Despite Risk of Bleeding, Dexamethasone Should Be Used after Tonsillectomy in Children

Is there an increased risk of post-tonsillectomy bleeding when dexamethasone is used intraoperatively?

Background: A number of underpowered randomized controlled studies have shown increased bleeding after adenotonsillectomy although a meta-analysis of these studies showed no difference in bleeding rate with dexamethasone.

Study design: Multi-institutional retrospective cohort study of children aged 1 to 18 years who underwent tonsillectomy from 2004 to 2010 and were discharged on the same day as surgery. Children with significant comorbidities or admission through the emergency room were excluded.

Setting: This analysis utilized the pediatric health information system (PHIS) database, a multi-institutional hospital administrative database of U.S. children’s hospitals.

Synopsis: A total of 97,242 children received dexamethasone, and 4,182 (3.0%) experienced bleeding within 30 days of surgery. The 30-day risk of revisits for bleeding was 3.11%. A total of 42,473 children had surgery without dexamethasone, and the cumulative revisit rate for bleeding was significantly lower at 2.71% (p=0.003); however, the difference in bleeding was higher only for days one to five after surgery, not on days six and seven, which are more commonly associated with secondary bleeding after tonsillectomy.

Limitations of this study include the generalizability: No children with significant comorbidities or admission were included. In addition, there was no accounting for surgical technique or NSAID use. Overall, however, because the bleeding rate was within the normal range and the 95% confidence interval range for the difference was only 0.13% to 0.67%, the authors suggested that this increase in bleeding rate does not constitute a clinically important difference; therefore, because the benefits of reduced nausea and vomiting are significant, they suggest that dexamethasone should still be used for children undergoing adenotonsillectomy.

Bottom line: While there may be a small increase in bleeding in the first five days after tonsillectomy when dexamethasone is used, the benefits of decreased nausea and vomiting with dexamethasone use suggest that it should still be used for children undergoing tonsillectomy.

Citation: Mahant S, Keren R, Localio R, et al. Dexamethasone and risk of bleeding in children undergoing tonsillectomy. Otolaryngol Head Neck Surg. 2014;150:872-879.