me in a real-world context to determine whether and how it might improve perioperative experiences and outcomes for caregivers and patients. Methods Caregivers of children aged 3 to 14 years undergoing tonsillectomy were included. Data from a historical control group and an intervention group with the same study parameters (eg, eligibility criteria and surgery team) were compared. Measures included the Parenting Self-Agency Measure, General Health Questionnaire-12, Parents’ Postoperative Pain Measure, Client Satisfaction Questionnaire-8, and engagement analytics, as well as analgesic consumption, pain, child activity level, and health service use. Data were collected on the day before surgery, 3 days after surgery, and 14 days after surgery. Participants in the intervention group received texts starting 2 weeks before surgery up to the eighth day after surgery. Descriptive and inferential statistics were used. Results In total, 51 caregivers (n=32, 63% control; n=19, 37% intervention) who were predominately women (49/51, 96%), White (48/51, 94%), and employed (42/51, 82%) participated. Intervention group caregivers had a statistically significant positive difference in Parenting Self-Agency Measure scores (P=.001). The mean postoperative pain scores were higher for the control group (mean 10.0, SD 3.1) than for the intervention group (mean 8.5, SD 3.7), both of which were still above the 6/15 threshold for clinically significant pain; however, the difference was not statistically significant (t39=1.446; P=.16). Other positive but nonsignificant trends for the intervention group compared with the control group were observed for the highest level of pain (t39=0.882; P=.38), emergency department visits (χ22=1.3; P=.52; Cramer V=0.19), and other measures. Engagement with resources linked in the texts was moderate, with all but 1 being clicked on for viewing at least once by 79% (15/19) of the participants. Participants rated the intervention as highly satisfactory across all 8 dimensions of the Client Satisfaction Questionnaire (mean 29.4, SD 3.2; out of a possible value of 32.0). Conclusions This cohort study with a historical control group found that Tonsil-Text-To-Me had a positive impact on caregivers’ perioperative care experience. The small sample size and unclear impacts of COVID-19 on the study design should be considered when interpreting the results. Controlled trials with larger sample sizes for evaluating SMS text messaging interventions aimed to support caregivers of children undergoing tonsillectomy surgery are warranted.
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Affiliation(s)
- Lori Wozney
- Mental Health and Addictions, Policy and Planning, Nova Scotia Health, Dartmouth, NS, Canada
| | - Negar Vakili
- Centre for Research in Family Health, IWK Health Centre, Halifax, NS, Canada
| | - Jill Chorney
- Mental Health and Addictions, IWK Health, Halifax, NS, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Alexander Clark
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Paul Hong
- Division of Otolaryngology, IWK Health, Halifax, NS, Canada
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
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14
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Cordray H, Alfonso K, Brown C, Evans S, Goudy S, Govil N, Landry AM, Raol N, Smith K, Prickett KK. Sustaining standardized opioid prescribing practices after pediatric tonsillectomy. Int J Pediatr Otorhinolaryngol 2022; 159:111209. [PMID: 35749955 DOI: 10.1016/j.ijporl.2022.111209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/19/2022] [Accepted: 06/09/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes. METHODS A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure. RESULTS From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28). CONCLUSION An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.
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Affiliation(s)
- Holly Cordray
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kristan Alfonso
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Clarice Brown
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean Evans
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven Goudy
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Nandini Govil
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - April M Landry
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhila Raol
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen Smith
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Kara K Prickett
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
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15
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Cooper JN, Koppera S, Bliss AJ, Lind MN. Characteristics associated with caregiver willingness to consider tonsillectomy for a child's obstructive sleep disordered breathing: Findings from a survey of families in an urban primary care network. Int J Pediatr Otorhinolaryngol 2022; 158:111143. [PMID: 35552164 DOI: 10.1016/j.ijporl.2022.111143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/29/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Tonsillectomy use is lower among Black children than White children in the U.S. despite their higher prevalence of obstructive sleep disordered breathing (oSDB). We aimed to identify factors associated with parents' willingness to consider tonsillectomy for their child's oSDB and to identify whether parents of Black children are less willing than parents of non-Black children to be willing to consider the procedure. STUDY DESIGN Prospective cohort study. SETTING Primary care network of a tertiary children's hospital. METHODS We surveyed parents/guardians of children aged 2-10 years with oSDB, to assess their knowledge about oSDB and tonsillectomy, perceived severity of their child's oSDB, perceived level of their child's sleep disturbance, perceived risks and benefits of tonsillectomy, stress, trust in their child's primary care physician and physicians in general, and health literacy. We also assessed child clinical and sociodemographic characteristics. Associations between these characteristics and parent/guardian willingness to consider tonsillectomy for their child's oSDB were assessed. RESULTS Of the 59 parents/guardians included, 90% were mothers and 71% were Black. Only 58% of caregivers of Black children but 85% of caregivers of non-Black children were willing to consider tonsillectomy (p = 0.04). Caregivers with another child who had undergone tonsillectomy and caregivers who perceived their child's sleep to be more disturbed were more often willing to consider tonsillectomy (both p = 0.02). CONCLUSIONS Parents of Black children are less willing to consider tonsillectomy for their child's oSDB, but this was not explained by any factors assessed in this study. Future studies should evaluate additional factors that may explain this difference and that might be targeted to ensure appropriate and equitable access to tonsillectomy among children with oSDB.
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Affiliation(s)
- Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA; Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH, USA.
| | - Swapna Koppera
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alessandra J Bliss
- Medical Student Research Program, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Meredith N Lind
- Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA; Department of Otolaryngology, The Ohio State University College of Medicine, Columbus, OH, USA
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16
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The Effect of Pre-Emptive Analgesia on the Postoperative Pain in Pediatric Otolaryngology: A Randomized, Controlled Trial. J Clin Med 2022; 11:jcm11102713. [PMID: 35628840 PMCID: PMC9146866 DOI: 10.3390/jcm11102713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/04/2022] [Accepted: 05/09/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Taylor M. Study of Patients’ Return to Surgery Post-Tonsillectomy and/or Adenoidectomy: A Relation Between Patient Age and Timing of Uncontrolled Bleeding. PATIENT SAFETY 2022. [DOI: 10.33940/data/2022.3.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Tonsillectomy and/or adenoidectomy (T/A) are common surgical procedures. Postoperative uncontrolled bleeding is a well-established complication; however, the relation between certain variables and uncontrolled bleeding are unclear.
Methods: We explored the Pennsylvania Patient Safety Reporting System database for event reports that described a patient who had a T/A procedure and later returned to surgery to control bleeding. We analyzed the post-T/A bleeding events according to numerous variables, such as patient sex and age, timing of the bleed, procedure performed (i.e., tonsillectomy and/or adenoidectomy), and bleeding site.
Results: We identified 219 event reports from 56 healthcare facilities over a four-year period. The study revealed that 78% of the patients were discharged and then returned to surgery to control bleeding. Patients ranged in age from 1–45 years and 53% were female. Among the 219 events, 41% were a primary bleed (0–1 postoperative days) and 59% were a secondary bleed (2–30 postoperative day). Additionally, 0–1 days and 6–7 days after operation were the periods when patients most frequently returned to surgery (range of 0–30 days). We expanded upon much of the previous research by exploring the relation between patient age and days postoperative return to surgery. We found that a majority of patients in age categories 1–10, 11–20, and 21–30 years had a secondary bleed; in contrast, a majority of patients age 31–45 had a primary bleed.
Conclusion: Our findings indicate that the post-T/A timing of uncontrolled bleeding may vary systematically as a function of patient age; however, future research is needed to better understand this topic. We encourage readers to use our findings, along with findings from previous research, to inform their practice and strategies to mitigate risk of patient harm.
