Comparison of Ibuprofen vs Acetaminophen and Severe Bleeding Risk After Pediatric Tonsillectomy

Diercks, Gillian R.; Comins, Jill; Bennett, Kara; Gallagher, Thomas Q.; Brigger, Matthew T.; Boseley, Mark E.; Gaudreau, Philip; Rogers, Derek J.; Setlur, Jennifer; Keamy, Donald G.; Cohen, Michael S.; Hartnick, Christopher J.

doi:10.1001/jamaoto.2019.0269

Cited by 47 publications

(35 citation statements)

References 26 publications

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“…8 Additionally, Dierks et al suggested in a noninferiority randomized clinical trial (RCT) that increased bleeding risk associated with Ibuprofen use could not be ruled out and that further investigation with regard to the dosing of Ibuprofen should be carried out for postoperative analgesia. 9 In contrast to this literature, Baugh et al suggested in the American Academy of Otolaryngology—Head and Neck Surgery tonsillectomy guidelines that NSAID pain relievers are safe and that they should be promoted for postoperative analgesia. 10 These claims were affirmed by Hartnick’s findings, which suggest that when 10 mg/kg doses of Ibuprofen given every 6 hours is compared with 15 mg/kg doses of Acetaminophen given every 6 hours there is no significant difference in bleeding rate when either is prescribed for post-tonsillectomy analgesia.…”

Section: Introductionmentioning

confidence: 99%

The Effect of Ibuprofen Dosing Interval on Post-Tonsillectomy Outcomes in Children: A Quality Improvement Study

Mast

Henderson

Carr

2020

Ann Otol Rhinol Laryngol

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Objective: In this Quality Improvement (QI project) it was hypothesized that an increase in dosing intervals for postoperative analgesia when alternating Ibuprofen and Acetaminophen would reduce post-tonsillectomy hemorrhage (PTH) rates for those undergoing tonsillectomies with or without adenoidectomy, while maintaining the standard of postoperative analgesia and reducing visits to the Emergency Room (ER) for reasons other than PTH. Data was collected from 353 children. Utilizing run chart analysis, it was determined that patients experiencing the 4-hour dosing interval had lower rates of PTH, fewer ER visits, and no increase in postoperative phone calls from caregivers. Patients and Methods: Patients were treated with standing Acetaminophen 15 mg/kg q6h and Ibuprofen 10 mg/kg q6h for postoperative analgesia from July of 2017 until January of 2018. Starting January of 2018 through November of 2018, the dosage interval was lengthened 1 hour. Data relating to PTH, ER visits for reasons other than bleeding, and phone calls from caregivers was collected. Results: Run charts were used to assess outcomes regarding PTH, postoperative visits to the ER for reasons other than PTH, and phone calls from caregivers. Our results suggest that a standing protocol of alternating Acetaminophen and Ibuprofen given every 4 hours improves the post-tonsillectomy hemorrhage rate without increasing ER visits or calls about pain. Conclusions: This data shows promise in reducing PTH and ER visits with a longer dose interval when alternating Acetaminophen and Ibuprofen for postoperative analgesia in tonsillectomy patients. A randomized clinical trial should be carried out to further validate these claims.

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Section: Introductionmentioning

confidence: 99%

The Effect of Ibuprofen Dosing Interval on Post-Tonsillectomy Outcomes in Children: A Quality Improvement Study

Mast

Henderson

Carr

2020

Ann Otol Rhinol Laryngol

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“…20 Other analyses that had a higher risk of bias because of observational study design identified a small but statistically significant increase in bleeding (OR, 1.38; CI, 1.11-1.72). 21 More recently, Diercks et al 22 completed a multicenter randomized controlled trial of 741 children undergoing tonsillectomy and/or adenotonsillectomy that randomized children to either ibuprofen 10 mg/kg or acetaminophen 15 mg/kg, with a primary outcome of rate of post-tonsillectomy bleeding requiring a return to the operating room. The authors found a rate of postoperative bleeding requiring a return to the operating room of 1.2% in the acetaminophen group and 2.9% in the ibuprofen group ( P = 0.12), but all patients in the study took ibuprofen every 6 hours for 9 days, which is far in excess of what is commonly used in practice.…”

Section: Discussionmentioning

confidence: 99%

Nonopioid, Multimodal Analgesia as First‐line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti‐inflammatory Drugs (NSAIDs)

Cramer

Barnett

Anne

et al. 2020

Otolaryngol.--head neck surg.

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Objective To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology–Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), “Opioid Prescribing for Analgesia After Common Otolaryngology Operations,” presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib. Data Sources National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT. Review Methods AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials. Conclusion NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects. Implications for Practice The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.

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“…33 However, there is newer evidence in the literature that ibuprofen can increase risk of post-tonsillectomy hemorrhage in certain patient populations. [34][35] There is ongoing concern regarding increased postoperative hemorrhage when ketorolac is used for analgesia, but there is conflicting evidence regarding the safety of ketorolac in pediatric tonsillectomy. [36][37] The anesthesiologists who do use opioids in the PACU for a normal-weight child with severe OSA are most likely to use fentanyl (51.8%) which has a rapid onset and short duration of action.…”

Section: Discussionmentioning

confidence: 99%

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

Roberts

Sayegh

Ellison

et al. 2019

Ann Otol Rhinol Laryngol

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Objective: The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA). Study Design: Online survey. Method: A sample of pediatric anesthesiologists received the survey by email. Results: 110 respondents were included. 46.4% worked in a free-standing children’s hospital and 32.7% worked in a children’s facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children’s hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA ( P < 0.05). Conclusion: Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.

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Comparison of Ibuprofen vs Acetaminophen and Severe Bleeding Risk After Pediatric Tonsillectomy

Cited by 47 publications

References 26 publications

The Effect of Ibuprofen Dosing Interval on Post-Tonsillectomy Outcomes in Children: A Quality Improvement Study

The Effect of Ibuprofen Dosing Interval on Post-Tonsillectomy Outcomes in Children: A Quality Improvement Study

Nonopioid, Multimodal Analgesia as First‐line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti‐inflammatory Drugs (NSAIDs)

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

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