A 2013 updated systematic review & meta‐analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti‐inflammatory agents on the risk of bleeding after tonsillectomy

Abstract

Background Although the literature suggests that non‐steroidal anti‐inflammatory drugs (NSAIDs) are effective in controlling post‐operative pain in the paediatric population, physicians have been reluctant to utilise these medications after tonsillectomy due to concerns of increased bleeding rates. While many surgeons prescribe opioid analgesics postoperatively, these are associated with a number of potential adverse side‐effects including nausea, vomiting, constipation, excessive sedation and respiratory compromise. Objective of review To compare bleeding rates and severity between recipients of NSAIDs versus placebo or opioid analgesics for tonsillectomy. Search strategy Two authors independently searched electronic databases including PubMed, OVID, EMBASE and Cochrane Review from inception to July 2012. The keywords used included: Adenotonsillectomy, Tonsillectomy, Analgesia, Bleeding, Perioperative and Postoperative. These were then combined in various combinations with specific NSAIDs. Evaluation method A systematic review and meta‐analysis of all randomised control trials comparing bleeding rates and severity between NSAIDs versus placebo or opioids post‐tonsillectomy. Results A total of 36 studies met our inclusion criteria including 1747 children and 1446 adults. When all of the studies were combined in a meta‐analysis using the most severe outcome, there was no increased risk of bleeding in those using NSAIDs after tonsillectomy. Use of NSAIDs in general [1.30 (0.90–1.88)] or in children [1.06 (0.65–1.74)] was not associated with increased risk of bleeding in general, most severe bleeding, secondary haemorrhage, readmission or need of reoperation due to bleeding. Similarly, there was no increased bleeding risk for specific NSAIDs in adults. In the studies looking at paediatric subjects, the overall odds ratio of bleeding was even lower than in the general population and not significant. This result is based on 18 studies, six of which had zero outcomes in either treatment arm. Similar to the general population analysis, there was no significant difference in any of the subanalyses: bleeds treated with reoperation, readmission or bleeds in children that could be managed conservatively. There were also no significant differences in the subanalyses of individual NSAIDs. Similarly, there was no significant difference in rates of bleeding in the subanalysis of studies that gave NSAIDs multiple times, for instance, both before and after surgery. Conclusions These results suggest that NSAIDs can be considered as a safe method of analgesia among children undergoing tonsillectomy.

Postoperative nonsteroidal anti-inflammatory drugs and risk of bleeding in pediatric intracapsular tonsillectomy

“…[6][7][8][9][10] In a 2003 study by Marrett, the preoperative use of NSAIDs was associated with increased risk of reoperation for hemostasis versus those who received placebo or narcotic. 6 A study by Møiniche that same year found that postoperative NSAID use leads to increased likelihood of having a PTH requiring reoperation.…”

The Use of NSAIDs in the Postoperative Period: Advantage and Disadvantages

“…An slightly increase of reoperation has been confirmed in a recent review, while results of another recent review consider NSAIDs safe not only because does not increase bleeding and secondary haemorrhage but does not influence the need of reoperation [121,122] . Two studies evaluating perioperative blood loss during preoperative administration of diclofenac and ibuprofen after hip arthroplasty and hip replacement have been discordant because an increase of 45% and 32% of blood loss [122,123]. In contrast, a recent study of Friedman et al have shown no increased risk of bleeding also when non-steroidal anti-inflammatory drugs or aspirin is associated to dabigratan in patients undergone to hip or total knee arthroplasty [124].…”

“…In a study of patients undergoing tonsillectomy, an increase of number of reoperation but not an increase in bleeding has been observed with a number needed to treat of 60 [120]. An slightly increase of reoperation has been confirmed in a recent review, while results of another recent review consider NSAIDs safe not only because does not increase bleeding and secondary haemorrhage but does not influence the need of reoperation [121,122] . Two studies evaluating perioperative blood loss during preoperative administration of diclofenac and ibuprofen after hip arthroplasty and hip replacement have been discordant because an increase of 45% and 32% of blood loss [122,123].…”

Intoxication à la morphine en pédiatrie : un cas clinique

“…Les inquiétudes concernant l'augmentation de la survenue d'hémorragies lors de l'usage des AINS à la suite d'une amygdalectomie relèvent de leur mécanisme d'action. En effet, les AINS inhibent de façon réversible les cyclo-oxygénases, ce qui diminue la production de prostaglandines et cause une réduction de l'agrégation plaquettaire 7 . Les enfants qui sont sous l'effet des AINS subissent une légère augmentation de la durée de la coagulation, qui reste néanmoins dans les limites de la normale 18 .…”

“…Les choix d'analgésiques pouvant être utilisés pour les enfants après une chirurgie en otorhino-laryngologie sont controversés. Les anti-inflammatoires non stéroïdiens (AINS) sont peu utilisés en raison des risques potentiels de saignements liés à leur activité antiplaquettaire 7 . Les effets indésirables liés aux opiacés peuvent en limiter l'usage chez pour les enfants.…”