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van Stein RM, Lok CA, Aalbers AG, H.J.T. de Hingh I, Houwink AP, Stoevelaar HJ, Sonke GS, van Driel WJ. Standardizing HIPEC and perioperative care for patients with ovarian cancer in the Netherlands using a Delphi-based consensus. Gynecol Oncol Rep 2022; 39:100945. [PMID: 35252523 PMCID: PMC8894234 DOI: 10.1016/j.gore.2022.100945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022] Open
Abstract
Implementation of HIPEC for ovarian cancer is ongoing, aiming to offer this treatment to all eligible patients in the Netherlands. Standardization reduces unwanted variation in clinical treatment. We intend to standardize patient selection, technical aspects, and perioperative care of CRS and HIPEC. This consensus study comprised a two-phase modified Delphi approach. Consensus was reached on 82% of items.
Objective Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is standard of care in the Netherlands in patients with stage III epithelial ovarian cancer following interval cytoreductive surgery (CRS). Differences in patient selection, technical aspects, and perioperative management exist between centers performing HIPEC. Standardization aims to reduce unwanted variation in clinical practice. As part of an implementation process, we aimed to standardize perioperative care for patients treated with CRS and HIPEC using a Delphi-based consensus approach. Methods We performed a two-phase modified Delphi method involving a multidisciplinary panel of 40 experts who completed a survey on CRS and HIPEC. During a consensus meeting, survey outcomes and available scientific evidence was discussed. Items without consensus (<75% agreement) were adjusted and evaluated in a second survey. Results Consensus was reached in the first round on 51% of items. After two rounds, consensus was reached on the majority of items (82%) including patient selection, preoperative workup, technical aspects of CRS and HIPEC, and postoperative care. No consensus was reached on the role of HIPEC in rare ovarian cancer types, preoperative bowel preparation, timing to create bowel anastomoses, and manipulation of the perfusate. Conclusions Dutch experts reached consensus on most items regarding interval CRS and HIPEC for ovarian cancer. This consensus study may help to align treatment protocols and to minimize practice variation. Topics without consensus may be put on the research agenda of HIPEC for ovarian cancer.
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19
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Tran AHL, Chin KL, Horne RSC, Liew D, Rimmer J, Nixon GM. Hospital revisits after paediatric tonsillectomy: a cohort study. J Otolaryngol Head Neck Surg 2022; 51:1. [PMID: 35022073 PMCID: PMC8756632 DOI: 10.1186/s40463-021-00552-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 10/31/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Tonsillectomy, with or without adenoidectomy, is the leading reason for paediatric unplanned hospital readmission, some of which are potentially avoidable. Reducing unplanned hospital revisits would improve patient safety and decrease use of healthcare resources. This study aimed to describe the incidence, timing and risk factors for any surgery-related hospital revisits (both emergency presentation and readmission) following paediatric tonsillectomy and adenotonsillectomy in a large state-wide cohort. METHODS We conducted a population-based cohort study using linked administrative datasets capturing all paediatric tonsillectomy and adenotonsillectomy surgeries performed between 2010 and 2015 in the state of Victoria, Australia. The primary outcome was presentation to the emergency department or hospital readmission within 30-day post-surgery. RESULTS Between 2010 and 2015, 46,583 patients underwent 47,054 surgeries. There was a total of 4758 emergency department presentations (10.11% total surgeries) and 2750 readmissions (5.84% total surgeries). Haemorrhage was the most common reason for both revisit types, associated with 33.02% of ED presentations (3.34% total surgeries) and 67.93% of readmissions (3.97% total surgeries). Day 5 post-surgery was the median revisit time for both ED presentations (IQR 3-7) and readmission (IQR 3-8). Predictors of revisit included older age, public and metropolitan hospitals and peri-operative complications during surgery. CONCLUSIONS Haemorrhage was the most common reason for both emergency department presentation and hospital readmission. The higher risk of revisits associated with older children, surgeries performed in public and metropolitan hospitals, and in patients experiencing peri-operative complications, suggest the need for improved education of postoperative care for caregivers, and avoidance of inappropriate early discharge.
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Affiliation(s)
- Aimy H L Tran
- Department of Paediatrics, Monash University and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Ken L Chin
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rosemary S C Horne
- Department of Paediatrics, Monash University and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joanne Rimmer
- Department of Otolaryngology, Head and Neck Surgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - Gillian M Nixon
- Department of Paediatrics, Monash University and The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia. .,Melbourne Children's Sleep Centre, Monash Children's Hospital, 246 Clayton Road, Victoria, 3168, Australia.
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20
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Stake CE, Manworren RCB, Rizeq YK, Minhas S, Quan H, Barsness KA. Use of Opioids and Nonopioid Analgesics to Treat Pediatric Postoperative Pain in the Emergency Department. Pediatr Emerg Care 2022; 38:e234-e239. [PMID: 32941362 DOI: 10.1097/pec.0000000000002227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The incidence, demographic characteristics, and treatment approaches for pediatric patients who present to the ED with a primary complaint of postoperative pain have not been well described. The purpose of this study was to describe opioid and nonopioid prescribing patterns for pediatric patients evaluated for postoperative pain in the Emergency Department (ED). METHODS Pediatric Health Information System is an administrative database of encounter-level data from 48 children's hospitals. Emergency department visits for postoperative pain from January 2014 to September 2017 were analyzed. Visits were matched by the Pediatric Health Information System identifier to associate corresponding same site surgery encounters directly preceding ED visits. RESULTS There were 7365 ED visits for acute postoperative pain, for which 4044 could be linked to corresponding surgical procedure. Eight-one percent of ED visits were within 7 days of surgery. Opioids were given at 1979 (49%) of visits, and nonopioids at 678 (17%) of visits. The most common surgeries preceding a postoperative pain ED visit were for tonsils and adenoids (48.5%). Age, sex, length of stay for both procedure and ED visits, procedure specialty, and the number of days between procedure discharge and admission to ED were associated with opioid administration during ED visits (P < 0.05). CONCLUSIONS Pediatric patients treated in the ED for postoperative pain were often treated with opioid and nonopioid analgesics, with wide prescriber variability. Further research is warranted to help balance optimal pain management and safe prescribing practices.
