Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

Leung, Peggy; DeVore, Elliana Kirsh; Kawai, Kosuke; Yuen, Sonia N.; Kenna, Margaret A.; Irace, Alexandria L.; Roberson, David W.; Adil, Eelam

doi:10.1177/0194599820970943

Cited by 9 publications

(9 citation statements)

References 53 publications

(126 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Most investigations have used similar definitions of tonsil bleeding (ie, return visits) and have included both single-institution data and large databases. A previous PHIS study found a bleeding rate of 1.58%; however, it did not create a probability model, which we have shown can be useful for providing an important perspective to surgeons when self-monitoring their rates.…”

Section: Discussionmentioning

confidence: 99%

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy

Johnson

Beams

Zaniletti

et al. 2023

JAMA Otolaryngol Head Neck Surg

View full text Add to dashboard Cite

ImportanceThe American Academy of Otolaryngology–Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored.ObjectiveTo use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event.Design, Settings, and ParticipantsThis retrospective cohort study used data from the Pediatric Health Information System for all pediatric (&lt;18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children’s hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023.Main Outcomes and MeasuresRevisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy.ResultsOf the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%.Conclusions and RelevanceThis retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

show abstract

Section: Discussionmentioning

confidence: 99%

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy

Johnson

Beams

Zaniletti

et al. 2023

JAMA Otolaryngol Head Neck Surg

View full text Add to dashboard Cite

show abstract

“…Leung and colleagues (2020) found that after the publication of the AAO–HNS guideline in 2011, physicians decreased opioid prescriptions, increased ibuprofen use, and that rates of PTH overall increased between 2011 and 2015 7 . Although the authors identify ibuprofen as a main risk factor, they acknowledge that their methodology did not allow them to examine ibuprofen dose, yet the findings were compelling enough for those authors to switch to 5 mg/kg/dose in their practice.…”

Section: Discussionmentioning

confidence: 99%

“…A recent retrospective cohort study utilizing the Pediatric Health System database (PHIS) by Leung and colleagues (2020) found an increase in PTH between 2011-2015 as compared to previous years, citing ibuprofen standardization as a possible main contributing factor. 7 A 2012 update to the original 2005 Cochrane Review included studies where a variety of nonsteroidal antiinflammatory drugs (NSAIDs) were administered, including ketorolac and variable ibuprofen dosages; this review concludes that insufficient evidence exists to rule out an increased risk of bleeding when NSAIDs are used in pediatric tonsillectomy. 8 In 2013, the FDA placed a boxed warning for codeine in children after tonsillectomy and/or adenoidectomy following a cluster of deaths attributed to the analgesic.…”

Section: Introductionmentioning

confidence: 99%

Post‐Tonsillectomy Ibuprofen: Is There a Dose‐Dependent Bleeding Risk?

et al. 2021

View full text Add to dashboard Cite

Objectives/Hypothesis Post‐tonsillectomy hemorrhage (PTH) is a potentially life‐threatening complication. A recent meta‐analysis suggests that ibuprofen may increase the risk of PTH. The aims of this study were to 1) re‐evaluate the effect of ibuprofen on PTH given additional recent evidence and 2) to evaluate a potential dose effect of ibuprofen. Study Design Meta‐analysis and meta‐regression; single‐institution retrospective review. Methods We conducted a systematic review of the literature and a meta‐analysis of 12 studies comparing postoperative ibuprofen analgesia to non‐nonsteroidal anti‐inflammatory drug (NSAID) controls. Next, we performed a meta‐regression analysis to assess for an effect of dose, if any, on rates of PTH. Five studies specifying a dose of 5 mg/kg (828 patients, 1,411 controls) and 7 studies using 10 mg/kg (5,633 patients, 7,656 controls) were included. We then conducted a novel single‐institution, retrospective review of data for 1,046 patients prescribed intermediate‐dose 7.5 mg/kg ibuprofen. Results Ibuprofen was not associated with an increased rate of PTH (log odds ratio [OR], 0.21; 95% confidence interval [CI] −0.15, 0.57). Meta‐regression showed that ibuprofen dose (5 and 10 mg/kg) did not have a statistically significant effect on PTH (OR, 1.32; 95% CI 0.30, 5.84). Uncontrolled, aggregate rates of PTH across all studies were 2.29% (N = 828) for 5 mg/kg and 4.65% (N = 5,633) for 10 mg/kg dosing. The rate of secondary hemorrhage in patients prescribed 7.5 mg/kg ibuprofen was 3.10% (N = 1,046). Conclusion We found no statistically significant increased risk of PTH when ibuprofen is prescribed at the low or high range of commonly used clinical dosages, compared to a non‐ibuprofen regimen. Further studies with less heterogeneity are needed to determine if there is a clinically relevant dose‐dependent difference in PTH with ibuprofen. Level of Evidence 3 Laryngoscope, 132:1473–1481, 2022

show abstract

“…Over 600,000 tonsil-related treatments are reportedly carried out annually across the globe ( 1 ). However, postoperative complications remain the greatest challenge for patient recovery, occurring in about 5%–15% of cases, the most common of which is related to post-tonsillectomy hemorrhage (PTH) ( 1 , 2 ). The incidence of PTH is approximately 1%–19%.…”

Section: Introductionmentioning

confidence: 99%

Development and validation of a machine learning-based predictive model for secondary post-tonsillectomy hemorrhage

Yang

et al. 2023

Front. Surg.

View full text Add to dashboard Cite

BackgroundThe main obstacle to a patient's recovery following a tonsillectomy is complications, and bleeding is the most frequent culprit. Predicting post-tonsillectomy hemorrhage (PTH) allows for accurate identification of high-risk populations and the implementation of protective measures. Our study aimed to investigate how well machine learning models predict the risk of PTH.MethodsData were obtained from 520 patients who underwent a tonsillectomy at The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army. The age range of the patients was 2–57 years, and 364 (70%) were male. The prediction models were developed using five machine learning models: decision tree, support vector machine (SVM), extreme gradient boosting (XGBoost), random forest, and logistic regression. The performance of the models was evaluated using the area under the receiver operating characteristic curve (AUC). Shapley additive explanation (SHAP) was used to interpret the results of the best-performing model.ResultsThe frequency of PTH was 11.54% among the 520 patients, with 10.71% in the training group and 13.46% in the validation set. Age, BMI, season, smoking, blood type, INR, combined secretory otitis media, combined adenoidectomy, surgical wound, and use of glucocorticoids were selected by mutual information (MI) method. The XGBoost model had best AUC (0.812) and Brier score (0.152). Decision curve analysis (DCA) showed that the model had a high clinical utility. The SHAP method revealed the top 10 variables of MI according to the importance ranking, and the average of the age was recognized as the most important predictor variable.ConclusionThis study built a PTH risk prediction model using machine learning. The XGBoost model is a tool with potential to facilitate population management strategies for PTH.

show abstract

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

Cited by 9 publications

References 53 publications

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy

Post‐Tonsillectomy Ibuprofen: Is There a Dose‐Dependent Bleeding Risk?

Development and validation of a machine learning-based predictive model for secondary post-tonsillectomy hemorrhage

Contact Info

Product

Resources

About