SAN DIEGO—The use of nonsteroidal anti-inflammatory drugs (NSAIDs) does not lead to increased postoperative bleeding following tonsillectomy, according to two research studies reported during the April 29 American Society of Pediatric Otolaryngology program at the Combined Otolaryngology Spring Meeting.
While tonsillectomy is the most common pediatric surgical procedure and pain the most common preoperative symptom, surgeons have long been concerned about hemorrhage that may be due to the administration of NSAIDs. There are approximately 4500 bleeds following tonsillectomy reported each year in the United States, with reports of one in 40,000 dying from bleeding. The reoperation rate related to the bleeding is 1% to 5.5%.
Cleveland Clinic Study
“However, even though there is significant use of NSAIDs in the public population and the hospital setting, we are not really certain how this affects bleeding,” commented Anita Jeyakumar, MD, a pediatric otolaryngologist at the Cleveland Clinic Foundation, who presented the first paper. “NSAIDs have been shown to reversibly inhibit thromboxane A2 production, potentially leading to inhibition of platelet aggregation, and prolonged bleeding time.”
Dr. Jeyakumar and her colleagues conducted a retrospective study of 1160 children up to 16 years of age, who underwent elective adenotonsillectomy or tonsillectomy at two institutions. Institution A had a firm policy of not using NSAIDs and Institution B used ibuprofen (5 mg/kg every six hours, as needed). All patients were followed for one month with the exclusion criteria those patients lost to follow-up and patients with preoperative bleeding disorders.
The researchers noted a 2.61% postoperative bleed rate in patients who were not allowed to take ibuprofen perioperatively, and a 1.02% postoperative bleed rate in patients who took ibuprofen perioperatively.
“In conclusion,” Dr. Jeyakumar said, “we found no immediate postoperative bleeding in either study arm. There was no statistical difference in bleeding rates between patients that received NSAIDs and those who did not. The p value was 0.75.”
Although noting that ibuprofen can be used in elective adenotonsillectomy patients, she suggested a further double-blind placebo-controlled trial.
New Zealand Report
In the second report, Colin S. Barber, MD, ChB, of the Department of Pediatrics at University of Auckland Medical School in Auckland, New Zealand, described his study of 1433 pediatric patients from 1993 to 2006 who had undergone tonsillectomy with or without other procedures. All patients were operated on by him, using the same technique, diathermy. All children were given both acetaminophen and an NSAID (usually ibuprofen 20 mg/kg/day in three divided doses) or diclofenac (2–3 mg/kg/day in two to three divided doses) postoperatively for 10 days together with perioperative doses of the same medications.
Dr. Barber noted that there were 45 instances of postoperative bleeding (3.14%). There were three primary bleeds (0.21%) and nine major secondary bleeds (0.62%); the remaining 33 secondary bleeds were all treated conservatively. Five of these patients went to the emergency room, but had bleeding so trivial they were not readmitted to the hospital. There was one suspected GI bleed (0.07%).
In conclusion, Dr. Barber said that his audit demonstrates that NSAIDs used perioperatively and throughout the postoperative period do not contribute to an elevation in the postoperative hemorrhage rate outside the standard reported ranges for post-tonsillectomy hemorrhage.
©2007 The Triological Society