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Affiliation(s)
| | | | - Yazan K Rizeq
- From the Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Sana Minhas
- From the Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Hehui Quan
- From the Ann & Robert H. Lurie Children's Hospital of Chicago
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The effect of telephone counseling and internet-based support on pain and recovery after tonsil surgery in children – a systematic review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2021.100027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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22
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Foster AA, Porter JJ, Monuteaux MC, Hoffmann JA, Hudgins JD. Pharmacologic Restraint Use During Mental Health Visits in Pediatric Emergency Departments. J Pediatr 2021; 236:276-283.e2. [PMID: 33771581 DOI: 10.1016/j.jpeds.2021.03.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the trends and hospital variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department (ED). STUDY DESIGN We examined ED visits with a mental health diagnosis in patients aged 3-21 years at children's hospital EDs from 2009 to 2019. We calculated the frequency of pharmacologic restraint use and determined visit characteristics associated with restraint use. We calculated cumulative percent change for visits with restraints and for all mental health visits. We used logistic regression to test trends over time and evaluate hospital variation in the frequency of restraint use. RESULTS We identified 389 885 mental health ED visits (54.9% female, median age 14.3 years) and 13 643 (3.5%) visits with pharmacologic restraint use. Characteristics associated with pharmacologic restraint use were late adolescent age (18-21 years), male sex, Black race, non-Latino ethnicity, public insurance, and admission to the hospital (P < .001). During the study period, both mental health ED visits increased by 268% and mental health ED visits with pharmacologic restraint use increased by 370%. The rate of pharmacologic restraint in this patient population remained constant. Hospital use of pharmacologic restraint for mental health visits varied significantly across hospitals (1.6%-11.8%, P < .001). CONCLUSIONS Pediatric mental health ED visits with and without pharmacologic restraint are increasing over time. In addition, the overall number of pharmacologic restraint use has increased threefold. Significant hospital variation in pharmacologic restraint use signifies an opportunity for standardization of care and restraint reduction.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | | | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Joel D Hudgins
- Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Lagrange C, Jepp C, Slevin L, Drake-Brockman TFE, Bumbak P, Herbert H, von Ungern-Sternberg BS, Sommerfield D. Impact of a revised postoperative care plan on pain and recovery trajectory following pediatric tonsillectomy. Paediatr Anaesth 2021; 31:778-786. [PMID: 33788340 DOI: 10.1111/pan.14187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/03/2021] [Accepted: 03/22/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND A previous cohort of adenotonsillectomy patients at our institution demonstrated moderate-severe post-tonsillectomy pain scores lasting a median (range) duration of 6 (0-23) days and postdischarge nausea and vomiting affecting 8% of children on day 1 following surgery. In this subsequent cohort, we evaluate the impact of changes to our discharge medication and parental education on post-tonsillectomy pain and recovery profile. METHODS In this follow-on, prospective observational cohort study, all patients undergoing tonsillectomy at our institution during the study period were discharged with standardized analgesia. Parents received a revised education package and a medication diary which were not provided to the previous cohort. Pain scores, rates of nausea and vomiting, medication usage and unplanned representation rates were collected by telephone from parents. RESULTS Sixty-nine patients were recruited. Moderate-severe pain lasted a median (range) of 5 (0-12) days. Twenty-nine (42%) had pain scores ≥4/10 beyond postoperative day 7. By postoperative day 5, only 37 (53%) parents continued to administer regular analgesia. The median number of oxycodone doses used was 5 (0-22), and only 28 (41%) parents had disposed of leftover oxycodone within 1 month of surgery. Twenty-four (35%) patients experienced nausea or vomiting postdischarge. The median (range) time for return to normal activities was 6 (0-14) days. Thirty-two/sixty-nine (46%) patients had unplanned medical representations. Most occurred between postoperative day 5 and 7. Pain contributed to 16 (35%) representations. CONCLUSIONS Despite extensive changes to our discharge protocols parents continued to report a prolonged period of pain, post operative nausea and vomiting, and behavioral changes. Further work is required to examine barriers to compliance with simple analgesia and education in appropriate methods of opioid disposal.
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Affiliation(s)
- Claudia Lagrange
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia
| | - Catherine Jepp
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia
| | - Lliana Slevin
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia
| | - Thomas F E Drake-Brockman
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | - Paul Bumbak
- Department of Otolaryngology-Head and Neck Surgery, Perth Children's Hospital, Perth, WA, Australia
| | - Haley Herbert
- Department of Otolaryngology-Head and Neck Surgery, Perth Children's Hospital, Perth, WA, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
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Khoury H, Azar SS, Boutros H, Shapiro NL. Preoperative Predictors and Costs of 30-Day Readmission Following Inpatient Pediatric Tonsillectomy in the United States. Otolaryngol Head Neck Surg 2021; 165:470-476. [PMID: 33400632 DOI: 10.1177/0194599820980709] [Citation(s) in RCA: 7] [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
OBJECTIVES To understand national trends in 30-day postoperative readmission following inpatient pediatric tonsillectomy and adenoidectomy. STUDY DESIGN Retrospective cohort study. SETTING Nationwide Readmissions Database. METHODS We used the Nationwide Readmissions Database to identify and analyze 30-day readmissions following inpatient tonsillectomy from 2010 to 2015. Using the International Classification of Disease codes, we identified 66,652 patients and analyzed the incidence, causes, risk factors, and costs of 30-day readmission. RESULTS Of 66,652 patients who underwent inpatient tonsillectomy, 2660 (4.0%) experienced a readmission. Readmitted patients were more commonly aged <2 years (23.4 vs 10.6%, P = .01) and had a greater burden of comorbidities, including preoperative anemia (3.9 vs 1.3%, P < .001), coagulopathy (3.5 vs 1.4%, P < .001), and neurologic disorders (19.1 vs 6.6%, P < .001). Readmitted patients experienced higher rates of postoperative complications (17.4 vs 9.0%, P < .001) and had a longer length of stay (4.5 vs 2.2 days, P < .001). Index cost of hospitalization was higher among readmitted patients ($14,129 vs $7307, P < .001), and each readmission cost an additional $7576. Postoperative hemorrhage (21.3%) and dehydration (17.7%) were the 2 most common causes for readmission. Independent predictors of readmission included age <3 years, multiple comorbidities, and postoperative neurologic complications. The incidences of tonsillectomies and readmissions declined during the study period, most notably between 2010 and 2012. CONCLUSION Readmission after inpatient tonsillectomy and adenoidectomy places a substantial financial burden on the health care system. Targeted strategies to improve preoperative assessment and optimize postoperative care may prevent readmission, reduce unnecessary health care expenditures, and improve patient outcomes.
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Affiliation(s)
- Habib Khoury
- Department of Head and Neck Surgery, University of California-Los Angeles, Los Angeles, California, USA
| | - Shaghauyegh S Azar
- Department of Head and Neck Surgery, University of California-Los Angeles, Los Angeles, California, USA
| | - Hannah Boutros
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nina L Shapiro
- Department of Head and Neck Surgery, University of California-Los Angeles, Los Angeles, California, USA
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Rabbani CC, Pflum ZE, Ye MJ, Gettelfinger JD, Sadhasivam S, Matt BH, Dahl JP. Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative analgesia. Int J Pediatr Otorhinolaryngol 2020; 138:110341. [PMID: 32891944 DOI: 10.1016/j.ijporl.2020.110341] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Determine the impact of ketorolac on post-tonsillectomy hemorrhage (PTH) and narcotic administration in children undergoing tonsillectomy. METHODS Retrospective case series from 2013 to 2017. Patients younger than 18 years undergoing tonsillectomy were included. PTH was the primary outcome measured. Secondary measures include percentage of patients requiring surgical intervention for PTH, average time to PTH, the number of post-operative opioid doses, and average post-operative opioid dose. Statistical methods include Chi-square, Wilcoxon rank sum, and binary logistic regression analyses. RESULTS During the study period, 669 patients received a single intraoperative dose of ketorolac (K+) and 653 patients did not receive ketorolac (K-). No differences were found in the rate of PTH (K- 6.5% vs. K+ 5.3%, RR = 0.82, 95% CI = 0.53 to 1.29, p = 0.40), surgical control of PTH (K- 4.0% vs. K+ 3.5%, RR = 0.87, CI = 0.51 to 1.51, p = 0.62), or average time [SD] to PTH (K- 6.0 [4.2] vs. K+ 5.2 [4.9] days; difference = 0.8 days; 95% CI, -1.3 to 2.9; p = 0.45). K+ patients had fewer post-operative opioid doses [SD] (K- 1.86 [1.14] vs. K+ 1.59 [1.23]; difference = -0.27; 95% CI, -0.053 to -0.49, Cohen d = 0.23) and a lower average opioid dose [SD] (K- 0.041 [0.032] vs. K+ 0.035 [0.030] mg/kg; difference = -0.006 mg/kg; 95% CI, -0.0003 to -0.012; Cohen d = 0.19). CONCLUSION Ketorolac did not increase risk of hemorrhage following tonsillectomy and decreased narcotic use.
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Affiliation(s)
| | | | - Michael J Ye
- Department of Otolaryngology-Head and Neck Surgery, USA
| | | | - Senthil Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruce H Matt
- Department of Otolaryngology-Head and Neck Surgery, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, USA.
