Association of ibuprofen use with post-tonsillectomy bleeding in older children
Introduction
Tonsillectomy, with or without adenoidectomy, is the second most common operation performed on children within the United States [1], as over 530,000 operations are performed annually in children younger than 15 years of age in the U.S. [2]. Although the indications for tonsillectomy have evolved, they are generally performed in response to chronic infections, obstruction, neoplastic changes, or biopsy requirements. With regard to age, the highest frequency occurs in the 5–7 year old age group, with the peak typically occurring in the 6th year [3].
A common complication of tonsillectomy, and the primary interest of our study, is post-operative hemorrhage, occurring in 1–12.5% of pediatric patients in the literature [[4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]], with 1 out of 40,000 patients dying secondary to bleeding [15]. Other complications include pain, dehydration, weight loss, low-grade fever, and pulmonary edema. Post-op bleeding may be classified as primary (transpiring within the first 24 h), or secondary (occurring between 1 and 10 days). Post-tonsillectomy bleeding can be expensive. Harounian et al. [16] found a mean national 30-day post-operative cost of $4580 for those receiving outpatient treatment (not requiring hospitalization or surgery) for a bleed, compared to $370 for those without post-operative bleeding events or bleeding events not treated. Likewise, a retrospective study in Utah in 2015 revealed that the mean cost for a visit to the emergency department status-post tonsillectomy was $1420 (95% CI, $1104–$1737), but rose to $1502 (95% CI, $1216–$1787) when hemorrhage was present and managed [17].
Historically, surgeons have avoided ibuprofen for pain control after tonsillectomy because of its perceived association with bleeding. However, with recent studies not reporting a significant difference in bleed rates in children given NSAIDs (such as ibuprofen) after tonsillectomy, the American Academy of Otolaryngology suggested in their 2011 tonsillectomy guidelines that NSAIDs can be safely used and should be promoted for pain control [18]. Additionally, the U.S. Food and Drug Administration (FDA) published a safety review in August 2012 indicating that certain children may be at risk of serious adverse events or death related to use of codeine post-tonsillectomy due to the possibility of having a hyperactive cytochrome P450 2D6 enzyme. Being an “ultra-rapid metabolizer” can increase the amount of morphine in the blood after taking codeine and result in potentially fatal side effects [19]. After the FDA went on to add a Boxed Warning in February of 2013 [20], many post-tonsillectomy patients at Penn State Hershey Children's Hospital were given discharge regimens including ibuprofen. In-house review suggested a slight increase in the percentage of children who had post-tonsillectomy hemorrhages, raising concern and stimulating our own investigation of bleeding and ibuprofen use after tonsillectomies.
The main objective of this study was to analyze post-tonsillectomy outcomes among patients discharged with ibuprofen compared to those not discharged with ibuprofen, with focus on hemorrhage rates, ER visits, and nurse phone calls.
Section snippets
Method
A retrospective study was performed on pediatric patients who had tonsillectomy with or without adenoidectomy at the Penn State Hershey Children's Hospital in the years 2012 to 2016. This study was approved by the Penn State Institutional Review Board (# 3013). To identify patients, CPT (Current Procedural Terminology) codes for tonsillectomy along with an age limit at time of operation (1–18 years old) were used to query the hospital database. Once these patients were selected, data was
Results
A total of 773 pediatric patients were reviewed in the study, including 366 (47.3%) females and 407 (52.7%) males. The age at the time of operation ranged from 1 to 18 years old, with mean age of 7.34 (SD = 3.84). Sixty point 5% of patients were Caucasian and 12.8% were African American. Most patients had cautery tonsillectomy; 33 had coblation used. Post-tonsillectomy patients were separated into 2 groups: 504 patients who were discharged with ibuprofen (ID) and 269 patients who did not
Discussion
Ibuprofen's mechanism of action makes its post-operative use and subsequent bleeding a legitimate concern. As a non-selective, reversible inhibitor of both COX-1 and COX-2, ibuprofen produces its effect mainly through reducing breakdown of arachidonic acid [9]. As it lessens the production of arachidonic acid metabolites, it is effective at reducing both post-tonsillectomy pain and disrupting platelet function/hemostasis [9]. The benefit of its pain reduction properties may make it an enticing
Conclusion
This study shows that discharging older children with ibuprofen for pain control post-tonsillectomy is associated with a significant increase in bleeding compared to those in the same age range who were not discharged with ibuprofen. Further clinical research needs to be performed and alternative post-tonsillectomy analgesic regimens should be considered in this age group in order to provide a safer post-operative experience.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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