Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States

Abstract

IMPORTANCEThe rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. OBJECTIVE To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up.EXPOSURES Tonsillectomy with or without adenoidectomy. MAIN OUTCOME AND MEASURESPostoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. RESULTSThe 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI,] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI,). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders.CONCLUSIONS AND RELEVANCE Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

Patient Characteristics and Postoperative Mortality in Children Undergoing Tonsillectomy

“…The 2 main causes of tonsillectomy-specific death are severe hemorrhagic shock due to postoperative hemorrhage and bleeding-related airway obstruction. 2,3 Postoperative bleeding may therefore likely be the vital precipitating factor in some of the deaths in this study, 1 especially for patients who experienced respiratory failure/arrest.…”

“…To the Editor A recent article 1 explored the association of patient characteristics with postoperative mortality in children undergoing tonsillectomy in 5 US states. As otolaryngologists, we are concerned that the authors did not determine the cause of death, especially tonsillectomy-specific death.…”

“…2,4 Use of techniques such as diathermy and coblation may potentially increase postoperative hemorrhage 4 ; however, information about tonsillectomy technique was not included in this study. 1 Moreover, other factors such as obesity, type of tonsillectomy (total or partial), and use of postoperative narcotics may affect postoperative mortality. 5 Therefore, it would be helpful to have In Reply Our study 1 of postoperative mortality associated with pediatric tonsillectomy was based entirely on a longitudinal analysis of inpatient and outpatient discharge data from 5 US states.…”

“…In addition, the National Prospective Tonsillectomy Audit confirmed that tonsillectomy technique is an important risk factor for postoperative hemorrhage . Use of techniques such as diathermy and coblation may potentially increase postoperative hemorrhage; however, information about tonsillectomy technique was not included in this study . Moreover, other factors such as obesity, type of tonsillectomy (total or partial), and use of postoperative narcotics may affect postoperative mortality .…”

Patient Characteristics and Postoperative Mortality in Children Undergoing Tonsillectomy—Reply

“…In Reply Our study of postoperative mortality associated with pediatric tonsillectomy was based entirely on a longitudinal analysis of inpatient and outpatient discharge data from 5 US states. These data provided no information about some of the factors (surgical technique, type of tonsillectomy, postoperative narcotic use) suggested by Dr Huang and colleagues as having possible relationships with mortality.…”