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Clark ST, Johnston J, Biswas K, Douglas RG. Effect of tonsillectomy on antibiotic prescribing in children. Int J Pediatr Otorhinolaryngol 2020; 138:110338. [PMID: 33152956 DOI: 10.1016/j.ijporl.2020.110338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Tonsillectomy is the second most common surgical procedure performed in pediatric otolaryngology. Multiple courses of antibiotics are usually prescribed prior to surgical intervention. Surgery is indicated when patients reach a certain number of infective episodes, or their obstructive symptoms warrant intervention. Little is known about the role of tonsillectomy on long term postoperative antibiotic use. Recently, our group published a retrospective case series that described the clinical characteristics and outcomes of children under the age of 16 years who underwent tonsillectomy. This study is a follow-up on this previous case series and its purpose is to determine whether tonsillectomy in this group of children led to a reduction in the number of antibiotics prescribed in the year following surgery. METHODS Data were collected from the clinical records departments of two district health boards in Auckland, New Zealand. Hospital morbidity records were reviewed for all children younger than 16 years old, who underwent a tonsillectomy between December 2015 and December 2017 in the Auckland region. All antibiotics prescribed following surgery were obtained from New Zealand's national community prescribing database. RESULTS A total of 1538 children underwent tonsillectomy during the study period. Following surgery, antibiotics were prescribed to 828 (54%) patients at the time of discharge, with an average of 1.2 ± 0.1 courses in the year following surgery. This was significantly reduced compared to preoperative antibiotic intake (3.4 ± 0.1 courses) in the year preceding surgery (p < 0.001). Readmission within 30 days of discharge was not associated with increased antibiotic usage postoperatively. In the two weeks following surgery, 25% of patients were prescribed a course of antibiotics for a presumed postoperative infection. CONCLUSIONS These findings support the benefit of tonsillectomy in reducing antibiotic consumption in the year following surgery. Furthermore, it has highlighted areas of practice, such as perioperative antibiotic prescription, which can be improved to further reduce the prescription of antibiotics for children with tonsillar hyperplasia.
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Affiliation(s)
- Sita Tarini Clark
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - James Johnston
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
| | - Kristi Biswas
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Richard George Douglas
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Mahant S, Richardson T, Keren R, Srivastava R, Meier J. Variation in tonsillectomy cost and revisit rates: analysis of administrative and billing data from US children's hospitals. BMJ Qual Saf 2020; 30:bmjqs-2019-010730. [PMID: 32606211 DOI: 10.1136/bmjqs-2019-010730] [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: 12/07/2019] [Revised: 04/28/2020] [Accepted: 05/25/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tonsillectomy is one of the most common and cumulatively expensive surgical procedures in children. We determined if substantial variation in resource use, as measured by standardised costs, exists across hospitals for performing tonsillectomy and if higher resource use is associated with better quality of care, as measured by revisits to hospital. METHODS We conducted a retrospective analysis of children undergoing routine outpatient tonsillectomy between 2011 to 2017 across US children's hospitals using an administrative and billing data source. The primary outcome measures were the hospital tonsillectomy standardised cost and the 30-day revisit rate to hospital. We analysed the interhospital variation in standardised cost by determining the number of outlier hospitals in standardised cost and the intraclass correlation coefficient. RESULTS 131 814 children (median age 6 years, IQR: 4,9; female sex 52.5%) underwent tonsillectomy for airway obstruction (62.9%) and infection (23.9%) across 28 hospitals. The median adjusted hospital standardised cost for tonsillectomy was $2392 (IQR: $1827, $2793; range: $1166 to $4222). There was substantial interhospital variation in costs as 11 (40%) hospitals were cost outliers, and the intraclass correlation coefficient was 0.62, suggesting that 62% of the variation in cost was attributable to variation between hospitals. The median hospital revisit rate was 9.5% (IQR: 7.8, 12.1) and higher hospital costs did not correlate with lower revisit rates (rs =0.03, 95% CI -0.36 to 0.41; p=0.87). CONCLUSIONS There is substantial variation in hospital resource use and standardised costs for routine outpatient tonsillectomy across US children's hospitals. Higher resource use is not associated with lower revisit rates. Further study is needed to understand the practices of lower resource use hospitals who deliver high quality of care.
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Affiliation(s)
- Sanjay Mahant
- Department of Pediatrics and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Troy Richardson
- Research and Statistics, Children's Hospital Association, Lexena, Kansas, USA
| | - Ron Keren
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rajendu Srivastava
- Department of Pediatrics, Primary Children's Hospital, Salt Lake City, Utah, USA
- Healthcare Delivery Institute, Intermountain Health Inc, Salt Lake City, Utah, United States
| | - Jeremy Meier
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, United States
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Zalan J, Vaccani JP, Murto K. Paediatric adenotonsillectomy, part 2: considerations for anaesthesia. BJA Educ 2020; 20:193-200. [PMID: 33456950 PMCID: PMC7807924 DOI: 10.1016/j.bjae.2020.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- J. Zalan
- Kingston Health Sciences Centre, Kingston, ON, Canada
| | - J-P. Vaccani
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - K.T. Murto
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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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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A descriptive analysis of pediatric post-tonsillectomy pain and recovery outcomes over a 10-day recovery period from 2 randomized, controlled trials. Pain Rep 2020; 5:e819. [PMID: 32440612 PMCID: PMC7209815 DOI: 10.1097/pr9.0000000000000819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/18/2019] [Accepted: 02/04/2020] [Indexed: 12/21/2022] Open
Abstract
Pediatric tonsillectomy involves an often painful and lengthy recovery period, yet the extended recovery process is largely unknown. This article describes postoperative recovery outcomes for 121 children aged 4 to 15 (mean 6.6 years, SD = 2.3) years enrolled in 1 of 2 clinical trials of analgesia safety and efficacy after tonsillectomy. Postoperative analgesia included scheduled opioid analgesic plus acetaminophen/ibuprofen medication use (first 5 days) and “as-needed” use (last 5 days). Clinical recovery as measured daily by the Parents' Postoperative Pain Measure (PPPM; an observational/behavioral pain measure), children's self-reported pain scores, side-effect assessments, need for unanticipated medical care, and satisfaction with recovery over 10 days was assessed. Higher Parents' Postoperative Pain Measure scores were correlated with poorer sleep, receipt of breakthrough analgesics, distressing side effects, higher self-reported pain scores, and need for unanticipated medical care. Higher self-reported pain scores were associated with more distressing adverse events, including nausea, vomiting, insomnia, lower parent satisfaction, and unplanned medical visits and hospitalizations. Pain and symptoms improved over time, although 24% of the children were still experiencing clinically significant pain on day 10. Scheduled, multimodal analgesia and discharge education that sets realistic expectations is important. This study adds to the emerging body of literature that some children experience significant postoperative pain for an extended period after tonsillectomy.
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Archer NM, Forbes PW, Dargie J, Manganella J, Licameli GR, Kenna MA, Brugnara C. Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy. JAMA Netw Open 2020; 3:e201804. [PMID: 32232448 PMCID: PMC7109594 DOI: 10.1001/jamanetworkopen.2020.1804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy. OBJECTIVE To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019. MAIN OUTCOMES AND MEASURES Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated. RESULTS A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger. CONCLUSIONS AND RELEVANCE Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.
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Affiliation(s)
- Natasha M. Archer
- Pediatric Hematology, Oncology Dana-Farber, Children’s Hospital Blood Disorders and Cancer Center, Boston, Massachusetts
| | - Peter W. Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Jenna Dargie
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Juliana Manganella
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Greg R. Licameli
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Margaret A. Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Carlo Brugnara
- Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts
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Lindquist NR, Feng Z, Patro A, Mukerji SS. Age-related causes of emergency department visits after pediatric adenotonsillectomy at a tertiary pediatric referral center. Int J Pediatr Otorhinolaryngol 2019; 127:109668. [PMID: 31526936 DOI: 10.1016/j.ijporl.2019.109668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/20/2019] [Accepted: 08/31/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The complications of tonsillectomy and adenoidectomy (T&A) are well-described and include bleeding, dehydration, nausea, respiratory complications, and pain. After the immediate postoperative phase, the overall 30-day emergency department (ED) return rate is as high as 13.3%. However, few studies have examined the types and rates of late post-operative complications for children undergoing T&A stratified base on patient age. Herein, we aim to better characterize ED return visits for children of all ages, with special attention to those patients under three years of age. METHODS This is a retrospective case series at a tertiary academic pediatric medical center. All patients 18 years of age or younger who underwent T&A over eighteen months were included. Data including ED return diagnosis, post-operative day of presentation, and need for surgical intervention was recorded for patients who presented to the ED within 30 days of their original surgery. RESULTS 5,225 patients were identified, with an overall late complication rate of 12.8%. There was no difference in the 30-day ED readmission rate for children under the age of three, although children under the age of two were more likely to present to the ED. There was a significantly higher risk of dehydration for children under the age of four years, and a significantly higher bleeding risk and need for reoperation for control of post-tonsillectomy hemorrhage (PTH) for children over the age of six. CONCLUSIONS The overall ED visit rate in this study is 12.8%, with no difference based on age. Patients younger than three years of age are more likely to return to ED for dehydration, while bleeding and need for control of oropharyngeal hemorrhage is more common in older children. Knowledge of the age-related late complications of T&A may direct appropriate anticipatory peri-operative counseling of risks and return precautions.
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Affiliation(s)
- Nathan R Lindquist
- Department of Otolaryngology, Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA
| | - Zipei Feng
- Department of Otolaryngology, Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA
| | - Ankita Patro
- Vanderbilt Department of Otolaryngology, Nashville, TN, USA
| | - Shraddha S Mukerji
- Texas Children's Hospital, Department of Otolaryngology, Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA.
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Reducing Readmissions Post-tonsillectomy: A Quality Improvement Study on Intravenous Hydration. J Healthc Qual 2019; 40:217-227. [PMID: 29864070 DOI: 10.1097/jhq.0000000000000143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Dehydration is a potentially preventable complication post-tonsillectomy and can result in an Emergency Department visit and/or readmission. Our objectives were to identify risk factors for dehydration readmissions and develop interventions to prevent them. METHODS We used retrospective chart reviews to determine if increased intravenous (IV) hydration post-tonsillectomy prevented hospital readmissions for dehydration. All children aged 1-18 years who underwent tonsillectomy between July 1, 2007 and September 30, 2015 were included in this quality improvement study. Using the Pediatric Health Information System database, patients who experienced a readmission for dehydration within 72 hours of surgery were identified and validated with internal data. We analyzed the pre-implementation and post-implementation readmission rates after standardization of increased IV fluids (1.5 times maintenance). An interrupted time series analysis was used to estimate the effects of our hydration initiative. RESULTS Of 11,157 patients who underwent tonsillectomy during the study period, 96 (0.9%) met the criteria for readmissions for dehydration. The pre-implementation readmission rate was 1% compared to 0.2% post-implementation, a reduction of 82%. CONCLUSIONS The hydration initiative was associated with a significant decrease in hospital readmissions. This safe, low-cost, easy-to-implement approach to preventing dehydration post-tonsillectomy could be explored at other institutions.
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Lawlor CM, Riley CA, Carter JM, Rodriguez KH. Association Between Age and Weight as Risk Factors for Complication After Tonsillectomy in Healthy Children. JAMA Otolaryngol Head Neck Surg 2019; 144:399-405. [PMID: 29543971 DOI: 10.1001/jamaoto.2017.3431] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The 1996 Tonsillectomy and Adenoidectomy Inpatient Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Pediatric Otolaryngology Committee recommended that children younger than 3 years be admitted following tonsillectomy. Recommendations for hospital observation were not included as a key action statement in the 2011 AAO-HNS Clinical Practice Guidelines for Tonsillectomy in Children. Objective To examine the association between posttonsillectomy complication rate and the age and weight of the child at the time of surgery. Design, Setting, and Participants This was a multicenter case series study with medical record review of 2139 consecutive children ages 3 to 6 years who underwent tonsillectomy at 1 tertiary care academic center and 5 acute care centers in New Orleans, Louisiana, between 2005 and 2015. Children with moderate to severe developmental delay, bleeding disorders, and other major medical comorbidities were excluded. Main Outcomes and Measures Complications examined included respiratory distress, dehydration requiring intravenous fluids, and bleeding. Results Of the 2139 patients, 1817 met inclusion criteria. A total of 1011 (55.6%) were male. The mean (SD) age at the time of the procedure was 46 (14) months (range, 12-72 months). The mean weight at the time of the procedure was 17 (5) kg (range, 9-43 kg). A total of 95 patients (5.2%) had a postoperative complication. Of the 455 children younger than 3 years in the study, 32 (7.0%) had complications compared with 63 (4.6%) of the 1362 patients 3 years or older. The odds of having a complication in children younger than 3 years was 1.5 times greater than it was in children 3 years or older (odds ratio [OR], 1.56; 95% CI, 1.00-2.42). When examining total complications, children younger than 3 years were more likely to experience a complication within the first 24 hours after surgery than children 3 years or older (25% vs 9.5%; OR, 3.17; 95% CI, 1.00-10.11). The children admitted to the hospital had a greater risk of complication than those treated as an outpatient, independent of age (6.9% vs 93.0%; OR, 3.49; 95% CI, 2.0.18-6.05). No association between weight and complications was found on logistic regression (area under the curve = 0.5268; P = .66). Conclusions and Relevance Healthy children younger than 3 years may be at an increased risk for complication following tonsillectomy. Those children may also be at increased risk for complications within the first 24 hours after surgery compared with children 3 years or older. Our data suggest that complications are independent of weight in these patients. In our cohort, those patients selected for overnight observation were associated with an increased number of adverse events following tonsillectomy, suggesting that clinician judgment is crucial in determining which patients are safe for outpatient tonsillectomy.
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Affiliation(s)
- Claire M Lawlor
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John M Carter
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Kimsey H Rodriguez
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
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Abstract
BACKGROUND Discharging hospitalized children involves several different components, but their relative value is unknown. We assessed which discharge components are perceived as most and least important by clinicians. METHODS March and June of 2014, we conducted an online discrete choice experiment (DCE) among national societies representing 704 nursing, physician, case management, and social work professionals from 46 states. The DCE consisted of 14 discharge care components randomly presented two at a time for a total of 28 choice tasks. Best-worst scaling of participants' choices generated mean relative importance (RI) scores for each component, which allowed for ranking from least to most important. RESULTS Participants, regardless of field or practice setting, perceived "Discharge Education/Teach-Back" (RI 11.1 [95% confidence interval, CI: 11.0-11.3]) and "Involve the Child's Care Team" (RI 10.6 [95% CI: 10.4-10.8]) as the most important discharge components, and "Information Reconciliation" (RI 4.1 [95% CI: 3.9-4.4]) and "Assigning Roles/Responsibilities of Discharge Care" (RI 2.8 [95% CI: 2.6-3.0]) as least important. CONCLUSIONS A diverse group of pediatric clinicians value certain components of the pediatric discharge care process much more than others. Efforts to optimize the quality of hospital discharge for children should consider these findings.
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Lee HH, Dalesio NM, Lo Sasso AT, Van Cleve WC. Impact of Clinical Guidelines on Revisits After Ambulatory Pediatric Adenotonsillectomy. Anesth Analg 2019; 127:478-484. [PMID: 29905617 DOI: 10.1213/ane.0000000000003540] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pediatric adenotonsillectomies are common and carry known risks of potentially severe complications. Complications that require a revisit, to either the emergency department or hospital readmission, increase costs and may be tied to lower reimbursements by federal programs. In 2011 and 2012, recommendations by pediatric and surgical organizations regarding selection of candidates for ambulatory procedures were issued. We hypothesized that guideline-associated changes in practice patterns would lower the odds of revisits. The primary objective of this study was to assess whether the odds of a complication-related revisit decreased after publication of guidelines after accounting for preintervention temporal trends and levels. The secondary objective was to determine whether temporal associations existed between guideline publication and characteristics of the ambulatory surgical population. METHODS This study employs an interrupted time series design to evaluate the longitudinal effects of clinical guidelines on revisits. The outcome was defined as revisits after ambulatory tonsillectomy for privately insured patients. Data were sourced from the Truven Health Analytics MarketScan database, 2008-2015. Revisits were defined by the most prevalent complication types: hemorrhage, dehydration, pain, nausea, respiratory problem, infection, and fever. Time periods were defined by surgeries before, between, and after guidelines publication. Unadjusted odds ratios estimated associations between revisits and clinical covariates. Multivariable logistic regression was used to estimate the impact of guidelines on revisits. Differences in revisit trends among pre-, peri-, and postguideline periods were tested using the Wald test. Results were statistically significant at P < .005. RESULTS A total of 326,993 surgeries met study criteria. The absolute revisit rate increased over time, from 5.9% (95% confidence interval [CI], 5.8-6.0) to 6.7% (95% CI, 6.6-6.9). The proportion of young children declined slightly, from 6.4% to 5.9% (P < .001). The proportion of patients having a tonsillectomy in an ambulatory surgery center increased (16.5%-31%; P < .001), as did the prevalence of obstructive sleep apnea (7.0%-14.0%; P < .001) and sleep-disordered breathing (20.6%-35.0%; P < .001). In a multivariable logistic regression model adjusted for age, sex, comorbidities, and surgical location, odds of a revisit increased during the preguideline period (0.4% increase per month; 95% CI, 0.24%-0.54%; P < .001). This monthly increase did not continue after guidelines (P = .002). CONCLUSIONS While odds of a postoperative revisit did not decline after guideline publication, there was a significant difference in trend between the pre- and postguideline periods. Changes in the ambulatory surgery population also suggest at least partial adherence to guidelines.
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Affiliation(s)
- Helen H Lee
- From the Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois
| | - Nicholas M Dalesio
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anthony T Lo Sasso
- Department of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - William C Van Cleve
- Department of Anesthesiology and Pain Medicine and the Surgical Outcomes Research Center, University of Washington, Seattle, Washington
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Subramony A, Kocolas I, Srivastava R. Pediatric Hospitalists Improving Patient Care Through Quality Improvement. Pediatr Clin North Am 2019; 66:697-712. [PMID: 31230617 DOI: 10.1016/j.pcl.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article reviews the industrial underpinnings of the quality improvement (QI) movement and describes how QI became integrated within the larger health care landscape, including hospital medicine. QI methodologies and a framework for using them are described. Key components that make up a successful QI clinical project are outlined, with a focus on the essential role of pediatric hospitalists and practical professional tips to be successful. QI training opportunities are reviewed with opportunities for hospitalists to get involved in QI on a national level. National QI networks are showcased, with multiple examples of advanced improvement projects that have significantly improved patient outcomes highlighted.
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Affiliation(s)
- Anupama Subramony
- Department of Pediatrics, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 269-01 76th Avenue, New Hyde Park, NY 11040, USA.
| | - Irene Kocolas
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine/Primary Children's Hospital, Intermountain Healthcare, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Raj Srivastava
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine/Primary Children's Hospital, Healthcare Delivery Institute, Intermountain Healthcare, 5026 State Street, Murray, UT 84107, USA
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Levin M, Seligman NL, Hardy H, Mohajeri S, Maclean JA. Pediatric pre-tonsillectomy education programs: A systematic review. Int J Pediatr Otorhinolaryngol 2019; 122:6-11. [PMID: 30921630 DOI: 10.1016/j.ijporl.2019.03.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Over 14,000 tonsillectomies are performed in Ontario annually. Challenges with home postoperative care frequently lead to Emergency Department (ED) visits. A 2013 Ontario Pediatric Health Council recommended the integration of patient education into tonsillectomy care. Understanding the existing educational services is fundamental to optimally implementing such programs into clinical settings. METHODS Systematic review of the Ovid Medline, Cochrane, CINAHL and EMBASE Classic databases were conducted using PRISMA guidelines. RESULTS Our search identified 335 articles. Final inclusion consisted of 10 studies. These studies included eight pre-operative booklets, one smartphone app, three text-message programs, one video program, one internet resource, and three caregiver programs. Most resources improved post-tonsillectomy ED visits, patient anxiety and pain management, while others had no effect on these factors. CONCLUSIONS There is mixed data regarding the efficacy of pre-tonsillectomy education programs on perioperative outcomes. Further research is required to better understand the utility of such programs and their implementation into healthcare settings.
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Affiliation(s)
- Marc Levin
- Michael G. DeGroote School of Medicine, McMaster University, Canada
| | - Nicole L Seligman
- Masters of Science in Child Life and Pediatric Psychosocial Care Program, McMaster University, Canada
| | - Heather Hardy
- Division of Otolaryngology - Head and Neck Surgery, McMaster University, Canada; Masters of Science in Child Life and Pediatric Psychosocial Care Program, McMaster University, Canada
| | - Sepideh Mohajeri
- Division of Otolaryngology - Head and Neck Surgery, McMaster University, Canada
| | - Jonathan A Maclean
- Division of Otolaryngology - Head and Neck Surgery, McMaster University, Canada.
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He Y, Cai Z, Yang J. Revisit rates following pediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 2019; 122:130-132. [PMID: 31009921 DOI: 10.1016/j.ijporl.2019.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/04/2019] [Accepted: 04/13/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To explore the rate of emergency department (ED) revisits and hospital readmissions following coblation tonsillectomy in children with sleep-disordered breathing (SDB) and/or recurrent tonsillitis. METHODS A total of 2045 children underwent coblation tonsillectomy were recruited in the retrospective study. The number of revisits or readmissions was recorded and the reasons were analyzed. RESULTS Overall, 119 (5.8%) had unplanned revisits after surgery. Of those children, 98 (4.8%) had one revisit, 19 (0.92%) had second revisits, and 2 (0.097%) had third revisits. The interval between surgery and first revisit or second revisit was 7.1 ± 5.2 days and 11.3 ± 4.8 days, respectively. The reasons for first revisits were hemorrhage, fever, pain, nausea/vomiting, dehydration. The reasons for second revisits were pain, hemorrhage, fever. Children with younger age (1-3 years old) and more blood loss during surgery had higher rate of first revisit rate. Most revisits were controlled well and only 4 cases of re-surgery was needed. CONCLUSIONS Revisit rate and reason after coblation tonsillectomy in children were similar to other surgical methods. Coblation tonsillectomy is a safe and effective surgery for children.
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Affiliation(s)
- Yuxia He
- Department of Otolaryngology, Affiliated Renhe Hospital of China Three Gorges University, Yichang, Hubei, China.
| | - Zhangqiao Cai
- Emergency Department, Affiliated Renhe Hospital of China Three Gorges University, Yichang, Hubei, China
| | - Jing Yang
- Emergency Department, Affiliated Renhe Hospital of China Three Gorges University, Yichang, Hubei, China
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Alsuhebani M, Walia H, Miller R, Elmaraghy C, Tumin D, Tobias JD, Raman VT. Overnight inpatient admission and revisit rates after pediatric adenotonsillectomy. Ther Clin Risk Manag 2019; 15:689-699. [PMID: 31239691 PMCID: PMC6560194 DOI: 10.2147/tcrm.s185193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 03/31/2019] [Indexed: 11/28/2022] Open
Abstract
Objective: Overnight admission may be necessary following adenotonsillectomy (T&A) in pediatric patients. This practice may reduce unplanned revisits following hospital discharge. Study design: Retrospective cohort study. Subjects: Children from the PHIS database. Methods: T&A performed in children during the years 2007–2015 were identified in the Pediatric Health Information System. The primary outcome was 7-day, all-cause readmission or emergency department (ED) revisit. Secondary analysis examined specific revisit types and 30-day revisits. The primary exposure was each institution’s annual rate of overnight stay after T&A. Results: The analysis included 411,876 procedures at 48 hospitals. Hospitals’ annual rates of overnight stay following T&A ranged from 3% to 100%, and 7-day revisit rates varied from 0% to 15%. The percentage or rate of 7-day revisits did not differ based on the use of overnight stay following T&A. At hospitals with higher overnight admission rates after T&A, 7-day revisits were more likely to take the form of inpatient admission rather than an ED visit. Conclusions: The current study confirms that pediatric hospitals vary widely in inpatient admission practices following T&A. This variation is not associated with differences in revisit rates at 7 and 30 days related to any cause. Although no mortality was noted in the current study, caution is suggested when deciding on the disposition of patients with comorbid conditions as risks related to various patients, anesthetic, and surgical-related issues exist. Risk stratification with appropriate identification of patients requiring overnight stay may be the most important for preventing acute care revisits after T&A.
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Affiliation(s)
- Mohammad Alsuhebani
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Hina Walia
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rebecca Miller
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles Elmaraghy
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Ear, Nose & Throat Surgery, The Ohio State University, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Vidya T Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
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Miller R, Tumin D, McKee C, Raman VT, Tobias JD, Cooper JN. Population-based study of congenital heart disease and revisits after pediatric tonsillectomy. Laryngoscope Investig Otolaryngol 2019; 4:30-38. [PMID: 30828616 PMCID: PMC6383313 DOI: 10.1002/lio2.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 11/25/2022] Open
Abstract
Objective Accurate assessment of risk factors such as congenital heart disease (CHD) can aid in risk stratification of children presenting for surgery. Risk stratification is especially important in tonsillectomy ± adenoidectomy (T/A), a common pediatric procedure that is usually performed electively, but that has a high rate of adverse events. In this study, we examined the association of CHD with revisits after T/A. Methods We identified children who underwent T/A at hospitals and hospital‐owned facilities during 2010 to 2014 using the State Inpatient Databases and State Ambulatory Surgery and Services Databases of Florida, Georgia, Iowa, New York, and Utah. We evaluated the association between CHD severity and the occurrence of an unplanned hospital readmission or ED visit within 30 days following discharge using multivariable logistic regression. Results The analysis included 244,598 patients, of whom 858 had minor or major CHD. In multivariable analysis, CHD was not associated with an increased risk of 30‐day revisits (minor OR = 1.1; 95% CI: 0.8, 1.5; P = .65; major OR = 1.2; 95% CI: 0.9, 1.6; P = .34). Other comorbidities, including chromosomal anomalies (OR = 1.4; 95% CI: 1.2, 1.6; P < .001), congenital airway anomalies (OR = 1.3; 95% CI: 1.03, 1.7; P = .03), and neuromuscular impairment (OR = 1.4; 95% CI: 1.2, 1.7; P < .001) predicted an increased likelihood of revisits. Conclusion Neither minor nor major CHD was independently associated with an increased risk of 30‐day revisits among children undergoing T/A. Other characteristics, particularly non‐cardiac comorbidities, socioeconomic status, and geographic region may be of greater utility for predicting revisit risk following pediatric T/A. Level of Evidence 2b
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Affiliation(s)
- Rebecca Miller
- Department of Anesthesiology and Pain Medicine Nationwide Children's Hospital Columbus Ohio
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine Nationwide Children's Hospital Columbus Ohio.,Department of Pediatrics The Ohio State University College of Medicine Columbus Ohio
| | - Christopher McKee
- Department of Anesthesiology and Pain Medicine Nationwide Children's Hospital Columbus Ohio.,Department of Anesthesiology and Pain Medicine The Ohio State University College of Medicine Columbus Ohio
| | - Vidya T Raman
- Department of Anesthesiology and Pain Medicine Nationwide Children's Hospital Columbus Ohio.,Department of Anesthesiology and Pain Medicine The Ohio State University College of Medicine Columbus Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine Nationwide Children's Hospital Columbus Ohio.,Department of Anesthesiology and Pain Medicine The Ohio State University College of Medicine Columbus Ohio
| | - Jennifer N Cooper
- The Research Institute Nationwide Children's Hospital Columbus Ohio.,Department of Pediatrics The Ohio State University College of Medicine Columbus Ohio
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Cheon EC, Longhini AB, Lee J, Hansen J, Jagannathan N, De Oliveira GS, Suresh S. Predictive factors for adverse outcomes in pediatric patients undergoing low-risk skin and soft tissue surgery: A database analysis of 6730 patients. Paediatr Anaesth 2019; 29:44-50. [PMID: 30447169 DOI: 10.1111/pan.13550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is a paucity of data regarding risk stratification of pediatric patients presenting for low-risk skin and soft tissue surgery. AIMS We sought to determine the incidence and independent predictors of postoperative complications and unplanned 30-day readmission in a cohort of children undergoing low-risk skin and soft tissue surgery. METHODS The study included pediatric patients who underwent minor procedures of the skin and soft tissue at continuously enrolled American College of Surgeons National Surgical Quality Improvement Program Pediatric hospitals over a two-year period. The primary outcome was a 30-day postoperative complication composite. The secondary outcome was unplanned 30-day readmission. RESULTS The final analysis included 6,730 patients. There were a total of 170 postoperative complications among 152 patients (2.23%) with the majority of complications being either wound-related or postoperative mechanical ventilation. The independent predictors for an increased risk of postoperative complication were American Society of Anesthesiologists classification ≥3 and nutritional deficiency. There were 41 unplanned readmissions (0.61%). The presence of a postoperative wound complication or a postoperative pulmonary complication during the index hospital stay was an independent risk factor for unplanned 30-day readmission. CONCLUSION Pediatric patients with American Society of Anesthesiologists classification ≥3 and nutritional deficiency undergoing low-risk surgery are at risk for the development of postoperative complications. Patients who develop wound and postoperative pulmonary complications are at higher risk for unplanned 30-day readmission. Identification of these higher risk patients may allow the anesthesiologist to implement targeted therapies to minimize the likelihood of occurrence of these complications.
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Affiliation(s)
- Eric C Cheon
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anthony B Longhini
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joseph Lee
- Department of Biological Sciences, Northwestern University, Chicago, Illinois
| | - Jennifer Hansen
- Department of Anesthesiology, Children's Mercy Hospital of Kansas City, Kansas City, Illinois
| | - Narasimhan Jagannathan
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gildasio S De Oliveira
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Illinois
| | - Santhanam Suresh
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Todd C, Brody-Camp S, Friedlander P. The Role of Otolaryngologists in Eradicating Human Papillomavirus-Reply. JAMA Otolaryngol Head Neck Surg 2018; 144:1186-1187. [PMID: 30286221 DOI: 10.1001/jamaoto.2018.2450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Cameron Todd
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sabrina Brody-Camp
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Paul Friedlander
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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44
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Research Needs Assessment for Children With Obstructive Sleep Apnea Undergoing Diagnostic or Surgical Procedures. Anesth Analg 2018; 127:198-201. [DOI: 10.1213/ane.0000000000003309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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45
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Tumin D, Raman VT, Tobias JD. Insurance Coverage and Acute Care Revisits After Pediatric Ambulatory Tonsillectomy. Clin Pediatr (Phila) 2018; 57:821-826. [PMID: 28945103 DOI: 10.1177/0009922817733695] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We investigated whether patterns of health insurance coverage were associated with 30-day all-cause acute care revisits after ambulatory tonsillectomy at a free-standing quaternary-care pediatric hospital. Insurance patterns were classified from past encounters as continuous private, continuous Medicaid, Medicaid-to-private change, or private-to-Medicaid change. Among 478/675 boys/girls (age 9 ± 4 years) selected for analysis, 148 (13%) had 30-day revisits, whereas 96 (8%) changed from Medicaid to private insurance, and 99 (9%) changed from private insurance to Medicaid. Revisits were most common in the private-to-Medicaid group, compared with continuous private coverage (19% vs 10%; 95% CI of difference: 1%-18%; P = .007). The private-to-Medicaid group was most likely to be overweight, have symptoms of sleep disordered breathing, and have more past clinical encounters. In multivariable analysis, the greater risk of acute care revisits among children with private-to-Medicaid change in coverage was attributable to greater comorbidity burden and past health care utilization.
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Affiliation(s)
- Dmitry Tumin
- 1 Nationwide Children's Hospital, Columbus, OH, USA.,2 The Ohio State University College of Medicine, Columbus, OH, USA
| | - Vidya T Raman
- 1 Nationwide Children's Hospital, Columbus, OH, USA.,2 The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- 1 Nationwide Children's Hospital, Columbus, OH, USA.,2 The Ohio State University College of Medicine, Columbus, OH, USA
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Ordemann AG, Hartzog AJ, Seals SR, Spankovich C, Stringer SP. Is weight a predictive risk factor of postoperative tonsillectomy bleed? Laryngoscope Investig Otolaryngol 2018; 3:238-243. [PMID: 30062141 PMCID: PMC6057213 DOI: 10.1002/lio2.155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/16/2017] [Accepted: 03/13/2018] [Indexed: 12/27/2022] Open
Abstract
Objective To determine if a correlation exists between weight-for-age percentile and post-tonsillectomy hemorrhage in the pediatric population. Study Design Retrospective study. Methods 1418 patients under the age of 15 who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital between June 2012 and March 2015 were included in this retrospective study. Patient demographic information, operative and postoperative variables, as well as category and day of postoperative tonsillectomy bleed, if one occurred, were recorded. Fisher's exact and ordinal logistic regression analyses were performed on the full cohort. Results The overall post-tonsillectomy hemorrhage prevalence was found to be 2.2%, with primary and secondary rates of 0.78% and 1.34%, respectively. Weight-for-age percentile, sex, indication for or method of tonsillectomy, or postoperative use of NSAIDs, antibiotics or narcotics were not significantly associated with post-tonsillectomy hemorrhage. There was a significant relationship between postoperative use of dexamethasone and higher rate of Category 3 post-tonsillectomy hemorrhage (P = .028). Conclusion The post-tonsillectomy hemorrhage rate in our study is consistent with that cited in the literature. No correlation was demonstrated between weight-for-age percentile and occurrence of post-tonsillectomy hemorrhage. Postoperative administration of dexamethasone was associated with a significant increased rate of post-tonsillectomy hemorrhage requiring surgical intervention, a novel finding. Level of Evidence 4.
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Affiliation(s)
- Allison G Ordemann
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
| | - Anna Jade Hartzog
- Department of Anesthesiology Vanderbilt University Medical Center Nashville Tennessee U.S.A
| | - Samantha R Seals
- Department of Mathematics and Statistics University of West Florida Pensacola Florida U.S.A
| | - Christopher Spankovich
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
| | - Scott P Stringer
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
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Nationwide readmissions after tonsillectomy among pediatric patients - United States. Int J Pediatr Otorhinolaryngol 2018; 107:10-13. [PMID: 29501287 DOI: 10.1016/j.ijporl.2018.01.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES 1) Investigate incidence and predictors of readmissions after tonsillectomy with or without adenoidectomy (T&A) in children. 2) Identify factors that may predict readmission. SETTINGS Nationwide cross-sectional survey of US hospital admissions. SUBJECTS and Methods: The 2013 Nationwide Readmission Database (NRD) was used to examine all-cause readmissions within 30 days of T&A in children (age <18 years). Logistic regression was used to analyze the associations of demographics, diagnosis, insurance status, length of index stay, and median household income with readmission. RESULTS 9079 children undergoing T&A resulted in 327 (3.6%) patients requiring readmission. The average age of children readmitted were 5.0 years and they were 51% female. The most common readmission diagnoses were dehydration (47%), hemorrhage (26%), and pain (16%). The average time to readmission was 7.3 days. The average times to readmission for hemorrhage, pain and dehydration were 6.3, 4.5 and 4.1 days, respectively. Children who needed respiratory intubation (OR = 4.0), had a medical or surgical complication (OR = 3.3), or prolonged hospital stay (OR = 1.03) during the index admission were more likely to be readmitted. Age, gender, payer and socioeconomic status and diagnosis of obstructive sleep apnea (OSA) did not increase the odds of readmission. CONCLUSIONS Readmissions in children after T&A were primarily due to dehydration, hemorrhage, and pain. Adequate symptom control in children has the greatest potential to reduce readmission rates following T&A.
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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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Baik G, Brietzke SE. Comparison of Pediatric Intracapsular Tonsillectomy and Extracapsular Tonsillectomy: A Cost and Utility Decision Analysis. Otolaryngol Head Neck Surg 2018; 158:1113-1118. [PMID: 29484925 DOI: 10.1177/0194599818760513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives To use decision analysis modeling to compare utility and cost outcomes of intracapsular tonsillectomy (ICT) and extracapsular tonsillectomy (ECT). To use sensitivity analysis to determine the most important factors influencing outcomes favoring one surgical method versus another. Study Design Decision analysis model. Setting Hypothetical cohort. Subjects and Methods A decision analysis model was created with computer software comparing the results of ICT and ECT. The model featured complications with completion tonsillectomy, such as postsurgical bleed, dehydration, and tonsillar regrowth. Outcomes were quantified with a utility scale ranging from 0.95 (1 surgical procedure without complications) to 0.55 (ICT, regrowth requiring completion ECT, post-ECT bleeding). Costs measured out-of-pocket costs for an insured patient and factored in different recovery times for ECT versus ICT. Results Based on baseline parameters, ECT had higher cumulative utility than ICT. Utility model results were highly dependent on the value of having a single uncomplicated surgery, as well as on the tonsillar regrowth rate. Utility was equal at a regrowth rate of 1.64%; rates above this value favored ECT. The base cost model showed that ICT ($4177.92) was less expensive than ECT ($4546.91), although ICT with regrowth had the highest outcome cost ($8393.91). ECT and ICT costs were equal at a tonsil regrowth rate of 17.8% and at a recovery period of 7.4 days. Conclusion Utility decision modeling based on best estimates for baseline parameters suggests that ECT may be slightly superior to ICT, but cost analysis suggests the opposite. However, the comparative results are highly dependent on subtle changes in the tonsil regrowth rate and the potential difference in recovery time.
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Affiliation(s)
- Grace Baik
- 1 Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Scott E Brietzke
- 1 Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Murto K. Clinical Prediction Rules, Adenotonsillectomy and Children With Obstructive Sleep Apnea: What's Next? J Clin Sleep Med 2017; 13:1371-1373. [PMID: 29151430 DOI: 10.5664/jcsm.6826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 10/30/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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